A brain-dead pregnant woman with prolonged somatic support and successful neonatal outcome: A grand rounds case with a detailed review of literature and ethical considerations
Our patient was a 35-year-old woman, gravida 2 para 2, with no previous history of chronic medical illnesses except for gestational diabetes. She presented at 16 weeks of gestation to the emergency department with an acute-onset excruciating headache after waking up in the morning. The patient had tonic-clonic convulsions at home as witnessed by her husband. In the emergency department, the patient had low Glasgow Coma Scores (GCS) that required intubation. At the emergency department, a computed tomography (CT) scan revealed a left frontal hematoma measuring 5 × 2.6 × 3.5 cm with mild edema and mass effect causing a midline shift of 4 mm to the right. There was also bleeding that spread to the left lateral ventricle via the third ventricle into the fourth ventricle. Additionally, there was a left subdural hematoma that measured 4 mm in diameter. The basal cisterns were still open.\nCT angiography (CTA) of the brain done on the same day revealed frontal lobe bleeding, carotid bifurcation aneurysm, and a small subarachnoidal bleeding. Especially relevant was the intraventricular bleeding that could lead to a later hydrocephalus. The patient was then sent to the operating room (OR) on the same day where a trial of coiling of the aneurysm failed. The patient was then admitted to the intensive care unit (ICU) for monitoring and supportive measures. She remained sedated on mechanical ventilation (MV). She was noted to have 2 mm size midposition pupils with sluggish reaction to light bilaterally. On the second day, a second trial of endovascular coiling failed.\nOn the third day in the ICU and upon physical examination, the patient had a sudden dilatation of the left pupil to 3 mm with a sluggish reaction to light, and the right pupil remained 1 to 2 mm in size. Additionally, her heart rate dropped to 55–59 beats/minute with a blood pressure of 110/60 mmHg that was managed with crystalloid and colloid therapy plus low doses of norepinephrine. Urgent CT of the brain was then performed and revealed modest subarachnoidal rebleeding with a spastic reaction of the vessels with extended ischemia in the middle cerebral artery (MCA). Moreover, there were signs of mesotemporal herniation on the left side. The third ventricle was well separated which indicated some flow problem at the aqueduct level.\nOn the fourth day, the patient was taken for another trial of coiling but that also was difficult; there was also an occlusion of the left carotid system by a thrombus. CT of the brain showed deterioration when compared to the previous examination; the ischemic areas were better demarcated corresponding to the left MCA and part from the left anterior cerebral artery with perforating branches to the basal ganglia. The midline shift had increased and there was an increase in the effacement of gyri and sulci.\nCerebral angiography revealed a thrombosis in the left internal cerebral artery (ICA) and MCA. Of note, there was no carotid artery aneurysm. Partial mechanical thrombectomy for MCA/ICA system was done.\nAfter the last attempt of failed coiling, the pupils became fixed and dilated at 7 mm bilaterally. Therefore, the patient was shifted to the OR on the same day for decompressive craniotomy and placement of external ventricular drains (EVD) for monitoring intracranial pressure (ICP). The patient then came from OR ventilated and sedated with fixed dilated pupils (right pupil 4 mm in size, and left was 7 mm in size) with no cough or gag reflexes and an ICP monitor reading of less than 10 mmHg. On the fifth day, the ICP started rising and reached up to 50 mmHg. Medical management for high ICP was started and included muscle relaxants, mannitol, hypertonic saline infusions, and thiopental coma without success. As such, ICP remained elevated until removal of the monitor on the eighth day of admission.\nUpon physical examination, the patients had a GCS of 3 with no gag or cough reflexes, while the pupils were 5 mm dilated in size and fixed. Consequently, sedation was stopped on the ninth day. Apnea test was not done due to a viable fetus and the use of vasopressors, whereas EEG was not done because of the local scalp and skull conditions as the brain tissue was visible.\nUpon 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 18th hospital day. Early in the hospital course, feeding was initiated through an NG tube. All decisions regarding the treatment of the patient were taken with the consensus of her family. The current status of the patient was discussed with a multidisciplinary approach and involved the adult and infant ethics committees. The decision was to continue somatic support until the patient was 32 weeks gestation and a cesarean section (CS) could be done. An ultrasound scan after admission revealed intrauterine growth retardation (IUGR) with biometry corresponding to 25 weeks gestation, an estimated fetal weight of 650 gm, and oligohydramnios with no other fetal anomalies. Subsequently, intrauterine monitoring of the fetus was performed using serial ultrasounds, heart rate monitoring, and amniocentesis. Betamethasone therapy was also administered for fetal lung maturity and prophylaxis of fetal respiratory distress syndrome.\nLower segment CS was performed. A preterm male in breech presentation was delivered with an Apgar score of 6/7/9 at 1, 5, and 10 min, respectively, and an average weight of 750 gm. The baby was immediately transferred to the neonatal intensive care unit (NICU). Application of nasal continuous positive airway pressure (CPAP) was necessary owing to a mild respiratory distress syndrome.\nApnea test was done twice on the mother with positive results on both occasions. On the basis of the clinical examinations and these confirmatory technical tests, death was pronounced.