Clinically brain-dead pregnant woman kept alive to save baby against parents wishes

[Supernovae]

This interesting systematic review from Germany shows good outcomes from maternal somatic support after brain death at 15 and 16 weeks, in 1989 and 1999, both from the US:

http://www.biomedcentral.com/1741-7015/8/74

(see table 1).

 

[al66pine]

This interesting systematic review from Germany shows good outcomes from maternal somatic support after brain death at 15 and 16 weeks, in 1989 and 1999, both from the US:
http://www.biomedcentral.com/1741-7015/8/74 (see table 1).

M BBM

Thanks Supernovae for linking the article. Interesting reading and making me curious about these patients and cases, and others.

Table 1 shows "An overview of the reported cases of extended maternal somatic support after brain death (BD) including neonatal outcomes" (bbm) for 20 studies in various countries, involving BD pregnant women (w one study seeming, imo, to focus on organ donation from mother-hosts). The article states: "In our search of the literature, we found 30 cases reported between 1982 and 2010."

If I understand your conclusion re gestational age 15 and 16 weeks, at mother's BD, you point to these 'good outcomes' in USA:

Bernstein study:
15 wk g.-age, 107 days on support, neo-natal outcome = "Male, 1555 gr, Apgar 6/9, Mild hyperbilirubinemia, Normal at 11 mo."
IDK what cognitive testing can be done at 11 mos., so do we know if this is overall 'good outcome.'

Spike study:
16 wk g.-age, 100 days on support, neo-natal outcome = "Male, 1440gr, Apgar 8/8." [No further info here re outcome]
IDK what cognitive testing was done at any age, so do we know if this is overall 'good outcome.'

Studies of 2 cases had earlier g.-ages than the above US cases. The 2 cases were 13 wk. g.-age at brain death, resulting in -
---"Spontaneous abortion at 19 weeks" (Anstotz study).
---"Intrauterine death at 14 weeks" (Lane study).

If more BD patients w 15-16 wk g-age fetus had support until successful delivery, would we find pub'ed studies?

The world of medicine continues evolving. Thx again for the link and putting my grey cells to work.

 

[MsFacetious]

If the father of the baby and the parents both agree on what to do, I see no dilemma here.
The court should only get involved when the next of kin do NOT agree. :twocents:

 

[al66pine]

If the father of the baby and the parents both agree on what to do, I see no dilemma here.
The court should only get involved when the next of kin do NOT agree. :twocents:

Ms F and others,
On the surface, for this case, could be okay.

What if BD pregnant woman's bro or sis object to removing support?
Can sibs' 'votes' override fetus' father or woman's parents agreement to discontinue support?

 

[Supernovae]

Another case report from 2013, this time from the United Arab Emirates:

http://www.ijciis.org/article.asp?i...ume=3;issue=3;spage=220;epage=224;aulast=Said

 

[al66pine]

Another case report from 2013, this time from the United Arab Emirates:
http://www.ijciis.org/article.asp?i...ume=3;issue=3;spage=220;epage=224;aulast=Said

Supernovae,
Thanks for link to 2013 article.

From Intro, which seems to refer to your earlier link as a comprehensive overview of BD pregnant pt. & their outcomes.
"....There are 30 cases reported in the literature between 1982 and 2010 on brain-dead pregnant women whose somatic non-neurological functions were maintained successfully to facilitate fetal maturation in the uterus.
However, of the cases reported, 12 viable infants were born and survived the neonatal period...." bbm

Re UAE patient in this case report:
"....this is the first case in literature with the longest somatic support (110 days).
Until this case report, the longest duration of somatic support was reported by Bernstein et al. (107 days)...." bbm
Amazing what medical professionals can accomplish in such a circumstance.

Still
"....Until now, due to the low number of cases that reported a successful somatic support in brain-dead pregnant women,
there are no definitive guidelines or proven management strategies in this context and
all the interventions are considered experimental." bbm

Thx again. Thoughts and prayers for all involved in decision making and care in these heart wrenching situations.

 

[MsFacetious]

Ms F and others,
On the surface, for this case, could be okay.

What if BD pregnant woman's bro or sis object to removing support?
Can sibs' 'votes' override fetus' father or woman's parents agreement to discontinue support?

If they come out and say they don't believe their sibling would have wanted that, yes.

Like I said with my sister. My Dad would keep her alive to save an 8 week fetus. He is 100% pro life.
My sister is pro-choice and I know she'd never want be kept alive to gestate unless she was nearly full term already.
In her case, her husband would honor her wishes. If he didn't, I'd battle my father for what my sister would want.

In this case it doesn't appear there is any friction. They all seem to agree. Which is rare. So, I say let them agree. :twocents:

 

[Supernovae]

@al66pine

On the long term outcomes point, in the context of the seriousness of the situation and the alternative, I would consider normal development at 11 months to be a win. Yes, I don't think that rules out autism, for example, and you don't know how they'll do at school compared to the other children, but it does rule out the more severe range of cognitive disabilities. I take your point about the other papers not mentioning medium term outcomes at all.

I don't know whether there are a whole host of failed attempts at maternal somatic support that aren't reported in the literature or whether there are so few case reports simply because it's such a rare set of circumstances, firstly for a pregnant mother to suffer an injury that leads to brain death, for this to be from a cause that doesn't immediately profoundly compromise the baby, for this to occur in a country with a healthcare system that can offer long term somatic support, for the care team to not automatically be scared off by the seriousness and lack of precedent, and for the family to agree.

In any case, what I draw from this is that there is a limited body of evidence from which to be making hard and fast pronouncements about prognosis. I'm not sure where the 12/30 figure is coming from, by my count it's 11 surviving babies (and one further dying on postnatal day 30 which, I suppose, is outside the neonatal period) from 24 cases, of which 18 give a foetal outcome either positive or negative. Of the 11 cases where bd occur at 20+ weeks (excl. the Suddaby study) 9 record a successful neonatal outcome, with one intrauterine death at 3 days post brain death at 20 weeks gestation, and one further gives no outcome, although given the baby was delivered at 32 weeks because of sufficient lung maturity (bd at 25 weeks), I presume it was successful. Of the 8 cases before 20 weeks, there were 2 long term survivors, one baby died 30 days after premature birth at 25 weeks (bd at 17 weeks), 4 intrauterine deaths (2 in 8 days or under of bd, one not given and the other because of maternal death after 49 days) and one spontaneous abortion at 19 weeks (bd 13 weeks). What wasn't recorded as happening was for a baby to be delivered at a later gestation but to be found to be so compromised from the maternal bd per se (if this doesn't seem an artificial distinction), that it didn't survive. It seems to be more a process of attrition due to the onset of complications that either cause maternal death or severely compromise the foetal environment. At later gestations there's a plan b, i.e. to deliver and take their chances with prematurity. Pre-viability there's nowhere else to go, either they manage to sustain the mother and foetus for a lengthy period of time, as in the two American cases (plus the one from the Said study), in which case all is well, or they don't.

 

[Supernovae]

Interesting from Said et al:

"Upon confirmation of this diagnosis, our patient received full ventilatory and nutritional support, vasoactive drugs, maintenance of normothermia, and other supportive measures required to prolong gestation and improve the survival prognosis of her fetus. The 110-day hospital course of the patient was complicated by medical problems that included severe hypotension managed with vasopressors, and hypertension treated with antihypertensives. Intranasal 1-deamino-8-d-arginine vasopressin (DDAVP, Rhone-Poulenc Rore Pharmaceutical Inc., Collegeville, PA) and water flushes through the nasogastric tube (NG) were initiated for the treatment of diabetes insipidus and hypernatremia. Additionally, the patient developed several episodes of sepsis due to pneumonia, urinary tract infection, and line infection that were treated successfully with antibiotics. Moreover, the patient developed meningitis that was treated with meropenem 2000 mg intravenously three times daily and vancomycin 1000 mg twice daily with a target trough level of 15 to 20 mg/L. Panhypopituitarism was also treated with thyroid hormone replacement and steroids. Hypothermia was managed with passive rewarming and blankets. A tracheostomy was performed on the 18 th hospital day. Early in the hospital course, feeding was initiated through an NG tube."

 

[Supernovae]

And again:

"Based on previous reports, the gestational age of the fetus was important in deciding to attempt somatic support following brain death. However, this is no longer an important issue especially with the important advances in life-support technology and critical care that enables the maintenance of vital functions. Additionally, there are case reports that describe the successful prolongation of pregnancy without regard to gestational age at the time of brain death."

 

[Cappuccino]

The High Court has ruled that life support should be turned off.

 

[K_Z]

Irish Court OKs Turning Off Life Support For Brain-Dead Pregnant Woman

The Irish Times reported that today's decision won't be appealed to the country's Supreme Court because "lawyers representing the interests of this particular unborn felt its interests had been fully considered."

http://www.npr.org/blogs/thetwo-way...ff-life-support-for-brain-dead-pregnant-woman

Court clears way for clinically dead pregnant woman to be taken off life support

Decision will not be appealed after court told interests of unborn had been fully considered

The court found as a fact there was no genuine prospect the somatic process would lead to the birth of a live baby.

Given that finding, it stressed this was not a case where the court’s view was influenced by any consideration, if the unborn child was born alive, it would be impaired to a greater or lesser degree.

The court also believed maintenance of the somatic support would deprive the mother of dignity in death and subject her father, her partner and her young children to “unimaginable distress in a futile exercise which commenced only because of fears held by treating medical specialists of potential legal consequences”.

It noted highly experienced medical practitioners, with the best interests of both mother and unborn in mind, did not believe there is any medical or ethical reason for continuing with a process which Dr Peter McKenna, a former Master of the Rotunda Hospital, had described as “grotesque” on the particular facts of this case.

The court also stressed it was not impressed by arguments, made by lawyers instructed to represent the interests of the woman herself, that she has no right to dignity arising from her having been declared brain dead.

The requirement to vindicate the right to life of the unborn does not mean the court disregards the mother’s right to retain in death her dignity and receive proper respect for her autonomy with due regard to the grief and sorrow of her loved ones and their wishes.

“It is a deeply ingrained part of our humanity and may be seen as necessary both for those who have died and also for the sake of those who remain living and must go on. The court therefore is unimpressed with any suggestion that considerations of the dignity of the mother are not engaged once she has passed away.”

Earlier this week, the High Court heard evidence from eight doctors, none of whom argued the somatic treatment should be continued. A number of the doctors said they believed the unborn had no reasonable prospect of surviving intact even if the somatic treatment was continued.

The court also heard the woman’s condition is deteriorating and she displays puffiness of the torso, her brain is rotting and she has a number of infections. The court was told by some of the medics and experts that continuing the treatment was not appropriate and amounted to “experimental” medicine.

http://www.irishtimes.com/news/crim...-woman-to-be-taken-off-life-support-1.2048616

(Many more articles available if one searches "Ireland brain dead pregnant woman".)

I'm thankful these judges were brave enough to make this ruling and set precedent for Ireland. It's time their 8th amendment was re-addressed, IMO.

IMO, their 30 year old 8th amendment was never crafted, nor intended to apply to extreme circumstances such as these. It is so poorly written and interpreted, IMO, that I could envision mandatory uterine ultrasounds and blood HCG's being added to CPR/ ACLS protocols for women. Or some unfortunate layperson or health care provider charged with murder if they stopped CPR on a pregnant woman. This issue of brain dead and dying pregnant women has nothing at all to do with elective abortion, and IMO, it's simply awful and nightmarish that the two issues have been conflated by bureaucratic and social ignorance, and wishful thinking.

As nightmarish as "forcing" the medical profession to use brain dead women to be gestational surrogates for those who can't conceive and carry. Is that next? Because we're not too far from that in these situations, IMO.

 

[MyBelle]

Thanks for the update. I know it mystifies some people as to why courts must get involved in what appears on the surface to be only a moral issue but we are nations with laws. Each case must resolved individually because physicians, not the court, must first determine the viability of the fetus. Truly tragic all around.

 

[necco]

Wishing the family peace and comfort now that this has been decided.
Also wishing peace and comfort for the medical staff who has been caring for the woman and fetus.

There are no winners in these cases. Every option is terrible because every option brings pain and loss. I'm glad that it has been decided, either way, and the family and staff are no longer stuck in limbo.

 

[panthera]

[FONT=proxima_nova_rgregular]" In their 29-page judgment, the judges accepted testimony from seven doctors who shared the view that the fetus couldn't survive for the needed extra two months to be delivered safely. They detailed how the woman's body was becoming a lethal environment rife with infections, fungal growths, and high temperatures and blood pressure."

http://www.nbcnews.com/health/healt...upport-ireland-highlights-strict-laws-n275231

Just as I had imagined, her body being kept on life-support was not a healthy environment for the fetus to become a healthy baby. Prayers for the family during this unimaginable tragedy.

MOO


[/FONT]

 

[jjenny]

[FONT=proxima_nova_rgregular]" In their 29-page judgment, the judges accepted testimony from seven doctors who shared the view that the fetus couldn't survive for the needed extra two months to be delivered safely. They detailed how the woman's body was becoming a lethal environment rife with infections, fungal growths, and high temperatures and blood pressure."

http://www.nbcnews.com/health/healt...upport-ireland-highlights-strict-laws-n275231

Just as I had imagined, her body being kept on life-support was not a healthy environment for the fetus to become a healthy baby. Prayers for the family during this unimaginable tragedy.

MOO


[/FONT]

In this particular case it sounds like the body is full of infections. But there have been a number of cases where a healthy infant was delivered to a brain dead mother.

 

[K_Z]

The court also stressed it was not impressed by arguments the woman has no right to dignity arising from her having been declared brain dead. The requirement to vindicate the right to life of the unborn does not mean the court disregards the mother’s right to retain in death her dignity and receive proper respect for her autonomy with due regard to the grief and sorrow of her loved ones and their wishes, it said.

Lawyers representing the interests of the unborn also argued, given the woman is clinically dead, the unborn’s right to life surpassed her right to a dignified death.

The court therefore is unimpressed with any suggestion that considerations of the dignity of the mother are not engaged once she has passed away.”

BBM

http://www.irishtimes.com/news/crim...to-be-taken-off-life-support-1.2048616?page=3

The case touched on a deeply divisive issue in Ireland, which has a controversial constitutional ban on abortion, with even the head of the Catholic Church in the country saying, "A woman isn't simply an incubator."

The case reignited fierce social tensions in majority Catholic Ireland over the rights of unborn children, prompting the Archbishop of Dublin Diarmuid Martin to speak out on the issue.

"From the point of view of Catholic teaching in general medical ethics, there is no obligation to use extraordinary means to maintain a life," Martin told Newstalk radio. "A woman isn't simply an incubator."

"As long as the eighth amendment remains in the constitution in its present form, the possibility of such a deeply tragic and private case being decided in the very public and distressing surroundings of the courts will be present."

The broad wording of the law has also been blamed for causing confusion in emergency situations in the past.

Earlier this month, Health Minister Leo Varadkar said the constitutional rules around abortion are "too restrictive" and have a "chilling effect" on doctors.

"Difficult decisions that should be made by women and their doctors, a couple or next-of-kin... on the basis of best clinical practice, are now often made on foot of legal advice. That is not how it should be."

BBM.

http://www.msn.com/en-us/news/world/irish-court-life-support-can-end-for-pregnant-woman/ar-BBhfsNG

Very important and precedent setting language-- and very brave public comments. I'm heartened to see some Catholic leaders commenting, as it seems so often pregnant women in these circumstances of medical catastrophes are reduced to being viewed by those interpreting laws, and certain zealous groups within society, as nothing more than a slab of meat with an occupied uterus, and not actual living, breathing, valuable and loved human beings who have died a tragic death.

I'm hopeful that these issues may finally be addressed by Ireland's legislators. This case, the other two <20 week pregnancies in brain dead mothers, and the unconscionable death of Savita Halappanavar should prompt outrage (and fear) from every Irish citizen.

Doctors and health care professionals must be able to appropriately treat medical catastrophes involving pregnant women without fear of lawsuits or criminal charges due to poorly worded and poorly interpreted laws or constitutional amendments. They shouldn't have to put a hopeless case on a ventilator, with extraordinary, futile, and costly care, and spend weeks getting to a court hearing, to make appropriate medical decisions.

This was never, ever a case that anyone thought would end in a living child (damaged or undamaged). There is an enormous difference between a 14 week fetus, and the 22+ week fetuses that make up the majority of the "good" outcomes in the anecdotal literature. Each situation is different, depending on the "down" time of the woman, her care, and history, and the circumstances of the fetus and the pregnancy.

Eight different doctors testified the *only* reason they ever put this terribly unfortunate woman on the vent with ICU support is due to fear of being charged with a crime. None of them ever thought what they were doing was a good thing, or that a living child could be produced. There is something deeply visceral, and profoundly disturbing about reading that, IMO-- but maybe that's due to my background as a health care professional.

I fully recognize that I'm completely unable to engage in the "magical thinking" that seems to cripple the critical thinking skills of so many people who think a 14 week fetus in a traumatically brain dead mother has any reasonable chance of survival. And I can't ever agree that "winging it", or essentially opportunistic "experimentation" (sequential anecdotal opportunities) is any kind of good, systematic, or ethical ways to advance knowledge in the medical field. Especially since we apparently can't even agree on how to design, construct, fund, and carry out ethical non-human primate and xenospecies animal models of research. Fetal research is the most restrictive and controversial of all areas of research.

http://en.wikipedia.org/wiki/Death_of_Savita_Halappanavar

 

[panthera]

In this particular case it sounds like the body is full of infections. But there have been a number of cases where a healthy infant was delivered to a brain dead mother.

That is true, however, my biggest concern was the length of time involved. Just very, very sad all around.



MOO

 

[MyBelle]

In this particular case it sounds like the body is full of infections. But there have been a number of cases where a healthy infant was delivered to a brain dead mother.

That's true. The legal issue always has been whether the infant is viable or not. And only doctors can determine that. Roe v Wade set it at 28 weeks and with advances in medicine over the past 30 years, now it is something like 22 or 23 weeks. Ireland's court made a sound and just decision. May the mother and baby rest in peace.

 

[Supernovae]

"The legal issue always has been whether the infant is viable or not. And only doctors can determine that. Roe v Wade set it at 28 weeks and with advances in medicine over the past 30 years, now it is something like 22 or 23 weeks. "

There are two slightly separate issues here: viability if delivered, which occurs at 22 weeks (just about, I believe there has also been at least one case of survival at 21 weeks), and the ability to maintain life support with the eventual outcome of a live born infant, taking into account the individual circumstances, the earliest example of which has been 15 weeks.