Case report: Prolongation of pregnancy in a woman who sustained brain death at 26 weeks of gestation

We report a case of maternal brain death at 26 weeks of gestation in which supportive intensive care, tocolytic drug therapy and close fetal surveillance resulted in prolongation of the pregnancy for 14 days. The indication for delivery was oligohydramnios and suspected placental insufficiency. The baby did well following an initial period of elective ventilation. A 33-year-old primigravida was admitted to the Intensive Care Unit with a provisional diagnosis of massive intracranial haemorrhage at 26 weeks of gestation. Her pupils were fixed and dilated on admission and she had a Glasgow Coma Scale of five. The management at that time was directed at cerebral protection and prevention of herniation of the cerebellar tonsils (coning). She was therefore intubated, sedated, paralysed and hyperventilated to a PaCO2 of 4 kPa. Dexamethasone and mannitol were administered. All sedation was stopped after 48 hours for assessment when she satisfied the criteria for brain death, although it was clear from 12 hours after admission that she had coned. Our management from this time was directed at fetal wellbeing by maintaining the stability of the mother physiological systems. This situation was discussed in detail with the woman’s family. The alternatives presented were immediate delivery or maternal support in an attempt to gain time to allow the baby to mature. The family wished that maternal support on the behalf of the fetus should be undertaken. The woman was given betamethasone injection, 12 mg, intra-muscularly, which was repeated 12 hours later, to stimulate fetal lung maturity. The welfare of her infant was monitored by cardiotocography, umbilical artery Doppler velocimetry and amniotic fluid volume assessment by ultrasound. Her blood volume was maintained, and anaemia was treated by blood transfusion. She received low molecular weight heparin. Her cardiovascular system was unstable, with intermittent hypertension and bradycardia. Sudden decrease in her systolic blood pressure occurred on her right side; these episodes became less frequent when she was nursed in an auto-rotating bed. Pulmonary function was initially maintained with a fraction of inspired oxygen concentration (FiG2) of 0.3, and positive end expiratory pressure (PEEP) of 5 cm H2O. On the fifth day after her admission, she developed a fever and purulent sputum. She was given intravenous amoxicillin and physiotherapy, and within three days her chest infection had resolved. The fetal monitoring tests were satisfactory. Blood cultures were negative. Diuresis, caused by the effect of coning, was evident from her admission. Her urine output was reduced to 80–120 mL per hour using desmopressin. Supplements of potassium were frequently required, although her renal function remained normal. Lack of gastrointestinal motility prevented nasogastric absorption of food given by a nasogastric tube, and so she received total parenteral nutrition. This proved very effective in maintaining normal albumin and total protein levels. On the fifth day after her admission, her serum cortisol was reduced, requiring intramuscular hydrocortisone. Hyperglycaemia occurred, which was treated by insulin. She was unable to maintain her temperature and was treated with a warm air over-blanket, which maintained her temperature at a physiological level. Three days after her admission she had regular uterine contractions. The cervix was partially effaced but not dilated. She received nifedipine 20 mg, three times daily sublingually, DOI: 10.1111/j.1471-0528.2005. 00801.x www.blackwellpublishing. com/bjog Case report