Abstract
Brain death is a concept used in situations in which life-support equipment obscures the conventional cardiopulmonary criteria of death, and it is legally recognized in most countries worldwide. Brain death during pregnancy is an occasional and tragic occurrence. The mother and fetus are two distinct organisms, and the death of the mother mandates consideration of the well-being of the fetus. Where maternal brain death occurs after the onset of fetal viability, the benefits of prolonging the pregnancy to allow further fetal maturation must be weighed against the risks of continued time in utero, and preparations must be made to facilitate urgent cesarean section and fetal resuscitation at short notice. Where the fetus is nonviable, one must consider whether continuation of maternal organ supportive measures in an attempt to attain fetal viability is appropriate, or whether it constitutes futile care. Although the gestational age of the fetus is central to resolving this issue, there is no clear upper physiological limit to the prolongation of somatic function after brain death. Furthermore, medical experience regarding prolonged somatic support is limited and can be considered experimental therapy. This article explores these issues by considering the concept of brain death and how it relates to somatic death. The current limits of fetal viability are then discussed. The complex ethical issues and the important variations in the legal context worldwide are considered. Finally, the likelihood of successfully sustaining maternal somatic function for prolonged periods and the medical and obstetric issues that are likely to arise are examined.
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Pallis C, Harley DH. From brain death to brainstem death. In: Pallis C, Harley DH, eds. ABC of brainstem death, 2 ed. London: BMJ, 1996:8–12.
Field DR, Gates EA, Creasy RK, et al. Maternal brain death during pregnancy. Medical and ethical issues. JAMA 1988;260:816–822.
Lane A, Westbrook A, Grady D, et al. Maternal brain death — medical, ethical and legal issues. Intens Care Med 2004;30:1484–1486.
Sheikh AA, Cusack DA. Maternal brain death, pregnancy and the foetus: the medico-legal implications for Ireland. Med Law 2004;23:237–250.
Feldman DM, Borgida AF, Rodis JF, Campbell WA. Irreversible maternal brain injury during pregnancy: a case report and review of the literature. Obstet Gynecol Surv 2000;55:708–714.
Finnerty JJ, Chisholm CA, Chapple H, et al. Cerebral arteriovenous malformation in pregnancy: presentation and neurologic, obstetric, and ethical significance. Am J Obstet Gynecol 1999;181:296–303.
Beca JP, Wells W, Rubio W. Maternal brain death during pregnancy. Rev Med Chil 1998;126:450–455.
Anstotz C. Should a brain-dead pregnant woman carry her child to full term? The case of the “Erlanger baby”. Bioethics 1993;7:340–350.
Powner DJ, Bernstein IM. Extended somatic support for pregnant women after brain death. Crit Care Med 2003;31:1241–1249.
Bosch X. Pregnancy of brain-dead mother to continue. Lancet 1999;354:2145.
Seibert S, Waldrop T, Marshall R. A matter of death and life. Where should German doctors draw the line? Newsweek 1992;120:55.
Ruling by a court keeps fetus alive. NY Times (print) 1986:7.
Colen BD. Ethics questions raised by pregnancy of comatose woman. Washington Post 1977:A3.
Guidelines for the determination of death. Report of the medical consultants on the diagnosis of death to the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. JAMA 1981;246:2184–2186.
Black PM. Brain death (first of two parts). N Engl J Med 1978;299:338–344.
Black PM. Brain death (second of two parts). N Engl J Med 1978;299:393–401.
Diagnosis of brain death. BMJ 1976;2:1187–1188.
Wijdicks EF. Brain death worldwide: accepted fact but no global consensus in diagnostic criteria. Neurology 2002;58:20–25.
Shewmon AD. The brain and somatic integration: insights into the standard biological rationale for equating “brain death” with death. J Med Philos 2001;26:457–478.
Shewmon DA. Spinal shock and brain death’: somatic pathophysiological equivalence and implications for the integrativeunity rationale. Spinal Cord 1999;37:313–324.
Veatch RM. Maternal brain death: an ethicist’s thoughts. JAMA 1982;248:1102–1103.
Shewmon DA. "Brainstem death," "brain death" and death: a critical re-evaluation of the purported equivalence. Issues Law Med 1998;14:125–145.
Pallis C, Harley DH. Prognostic significance of a dead brainstem. In: Pallis C, Harley DH, eds. ABC of brainstem death, 2 ed. London: BMJ, 1996:28–33.
Dillon WP, Lee RV, Tronolone MJ, et al. Life support and maternal death during pregnancy. JAMA 1982;248:1089–1091.
Slattery MM, Morrison JJ. Preterm delivery. Lancet 2002;360:1489–1497.
MacDonald H. Perinatal care at the threshold of viability. Pediatrics 2002;110:1024–1027.
Heikkinen JE, Rinne RI, Alahuhta SM et al. Life support for 10 weeks with successful fetal outcome after fatal maternal brain damage. Br Med J (Clin Res Ed) 1985;290:1237–1238.
Bernstein IM, Watson M, Simmons GM, et al. Maternal brain death and prolonged fetal survival. Obstet Gynecol 1989;74:434–437.
Vives A, Carmona F, Zabala E, et al. Maternal brain death during pregnancy. Int J Gynaecol Obstet 1996;52:67–69.
Catanzarite VA, Willms DC, Holdy KE, et al. Brain death during pregnancy: tocolytic therapy and aggressive maternal support on behalf of the fetus. Am J Perinatol 1997;14:431–434.
Iriye BK, Asrat T, Adashek JA, Carr MH. Intraventricular haemorrhage and maternal brain death associated with antepartum cocaine abuse. Br J Obstet Gynaecol 1995;102:68–69.
Lewis DD, Vidovich RR. Organ recovery following childbirth by abrain-dead mother: a case report. J Transpl Coord 1997;7:103–105.
Spike J. Brain death, pregnancy, and posthumous motherhood. J Clin Ethics 1999;10:57–65.
Nettina M, Santos E, Ascioti KJ, Barber MA. Sheila’s death created many rings of life. Nursing 1993;23:44–48.
Wuermeling HB. Brain-death and pregnancy. Forensic Sci Int 1994;69:243–245.
Yogev Y, Ben-Haroush A, Chen R, Kaplan B. Intra-uterine fetal brain death: report of two cases and review of the literature. Eur J Obstet Gynecol Reprod Biol 2002;105:36–38.
Jennett B, Hessett C. Brain death in Britain as reflected in renal donors. Br Med J (Clin Res Ed) 1981;283:359–562.
Hung TP, Chen ST. Prognosis of deeply comatose patients on ventilators. J Neurol Neurosurg Psychiatry 1995;58:75–80.
Jorgensen EO. Spinal man after brain death. The unilateral extension-pronation reflex of the upper limb as an indication of brain death. Acta Neurochir (Wien) 1973;28:259–273.
Jennett B, Gleave J, Wilson P. Brain death in three neurosurgical units. Br Med J (Clin Res Ed) 1981;282:533–539.
Shewmon DA. Chronic "brain death": meta-analysis and conceptual consequences. Neurology 1998;51:1538–1545.
Loewy EH. The pregnant brain dead and the fetus: must we always try to wrest life from death? Am J Obstet Gynecol 1987;157:1097–1101.
Sheikh AA, Cusack DA. Maternal brain death, pregnancy and the foetus: the medicolegal implications. Med Leg J Irel 2001;7:75–85.
Korzeniowski OM. Antibacterial agents in pregnancy. Infect Dis Clin North Am 1995;9:639–651.
Einarson A, Shuhaiber S, Koren G. Effects of antibacterials on the unborn child: what is known and how should this influence prescribing. Paediatr Drugs 2001;3:803–816.
Christensen B. Which antibiotics are appropriate for treating bacteriuria in pregnancy? J Antimicrob Chemother 2000;46(Suppl 1):29–34; discussion 63–65.
King CT, Rogers PD, Cleary JD, Chapman SW. Antifungal therapy during pregnancy. Clin Infect Dis 1998;27:1151–1160.
Czeizel AE, Rockenbauer M. A lower rate of preterm birth after clotrimazole therapy during pregnancy. Paediatr Perinat Epidemiol 1999;13:58–64.
Iwai A, Sakano T, Uenishi M, et al. Effects of vasopressin and catecholamines on the maintenance of circulatory stability in braindead patients. Transplantation 1989;48:613–617.
Hauksson A, Akerlund M, Melin P. Uterine blood flow and myometrial activity at menstruation, and the action of vasopressin and a synthetic antagonist. Br J Obstet Gynaecol 1988;95:898–904.
Koren G, Pastuszak A, Ito S. Drugs in pregnancy. N Engl J Med 1998;338:1128–1137.
Laffey JG, Kavanagh BP. Hypocapnia. N Engl J Med 2002;347:43–53.
Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery. Obstet Gynecol 1986;68:571–576.
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Farragher, R.A., Laffey, J.G. Maternal brain death and somatic support. Neurocrit Care 3, 99–106 (2005). https://doi.org/10.1385/NCC:3:2:099
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DOI: https://doi.org/10.1385/NCC:3:2:099