A new case report describes how a brain-dead woman was able to carry a fetus almost to term before the healthy baby was eventually delivered by cesarean section. Though similar incidents are rare, a recent systematic review uncovered 35 examples of pregnant women becoming brain-dead, 27 of which ended with a live birth, including three vaginal deliveries.
Describing the latest case, researchers from the University of Florida explain that the 31-year-old woman was 22 weeks pregnant when she presented to a clinic with a severe headache. Soon afterwards, she experienced “seizure-like activity,” before becoming unresponsive.
“Scan findings met the nuclear medicine criteria for ‘brain death’ and the patient was declared dead on the day of admission,” write the study authors. Further analyses revealed that the woman had suffered a bleed on the brain.
“After a multidisciplinary meeting with neurointensivists, neonatal ICU specialists, obstetricians, as well as legal, ethics, and social worker teams, the patient’s family expressed the desire to maintain the pregnancy and bring the fetus to viability by continuing somatic support of the patient,” say the researchers.
Unsurprisingly, keeping the baby alive was not easy and required extensive medical intervention. Aside from placing the brain-dead mother on a ventilator and inserting a nasogastric feeding tube, doctors also had to regulate her thyroxine levels and blood pressure, while blood thinners were administered to prevent clots from forming.
The patient also suffered from numerous infections, resulting in pneumonia and other complications. Various medications, including antibiotics, were therefore given to protect the fetus.
After a further 11 weeks, surgeons performed a cesarean, delivering the baby at 33 weeks of gestation. “The infant did well after delivery and did not require resuscitation,” write the authors.
“She was brought to the neonatal intensive care unit for admission secondary to her gestational age. She was discharged home after five days,” they continue. At this point, the mother’s life support was terminated.
Though extremely rare, such cases are not unheard-of. According to the aforementioned review, around two-thirds of women who become brain-dead during pregnancy suffer a bleed on or around the brain.
Of the 35 patients identified by the study, 69 percent required treatment for infections such as pneumonia or sepsis, while 63 percent developed circulatory instability and 56 percent suffered from diabetes insipidus. Overall, gestational age at time of diagnosis of brain death was the biggest predictor of the outcome, with only 50 percent of those who became comatose before 14 weeks pregnant going on to have live babies.
In contrast, live births were reported in 100 percent of cases in which a pregnant woman became brain-dead after 24 weeks of gestation. Overall, the study authors found that eight of the 35 fetuses died in utero while the remaining 27 were carried to term.
Of these, two died shortly after birth and two more were left with severe neurological complications, though 23 appeared healthy at long-term follow-up. Unsurprisingly, the vast majority of births were by cesarean, although two of the brain-dead women had vaginal deliveries after going into spontaneous labor while one more had an induced vaginal birth.
Despite these surprisingly successful stats, the authors of the new case report speculate that survival rates may be inflated due to “publication bias”. In other words, brain death during pregnancy may be more common than the review suggests, yet cases with negative outcomes may not be reported.
