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Extended somatic support for pregnant women after brain death

Powner, David J. MD, FCCP, FCCM; Bernstein, Ira M. MD

doi: 10.1097/01.CCM.0000059643.45027.96
REVIEW ARTICLE
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Objective To review case reports of pregnant women who have been supported after brain death until successful delivery of their infants. From these reports and other literature about brain death, normal physiologic changes of pregnancy, and specific needs for fetal development, recommendations were made to assist in supporting pregnant women after brain death until delivery of a mature fetus who is likely to survive.

Data Sources Personal files and experiences, MEDLINE review of case reports and publications about physiologic changes present during normal pregnancy and after brain death, and the critical needs for fetal development were included.

Data Extraction Eleven reports of ten patients comprise the accumulated clinical experience. Hypotension, requiring fluid administration and inotropic/vasopressor therapy, occurred in all the mothers, and in six cases, was the reason for urgent delivery. The longest period of support was 107 days, from 15 to 32 wks of gestation. Two mothers also became organ donors. Recurrent infections, thermolability, and other complications common to prolonged ICU care were encountered. All infants survived. One had congenital abnormalities caused by phenytoin use by the mother. When followed, all others developed within normal growth and mental variables. These cases plus literature citations noted above were used to develop recommendations for maternal/fetal care.

Conclusion Preservation of uterine/placental blood flow is the most important priority during somatic support. Imprecise autoregulation of the uterine vasculature during maternal hypoxemia or hypotension makes this goal a significant challenge. Special considerations for nutrition; medication use; cardiovascular, respiratory, or endocrine therapy; fetal monitoring; hormone replacement; and ethical concerns are discussed.

From the Department of Neurosurgery, University of Texas, Houston, TX (DJP); and the Department of Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington, VT (IMB).

Preservation of uterine/placental blood flow is the most important objective in promoting fetal maturation during somatic support of a brain-dead mother.

© 2003 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins