An accident or a catastrophic disease may occasionally lead to brain death BD during pregnancy. Management of brain-dead pregnant patients needs to follow special strategies to support the mother in a way that she can deliver a viable and healthy child and, whenever possible, also be an organ donor. This review discusses the management of brain-dead mothers and gives an overview of recommendations concerning the organ Stephan ouaknine wife sexual dysfunction therapy.
The collected data included the age of the mother, the cause of brain death, maternal medical complications, gestational age at BD, duration of extended life support, gestational age at delivery, indication of delivery, neonatal outcome, organ donation of the mothers and patient and graft outcome. In our search of the literature, we found 30 cases reported between and A nontraumatic brain injury was the cause of BD in 26 of 30 mothers.
The maternal mean age at the time of BD was The mean gestational age at the time of BD and the mean gestational age at delivery were 22 and Twelve viable infants were born and survived the neonatal period. The management of a brain-dead pregnant woman requires a multidisciplinary team which should follow available standards, guidelines and recommendations both for a nontraumatic therapy of the fetus and for an organ-preserving treatment of the potential donor. Death is pronounced on the basis of well-defined clinical examinations followed by confirmatory technical tests.
Recent improvements in life support technology and critical care management make it possible to maintain the patient's vital functions after BD. The question whether to offer life support to brain-dead patients and how long it should be provided has become a controversial ethical issue. "Stephan ouaknine wife sexual dysfunction" issue is still more complex when BD occurs during pregnancy. Of course, the incidence of BD in pregnant women is very low and there are only few case reports.
As shown by Suddaby et al. When confronted with BD in a pregnant woman, physicians must primarily focus on saving the life of "Stephan ouaknine wife sexual dysfunction" fetus, and therefore the treatment protocol should give special recommendations on how to support the mother in a way that she can deliver a viable and healthy child.
After delivery, brain-dead pregnant women may also be candidates for organ donation. Therefore, two aspects must be considered in case of maternal BD: Hence, if the mother and the fetus are regarded as two distinct organisms, maintaining the vital functions of a brain-dead pregnant patient may be ethically justifiable to support both the birth of a child and possible organ donation.
In such a situation, various clinical disciplines such as neurosurgery, intensive care medicine, obstetrics, neonatology, anesthesiology, transplantation surgery and an ethics committee should work together to minimize maternal and fetal morbidity as well as mortality.
Since only a few reported cases are to be found in the medical literature, most approaches to managing a brain-dead mother remain experiential and relatively little publicized.
In this article, we review the available cases of prolonged somatic support in brain-dead pregnant women and analyze when and under which circumstances the pregnancy should be maintained and what challenges are to be faced. To present a protocol to support such patients, we discuss the management of the brain-dead mother and fetus, related recommendations and legal and ethical issues.
Key words used in electronic searching included "maternal brain death," "pregnancy," death," "management of brain death" and "fetal monitoring. Additionally, to include all existent studies, we also contacted experts in the related fields of brain death and pregnancy. All studies which reported at least one case of maternal brain death during pregnancy were eligible for inclusion.
We excluded studies dealing with pregnancy in a persistent vegetative state because brain death adds complexities to pregnancy that are very different from a persistent vegetative state, calling for different management and obstetric strategies, as well as other legal and ethical considerations. Furthermore, we excluded studies which only discussed ethical and legal issues and studies providing insufficient data. There were no language restrictions.
One reviewer ME screened all titles and abstracts to assess whether they were potentially eligible for inclusion and whether full text was required. Then abstracts and full texts for all potentially eligible studies were reviewed by two researchers ME and EKwho independently evaluated these articles and extracted their data. Any disagreement during study selection and the data extraction process was resolved by discussion with a third author AM. According to our search of the medical literature, 30 cases of maternal BD 19 case reports and 1 case series were reported between and The collected data included the age of the mother, the cause of BD, maternal medical complications, gestational age at BD, duration of life support and gestational age at delivery.
"Stephan ouaknine wife sexual dysfunction" addition, we evaluated the indication of delivery, mode of delivery, neonatal outcome and organ donation by the mothers, as well as the transplant outcome.
In our analysis, we particularly focused on the critical care management of brain-dead mothers such as respiratory and cardiovascular support, endocrinology and thermoregulation, nutritional support and organ donation, as well as aspects of obstetric management, including fetal monitoring. The statistical analysis was performed using SPSS All statistical data regarding maternal age, duration of maternal support, gestational age and fetal birthweight were expressed as means.
According to our search, between and19 Stephan ouaknine wife sexual dysfunction reports and 1 Stephan ouaknine wife sexual dysfunction series were published. Flow chart of abstracts and articles identified and evaluated during the review process. In the 30 reported cases, the maternal mean age at the time of BD was Two mothers were 18 Stephan ouaknine wife sexual dysfunction old and a third one was 40 years old at the time of pregnancy.
Trauma was the cause of BD in 4 of 30 mothers, and the other 26 died of nontraumatic brain injuries. The mean duration of maternal support was In two cases, children were delivered on the second day after BD was Stephan ouaknine wife sexual dysfunction. Conversely, in two Stephan ouaknine wife sexual dysfunction, mothers were supported for more than days before delivery.
The mean gestational age at the time of BD was 22 weeks range, wk. In 10 of 19 reported cases, the baby was delivered later than week The mean gestational age at delivery was The indications for delivery in all reported cases were maternal or fetal difficulties, including maternal hemodynamic instability seven casesfetal distress three casesoligohydramnion two casesintrauterine growth retardation one case and abnormal pattern of the placental structure one case.
In two cases in which maternal BD began at week 13 of gestational age, spontaneous abortion occurred at weeks 13 and In four cases, there was intrauterine death.
We did not find any information about the fate of the fetuses in the published case series. Children who were born included 1 female and 10 male infants. No information regarding sex was given about one infant. The average birthweight was 1, g Stephan ouaknine wife sexual dysfunction,gand the mean Apgar score was 7 and 8 at 1 and 5 minutes, respectively. Congenital defects were reported for only one infant, who was diagnosed with fetal hydantoin syndrome resulting from previous chronic phenytoin usage by the mother.
Four infants required temporary mechanical ventilation because of neonatal respiratory distress syndrome or pneumonia. Fungemia was diagnosed in one infant, and he was treated with amphotericin B.
However, not every infant was sufficiently followed to determine the long-term effects of prolonged maternal life support.
Postnatal follow-up up to 24 months was available only for six infants. In three reported cases after successful delivery, organ donation from the brain-dead mother was carried out. In two cases, organ procurement was accomplished after the intrauterine death of the fetus.
In yet another five cases, organ donation was performed, but no report about the status of the fetus was provided. In six patients, consent was given by the patient's family to donate heart, lung, liver, pancreas and kidneys. In four donors, no information was given concerning donated organs.
The 1-year graft survival in the reported cases was excellent. Only one liver Stephan ouaknine wife sexual dysfunction one pancreas were lost in two patients owing to their primary nonfunction. Clinically, following the onset of BD, it is possible to sustain a brain-dead mother's somatic functions over a longer period.
Manifold physiological changes
Stephan ouaknine wife sexual dysfunction during pregnancy and brain death, as well as the prolonged hospital stay after BD, present enormous challenges, however, both for the treating clinicians and for the family. The important question is from which gestational age onward should the pregnancy be supported?
Stephan ouaknine wife sexual dysfunction present, it seems that there is no clear lower limit to the gestational age which would restrict the physician's efforts to support the brain-dead mother and her fetus.
As reported by Slattery et al. Therefore, depending on maternal stability and fetal growth, the decision must be made on an individual basis. According to our findings, prolonged somatic support can lead to the delivery of a viable child with satisfactory Apgar score and birthweight. Such children can also develop normally without problems resulting from their intrauterine conditions.
Furthermore, after the delivery, mothers could be considered as potential organ donors. This schema is not a definitive guideline, because the technical support and the experience of the responsible medical team must also be taken under consideration. Also, the number of reported cases is too small to define the rate at which intensive care support of the brain-dead mother can result in a healthy infant.
The percentage of successful cases cannot be determined, because there are no reports describing failure of intensive
Stephan ouaknine wife sexual dysfunction support from all medical centers.
Finally, it cannot be established whether a relative infrequency of cases such as those that we found in the published literature reflects the rarity of the event, perfect success in all prior situations, Stephan ouaknine wife sexual dysfunction to initiate intensive efforts required to support the brain-dead patient or simply publication bias. Recommendations for the management of maternal brain death.
However, we maintain that the management of a brain-dead pregnant woman should follow the existent standards, guidelines and recommendations both for nontraumatic therapy for the fetus and organ-preserving treatment for the donor [ 4 - 6 ].
What follows here is the summary of these guidelines and recommendations. In the initial phase of BD, tachycardia was detected in less than half of the patients [ 78 ]. However, subsequently the heart rate slowed in all of these patients as factors such as hypothermia and subclinical myocardial hypoxia antagonized the sympathetic activation occurring during the initial phase of BD [ 7 ]. Hypertension in this situation is a rare, usually self-limiting event.
In prolonged hypertension, short-acting substances such as urapidil or nitroprusside were applied [ 910 ]. Typically, at some point, BD patients also develop hypotension [ 9 ]. The initial treatment for hypotension consists of aggressive fluid replacement, which is usually done with crystalloids such as lactated Ringer's solution in normal 0.
Recent studies suggest that to keep intravascular volume and colloid oncotic pressure within physiological ranges [ 9 ], hydroxyethyl starch can also be applied in case of a negative effect on the renal graft function [ 11 ].
However, it must be kept in mind that low oncotic pressure and hypoalbuminemia can Stephan ouaknine wife sexual dysfunction pulmonary edema [ 1213 ]. Fluid-resistant hypotension can be treated using continuous intravenous dopamine receptor agonists, which should be titrated until a mean arterial pressure of 80 to mmHg is reached [ 16 ]. In maternal BD, special attention needs to be paid to mechanical ventilation. To facilitate the elimination of carbon dioxide from the fetus and Stephan ouaknine wife sexual dysfunction a result of the progesterone effect on the respiratory center, the pregnant mother develops hypocarbia mediated by an increase in tidal volume and respiratory rate.
Hypocarbia is compensated by an increase in excretion of bicarbonates by the kidneys [ 17 ]. Seventy-eight percent of brain-dead patients who were kept alive for more than a few days developed central diabetes insipidus DI resulting from posterior pituitary gland failure [ 19 ]. Administration of vasopressin and aggressive volume replacement should be performed for the treatment of DI [ 4 ]. Kaplan, A. Steven Chughtai Bilal, Dunphy Claire, Lee Richard, Lee Daniel.
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