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Maternal Brain Death During PregnancyMedical and Ethical Issues

David R. Field, MD; Elena A. Gates, MD; Robert K. Creasy, MD;

Albert R. Jonsen, PhD; Russell K. Laros, Jr, MD

We present in detail a case of a 27-year-old primigravida who was maintained ina brain-dead state for nine weeks. An apparently normal and healthy male infantweighing 1440 g was delivered. The newborn did well and was found to begrowing and developing normally at 18 months of age. Although the technicalaspects of prolonged life support are demanding and the economic costs arevery high ($217 784), there are ample ethical arguments justifying the separa-tion of brain death and somatic death and the maintenance of the brain-deadmother so that her unborn fetus can develop and mature.

(JAMA 1988;260:816-822)

BRAIN death, the unequivocal and irreversible loss of total brain function, isa concept used to determine when deathhas occurred in cases in which life-support equipment obscures the conventional cardiopulmonary criteria ofdeath.1,2 This concept has gained wideacceptance in the medical and legal communities, and most states have passedbrain-death statutes specifying the criteria needed to make the diagnosis ofbrain death and equating that diagnosiswith the pronouncement of death.2Despite meticulous supportive care,

brain death is usually followed by cardiovascular collapse within a few daysand, once such a diagnosis is made, it

is generally considered unethical tosquander costly medical resources bycontinuing to support vital functionsusing artificial means.

Maternal brain death during pregnancy is one instance in which prolongedmaintenance of the mother's vital functions might be justified for the sakeof the fetus. Tb our knowledge, Dillonet al3 reported the first case in whichprolonged support of a brain-deadmother resulted in the birth of an infantwho survived. Though they suggestedguidelines for the treatment of these

patients, the decision of whetherto

continue maximum supportive care in theserare and tragic cases remains a controversial one.4

Fundamental to this controversy areethical and economic issues as well asunanswered questions concerning thephysiologic consequences to both themother and fetus of prolonged supportof the organ systems most prone to failure after brain death. We will examinethese issues and questions using as aframework for our discussion the case

report of a woman who delivered a sur-

viving infant 63 days after the diagnosisof brain death was made.

REPORT OF A CASE

On Jan 25,1983, a previously healthy27-year-old grvida 1, para 0 womanpresented to her local hospital at 22weeks' gestation with a five-day historyof worsening headaches followed byseveral hours of vomiting and disorientation. Results of physical examinationwere consistent with a 22-week

gestation and were otherwise unremarkable;normal vital signs and no focal neurologic deficits were noted. Results of alumbar puncture were normal exceptfora slightly elevated opening pressureof 20 cm of water and the presence offour segmented neutrophils per cubicmillimeter of cerebrospinal fluid. Fourhours after presentation, the patienthad a generalized seizure and a respiratory arrest.

After cardiopulmonary resuscitation,ventilatory support was continued inthe intensive care unit, where examination

revealedno

responseto

painfulstimuli, fixed and dilated pupils, papil-ledema, and absent doll's eye movements. A computed tomographic scan ofthe head showed marked dilatation ofthe lateral and third ventricles with amass obstructing the fourth ventricle.A ventriculostomy was placed andrevealed clear cerebrospinal fluid thathad an opening pressure of 50 cm ofwater. Dexamethasone sodium phosphate and mannitol were given, but theelectroencephalogram was again iso-electric two days later. There was no

From the Department of Obstetrics, Gynecology, andReproductive Sciences (Drs Field, Gates, Creasy, andLaros) and the Division of Ethics in Medicine (Dr Jon-sen), University of California, San Francisco. Dr Field isnow with the Department of Obstetrics and Gynecolo-gy, Naval Hospital, Oakland, Calif. Dr Creasy is nowwith the Department of Obstetrics and Gynecology,University of Texas, Houston. Dr Jonsen is now with theDepartment of Medical Ethics, University of Washing-ton, Seattle.

Reprint requests to Department of Obstetrics, Gyne-cology, and Reproductive Sciences, M-1485, Universi-ty of California, San Francisco, CA 94143-0132 (DrLaros).

by guest on October 14, 2010www.jama.comDownloaded from
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change in the patient's condition, and adiagnosis of brain death was made atthat time, using the Harvard criteria.5During this period the fetal heart ratepattern remained normal. In accordance with the strongly expressedwishes of the father, a decision wasmade to provide cardiorespiratory support to the mother in an attempt tomaintain the fetus in utero until it

reached a viable gestational age.Bilateral patchy pulmonary infiltrates consistent with the adult respiratory distress syndrome (ARDS) soonappeared roentgenographically. Diabetes insipidus developed, and injectionsof vasopressin were required to controlthe massive diuresis and hypernatre-mia. Trimethoprim and sulfamethoxa-zole were given to treat a Klebsiellaurinary tract infection. Total parenteralnutrition (TPN) was begun, providing6300 kJ/d, and 2 U of packed red bloodcells was transfused. The patient wastransferred to Moffitt Hospital at the

University of California at San Francisco (UCSF) on the 14th day of herhospitalization, at 24 weeks' gestation.

On admission at UCSF, the patienthadatemperatureof38.9C, and resultsof the neurologic examination were consistent with the diagnosis of braindeath. The uterine fundus measured 23cm, and a sonogram revealed a vigorousfetus with anthropomtrie criteria consistent with 24 weeks' gestation. Fullventilatory support was continued andmodulated on the basis of frequent arterial blood gas determinations. Maximum effort was directed at

treatingthe

severe hypotension, temperature fluctuations, diabetes insipidus, hypothy-roidism, and cortisol deficiency thatwere thought to be the result of loss ofthe autoregulatory function of thebrain. The hypotension responded toplasma expanders and a combination ofvasopressors. Heating and cooling blankets stabilized the patient's temperature. A vasopressin infusion alleviatedthe signs of diabetes insipidus, and boththyroxine and cortisol were administered in normal replacement doses.

A trial of nasogastric feedings failed.

Therefore,TPN was

restarted andmaintained at a rate that supplied 9500kJ/d. Hyperglycemia developed andwas treated with a continuous insulininfusion. Nutritional assessments revealed that the patient had a positivenitrogen balance, and the serum albumin concentration rose from 362 to 449u.mol/L during the hospitalization.Fetal heart tones were monitored everyshift, and serial obstetric sonogramswere performed. After 26 weeks of gestation, weekly betamethasone sodiumphosphate injections (12 mg every 12

hours for two doses) were given, andnonstress tests were performed twice aweek.

On the 28th day of hospitalization,enterococcal bacteremia developed; thiswas initially treated with ampicillin sodium and gentamicin sulfate. This regimen was changed to piperacillin sodiumafter the sensitivity results were reported, and the bacteremia resolved. A

Staphylococcus aureus bacteremia developed on the 58th day of hospitalization and was treated with nafcillin sodium. During the course of thattreatment, a repeated sonogramshowed no evidence of fetal growth overthe previous two weeks. Because of thesuspected intrauterine fetal growth retardation and recurrent septicemia, adecision was made to deliver the fetusby cesarean section on the 63rd hospitalday at 31 weeks' gestation. A 1440-gmale infant with Apgar scores of8 at oneand five minutes was delivered onMarch 29, 1983. Maternal ventilatorysupport was discontinued postopera-tively, and cardiac activity ceasedshortly thereafter. The autopsy revealed holonecrosis of the brain thatobliterated the histologie findings andprevented a tissue diagnosis. Theautopsy also showed bilateral broncho-pneumonia, congestive hepatomegalywith mild fatty change, and bilateralpyelonephritis.

The infant was cared for in the neonatal intensive care unit, where mild respiratory distress syndrome developed.However, he generally did well and wastransferred to a

hospitalnearer his

home at 3 weeks of age. On follow-upexamination at 18 months of age, he wasfound to be growing and developingnormally.COMMENT

Brain death can be diagnosed usingseveral sets of guidelines'2,M that havein common the documentation of absolute and incontrovertible cessation oftotal brain function. Brain death is thusclearly delineated from other states ofprofoundly impaired brain function inwhich supportive care to preserve vital

functions is also required. The mostsevere of these other conditions, variously called cerebral death,'1 persistentvegetative state,9 or the apallic syndrome,10 is characterized by the functional loss of the cerebral hemisphereswith retention of at least some brain-stem function. This residual brain-stemfunction allows patients to sometimessurvive for years. Brain death, in whichthe entire brain is destroyed as surely asif decapitation had occurred, is distinctly different from cerebral death.The preservation of vital functions,

even with the most intensive care, issaid to never last for more than 14 daysafter brain death. "

Somatic survival after brain death isnot a natural event. It represents theculmination of impressive advances inmedical knowledge, skills, and technology applied to life-support strategies incritical care medicine. The use of suchresources on a person already declared

dead, however, has previously beenadvocated only for relatively short periods to preserve viable organs for transplantation. 12 " The longer-term sequelaeof such support are unknown. Nevertheless, several reviews have examinedthe fate of patients receiving maximumsupportive care who retrospectively fitthe criteria of brain death. These surveys conclude that cardiopulmonaryrespiratory function can, on average, bemaintained for only a few days afterbrain death.7,11,1616 In their series of over1200 brain-dead patients, Jennett andHessett" were unable to find a singlecase of brain death with cardiac survivalbeyond 14 days, but cases of more prolonged somatic survival have subsequently been reported.3,17,18 It is possiblethat this lack of prolonged somatic survival is due as much to the prognosticfutility of maintaining cardiorespira-tory support in a brain-dead patient as itis to any inherent technical difficulty inmaintaining such support.

Brain death complicating pregnancyis one instance in which prolongedmaternal cardiorespiratory supportmight be justified for the sake of thefetus. As far as we

know,ours is the

second reported case in which this support was undertaken with successfulneonatal results and represents by farthe longest time a mother has receivedsuch support. Dillon et al3 reported twocases of pregnancy complicated bymaternal brain death. In their first casethe mother was at 18 weeks' gestation,and although the procedures for documenting brain death were not fully carried out, the authors decided to stop lifesupport. In their second case, braindeath was diagnosed at 25 weeks' gestation, and the maternal vital functionswere

maintained forseven

days, untilmaternal hypotension associated withvariable fetal heart rate decelerationsprompted the delivery of a surviving930-g infant.

Dillon et al3 suggested a managementplan for these patients based on the neonatal survival statistics in their nursery,19 economic considerations, and thelack of evidence that support could prolong somatic life for more than a coupleof weeks after brain death. They recommended that when maternal brain deathoccurs before 24 weeks' gestation, no



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Suggested Measures for Physiologic Support inPregnancy Complicated by Maternal Brain Death

Mechanical ventilation with ventilator with volumepreset.

Start with a tidal volume of 10 to 15 mlVkg,respirations of 10/min to 12/min, and a fractionof inspired oxygen (Fio2) of 1.0. Makesubsequent ventilator adjustments on the basisof arterial blood gas determinations.

Decrease the Fio2 to


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heart cadaver" can be maintained formonths.

Experience with cardiac and renaltransplant donors has demonstratedthat hypotension, requiring treatmentwith pressor agents, develops in thevast majority of brain-dead patients.12,13The problem of hypotension is particularly important in pregnant womenbecause the uterine vasculature is not

an autoregulated system, and maternalhypotension severely decreases theuteroplacental blood flow.27 The development of diabetes insipidus, with itsattendant intravascular volume contraction, can complicate the differentiation between hypovolemia and the lossof central autoregulation as the cause ofthe hypotension. We therefore recommend the determination of centralvenous pressures as an important aid inthe management of the fluid status. Ifpulmonary edema develops, we strongly recommend that a Swan-Ganz catheter be used to differentiate cardiogenicpulmonary edema from ARDS and toguide fluid therapy. Once fluid-resistant hypotension is documented,the hypotension should be aggressivelytreated pharmacologically. The use ofvasopressors requires that an arterialline be inserted to continuously monitorblood pressure.

Because of its unique pharmacologieproperties, low-dose dopamine hydro-chloride was chosen as the initial agentfor treating the hypotension seen in ourpatient. In low doses, dopamine has aweak betamimetic effect on the heart,

increasing contractilityand the heart

rate without increasing myocardial oxygen consumption disproportionately.It also stimulates dopaminergic receptors in the renal, mesenteric, and coronary vasculature, causing vasodilatation. Unlike pure beta-stimulants,dopamine causes vasoconstriction ofskeletal muscle, so while its net effect isto elevate blood pressure, the renal andsplanchnic blood flows are preserved.28These actions of dopamine, however,are dose dependent. In dosages exceeding 15 to 20 |xg/kg/min, the principaleffect is on alpha-receptors, resulting in

generalizedvasoconstriction and de

creased uteroplacental perfusion. Dopamine, therefore, needs to be administered by continuous intravenousinfusion starting at 2 to 5 p-g/kg/min andtitrating upward to achieve the desiredhemodynamic effect. If that effect isnot seen by the time infusion rates approach 12 to 15 p,g/kg/min, we recommend adding dobutamine hydrochloride(Table).

Dobutamine is a sympathomimeticamine that has major cardiac ^adren-ergic activity along with minor z- and

ct-adrenergic activity. Like dopamine,it should be given by intravenous infusion, and it also appears to have a bipha-sic effect on peripheral blood vessels atlow dosages (ie, 5 p,g/kg/min), causingsome increase in tone, while higher dosages (ie, 30 p,g/kg/min) induce muscularrelaxation.29 Dobutamine's ability toimprove ventricular contractility without markedly increasing the heart rateor dilating resistance vessels suggeststhat in low doses it is a useful adjunctivemeasure for the control of hypotensionin this setting.

Endocrine problems caused by thedevelopment of panhypopituitarismcontributed to the hypotension in ourpatient. The most prominent of thesewas diabetes insipidus, a condition thatdevelops in the majority of brain-deadpatients who are kept alive for morethan a few days.30 In this condition, massive polyuria and the resultant hyperna-tremia can generally be controlled bygiving vasopressin either intramuscularly or by intravenous infusion and byusing pulmonary artery and wedgepressures to guide fluid replacement.12Hypotension is also associated with secondary adrenocortical insufficiency,which should be anticipated in these patients and treated with replacementdoses of corticosteroids if it is found.Finally, the mother should always bekept in a lateral or lateral tilting positionto avoid the detrimental supine hypo-tensive effects of uterine aortocavalcompression. The importance of this isemphasized by a case report of maternalsurvival after

"postmortem"cesarean

section emptied the uterus and allowedeffective blood flow to return.31 Hypotension was effectively treated in ourpatient by the use of fluid resuscitation, invasive hemodynamic monitoring, aggressive pharmacologie support,hormonal replacement therapy, andoptimal maternal positioning, and themean arterial pressures were maintained in a range that is believedto ensure optimal uteroplacentalperfusion.

Temperature Liability

Because of the loss of the hypothal-amic thermoregulatory mechanism, thenormal diurnal fluctuations ofbody temperature are characteristically absentin brain death, and the body temperature tends to follow that of the environment. Jorgensen32 found that this poiki-lothermia was a constant finding whensomatic survival was maintained formore than 24 hours. Although a minority of his patients demonstrated initialhyperthermia, all had final asystolewithin 24 hours. Thus, hypothermiaseems to be the predominant manifesta-

tion of the loss of thermorgulation inbrain-dead patients with prolongedsomatic survival unless specific stepsare taken to prevent it.

Prolonged maternal hypothermia isnot a situation often encountered in clinical practice, and its effect on the fetus isunknown. The fetus normally dependson passive thermorgulation by heatexchange with the mother's blood at the

intervillus space. Our knowledge concerning the degree of active thermorgulation in the fetus is limited. Gluckmanet al33 showed that the fetal lamb responds to cooling with shivering andthat cooling cutaneous thermoreceptorson the fetus can alter fetal electrocorti-cal activity and breathing patterns.This suggests that cooling is a deleterious state, since fetal energy is directedaway from the primary process ofgrowth and development during hypothermia. We therefore recommend vigilance in maintaining a normal maternaltemperatureby using warming blanketsandwarm,inspired,humidified air.Though it was rarely seen during prolonged support after brain death, ourpatient also had periods of hyperther-mia. After an infectious process hadbeen ruled out, we believed that thishyperthermia was a further reflectionof poikilothermia, since our patient hadan autonomous internal heat generator,the metabolically active fetus. The deleterious effects of prolonged maternalhyperthermia on the fetus have beensuggested by previous studies,34,36 andwe recommend the use of cooling blankets as needed to maintain the maternalcore temperature in the normal range.

Nutritional SupportOur patient had no intrinsic gastroin

testinal pathologic findings and was in astate of good nutritional balance beforeher intracranial catastrophe. Sincebowel sounds were present when shewas admitted to our unit, enterai tubefeedings were begun with the aim ofproviding 10100 kJ/d. Sampson andPeterson36 had previously reported thecase of a pregnant patient in a posttrau-matic vegetative state who was given

nasogastric feedings forseven

monthsbefore she delivered an adequatelygrown infant after 33 weeks of gestation. Smith et al87 also reported theirsuccessful experience with the use oflong-term enterai hyperalimentation intwo pregnant diabetics with hypereme-sis gravidarum. In our patient, however, the plan to provide enterai nutrition through a nasogastric tube wasthwarted due to the poor motility of hergastrointestinal tract. This poor motility was reflected by largegastric residuals and reflux rgurgitation even



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though the feeding tube was passedthrough the pylorus into the duodenum.Therefore, TPN was initiated through asubclavian vein.

There have been a number of reportsof the use of TPN during pregnanciescomplicated by a variety of disorders.3"2 The use of TPN during pregnancy has been shown to be beneficialaccording to the criteria of maintenanceof a positive nitrogen balance, maternalweight gain, and normal fetal growth asreflected by sonographic measurementsand birth weight.41 However, there aremajor risks associated with TPN,including hyperglycemia, sepsis, andcomplications resulting from placementof a central line. Hyperglycemia is acommon complication in any patientreceiving TPN, but it seems especiallylikely to occur when TPN is given during pregnancy, a condition that is itselfinherently diabetogenic. If it is not controlled, maternal hyperglycemia stimulates fetal insulin production and resultsin increased fetal fat storage. A syndrome similar to that seen in the infantsof diabetic mothers could then develop.Therefore, when maternal hyperglycemia appears during TPN, we recommend aggressive treatment with continuous insulin infusion to maintaineuglycemia.

We calculated the patient's energyneeds to be 9500 kJ/d based on the recommendation of 130 to 150 kJ/kg/d forideal body weight.43 This daily energywas given in the form of a fat emulsion(2100 kJ), 100 g of protein (1700 kJ), anda 20%

dextrosesolution that

suppliedthe rest of the calculated energyrequirement. Heller,44 studying TPN inpregnant rats receiving 50% of theirenergy intake as fat, concluded thatthere is a risk of fatty infiltration of theplacenta if parenteral fat emulsions areused during pregnancy. However, thiscomplication has not been seen whencommercial fat emulsions are used clinically to supply up to 20% of the dailyenergy requirements during pregnancy. We therefore recommend thatmoderate amounts of fat emulsion beadded to the TPN solutions used during

pregnancy, not only to prevent maternal essential fatty acid deficiency butalso to provide linoleic acid for the fetus.When this regimen was used, ourpatient's nutritional status was judgedto be adequate on the basis of positivenitrogen balance tests, a 16-kg weightgain, and a rise in her serum albuminconcentration to levels normal for

pregnancy.

Miscellaneous Medical Problems

In addition to diabetes insipidus andsecondary adrenal insufficiency, the

patient's panhypopituitarism was evidenced by secondary hypothyroidismthat required physiologic replacementdoses of levothyroxine. Perfusion of thekidneys was maintained by the aggressive treatment of hypotension,and renal function remained normal throughout the patient's course.Because of the increased risk of thrombosis associated with prolonged bedrest in the absence of any muscle tone,prophylactic heparin sodium was givensubcutaneously in doses of 5000 U every12 hours.

Intensive infection-control precautions were an integral part of thepatient's care. She remained continuously at high risk for septicemia becauseshe was receiving mechanical ventila-tory support, was receiving TPN, andhad a Swan-Ganz catheter as well as a

urinary catheter and an arterial line inplace. Since she had lost the ability todemonstrate many of the signs of infection because of her poikilothermy andhypotensive state, infection surveillance consisted of maintaining a constant high index of suspicion and utilizing frequent blood, urine, and sputumcultures as a screen for pathogenic organisms. Bladder and respiratory colonizations were aggressively treated.Great care was exercised in maintainingstrict asepsis in handling the intravenous lines, and these lines were changedregularly. Finally, the importance ofexpert, dedicated nursing care in theoverall management of this state cannotbe overemphasized.

Obstetric StrategiesOur premise was that by artificially

supporting the maternal vital functionswe could maintain an intrauterine environment that was at least adequate toallow the fetus to develop in utero untilit had reached a gestational age compatible with a chance of extrauterine survival. At UCSF, 28 weeks' gestation isassociated with a greater than 80%chance of neonatal survival. The attainment of this gestational age was ourinitial goal. However, the care of a 28-week-old neonate in the intensive care

nursery is itselfa

costly and precariousproposition that becomes less so witheach subsequent week of gestation.46We therefore decided to prolong maternal life support until 34 weeks of gestation as long as there were no indicationsof deterioration in the condition of themother or the fetus. This strategy is atodds with the guidelines proposed byDillon et al.3

It is always difficult for the obstetrician to determine the gestational age atwhich it becomes reasonable to intervene for the sake of the fetus. Usually,

the fetal benefits, measured in thechance for good-quality survival, mustbe weighed against the risks to themother of operative delivery. Since apostmortem cesarean section entailedno additional risk to the mother, at 26weeks' gestation we were prepared tointervene for the sake of the fetus ifthere was any significant deteriorationin the mother's physiologic meausures.

As others have recommended, deliverywas to be by classic cesarean section toprovide the most expeditious and leasttraumatic birth for the fetus.46 A surgical kit was kept at the patient's bedside, and standing orders were madeto increase the mother's fraction ofinspired oxygen to 100% at the firstsign of acute maternal deterioration.Informed consent was obtained fromthe father, who was in complete agreement with this plan.

Our primary means of providing themost beneficial intrauterine environment for the fetus was to ensure that the

maternal physiologic measures were asclose to normal as possible. However, itwould be naive to presume that wecould, even with our sophisticated supportive and monitoring techniques,maintain an intrauterine environmentas conducive to fetal growth and development as the one present in an otherwise healthy grvida. Because ofthis, at 27 weeks of gestation, we instituted the same strategy of aggressivefetal surveillance that we would use in

any extremely high-risk pregnancy.Although the usefulness of antepartumfetal heart rate

monitoringat that ges

tational age has been questioned, thereis evidence that it is predictablebetween 27 and 30 weeks' gestation.47We therefore used a regimen ofnonstress tests twice weekly with oxy-tocin challenge tests reserved for use ifthe nonstress test results were suspicious or nonreactive. Ultrasound examinations were performed every twoweeks to document adequate fetalgrowth. It was, finally, the lack ofsonographically detected fetal growthduring the last two weeks of the pregnancy, coupled with recurrent maternal

sepsis, that promptedus to deliver the

infant.

Ethical Considerations

In the last two decades, the traditional cardiopulmonary signs that indicated death have been supplemented bysigns of the loss of brain activity. Thischange was made necessary by theintroduction of techniques of respiratory support that could mask the traditional signs of the onset of death. Also,the introduction of renal and cardiactransplantation stimulated interest in a



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means of determining death that couldallow organs to be removed from a stilloxygenated but legally dead body. Criteria for this new definition of deathwere first issued by a committee of theHarvard Medical School, Boston.6 In1981, the President's Commission forthe Study of Ethical Problems in Medicine and Biomdical and BehavioralResearch48 recommended a uniform

statute that has now been adopted bymost American jurisdictions:An individual who has sustained either: (1)irreversible cessation of circulatory and respiratory function or (2) irreversible cessationof all functions of the entire brain, includingthe brain stem, is dead. A determination ofdeath must be made in accordance withaccepted medical standards.

It is now possible to separate physically and temporally the death of theentire organism and the "death" of thebrain.49 A delay of extubation in a personjudged to be dead by brain criteria canbe justified for compassionate reasons,such as the expected arrival of relatives,for the perfusion of organs to be transplanted, and for certain research purposes. Recently, another situation hasarisen because ofthe technical advancesreported in this article, namely, theability to support the vital activity of apregnant woman who is dead by braincriteria to allow her fetus to matureuntil a safe delivery is possible.

During the course ofprenatal care, anobstetrician's primary obligation to thepregnant patient is to support her biologic and mental well-being both for hersake and to

promotethe life and health

of her fetus. Increasingly, the fetus isconsidered a patient as well, by virtue ofthe fact that it is a developing humanwhose treatable conditions can beaffected by specific medical interventions. For the individual physician, thefetus becomes a potential patient whenits mother presents for prenatal care.

In recent years, a small medical,legal, and ethical literature hasappeared concerning the issues raisedby the maternal refusal of a procedureor regimen recommended for the welfare of her fetus.60"64 A series of judicial decisions

granting permissionfor

such interventions despite maternal refusal has stimulated interest in thisquestion.66 Despite the judicial readiness to intervene on behalf of the fetus,most authors argue that maternalautonomy should have ethical and legalpriority in all, or almost all, circumstances.6"8 This statement of theCommittee on Ethics of the AmericanCollege of Obstetricians and Gynecologists69 reflects this viewpoint:The use of judicial authority to implementtreatment regimens in order to protect the

fetus violates the pregnant woman'sautonomy. . . Resort to the courts is almostnever justified.

The substantive issues in this conflictbetween maternal and fetal "rights" donot seem relevant to the case ofmaintenance of a maternal cadaver to incubatea fetus to viability. Maternal autonomy,in the sense of the active preferences ofthe mother, ceases with her death. Her

actual permission or refusal is irrelevant because it is impossible to obtain.Although legal and ethical traditiondoes respect the previously expressedwishes of the decedent with regard toinheritance, disposition of remains, andtransplantation,60,61 this tradition wouldnot seem to override in importance theobligation to save an endangered fetallife. Even a maternal refusal expressedbefore death does not, in itself, carryweight against the possibility of fetalsurvival. The mother is not harmed; noright of hers is violated, and great goodcan be done for another. Thus, this caseseems to present a straightforwardinstance of the medical rescue of thefetus from death.

A long tradition of fetal rescue existsin Western society. Asklepios was "cutout alive from the womb of his deadmother by Apollo. "62 During the reign ofKing Numa Pompilius of Rome in theseventh century BC, the Lex Regia wasestablished, mandating the abdominaldelivery of a term fetus in the event ofthe death of its mother. Six hundredyears later, during the time of theRoman emperors, this became knownas the Lex

Cesrea,the

originationof

the term cesarean delivery.62 The discussion of postmortem cesarean delivery has been continued in the medicalliterature.63 Currently available technology has made postmortem somaticsupport of a mother possible to effectthe "rescue" of her very prematurefetus. Could the existence of this technology lead to the requirement that it beapplied in all cases of maternal death?

In traditional ethics, the obligation torescue an endangered life is serious butconditional. An evaluation of the risksand benefits attendant on the effort torescue

is required. Efforts torescue

should be carried out unless they exposethe rescuer to serious risk. In the case ofthe fetus after the death of its mother,however, the obligation to rescue wouldbe conditioned primarily on risks to therescued. The mother is now beyond benefit or harm. Decisions should be basedon the principles of nonmaleficence andbeneficence toward the fetus, or, moreproperly, toward the child who will beborn. These principles should be appliedby assessing the risk of death in uteroless a risk than a certainty, the risk of

premature delivery with attendantmorbidity and mortality, and the risk ofiatrogenic damage. These should beweighed against the expected benefit ofdelivery of a viable and healthy infant.We judge that it is ethically acceptableto strive to rescue the fetus if there is areasonable chance it will reach fetal

maturity.Once maternal support has been

elected, ongoing intrauterine fetalassessment may suggest a shift in thebalance of risk and benefit, leading to adecision to deliver before fetal maturityhas been achieved. For this reason, it isless clear whether the anticipated riskswould be justified in the case of a fetusthat is clearly quite remote from viability. In such a case, delivery beforematurity would seem likely. Certaindeath in utero or at immediate deliveryis exchanged for the potential risk oflong-term damage due to prematuredelivery or to the extraordinary careprovided the mother's body. Furtherexperience with cases such as the present one may provide evidence justifying intervention earlier in gestation.

Risks and benefits to the family and tosociety should also be considered,though they are unlikely to be decisive.Cost is a major concern, both to theindividual family and to society as awhole. In the present case, costs formaternal care totaled $183 081, and thecost of the neonatal care was $34 703.Maternal somatic support may be cost-efficient if weeks of neonatal intensivecare are prevented by the less costly

supportof a

cadaver.In

thecase of the

clearly previable fetus, however, such acost analysis would not provide justification. Societal risk also arises in thepossibility that a precedent may be setrequiring maternal somatic support inall cases, regardless of the individualconsiderations that have been outlined.Were this to occur, the best interests ofthe individual fetus might no longer bethe basis for decisions about maternalsupport.

It is important that the person bestable to speak for the interests of thefetus be in a position to make necessary

decisions about maternal somatic support. When decisions are required in thesetting of neonatal intensive care, parents are given fairly broad limits as tothe treatment they wish administeredto their children, because it is generallyassumed that they have their children'sbest interests in mind.64 Furthermore,the next of kin traditionally has theauthority to make decisions about thedisposition of the body after death. Thishas support in the American legal tradition through the Uniform AnatomicalGift Act.60 In the case presented here,



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the husband of the deceased is also thefather of the fetus and, thus, is theappropriate decision maker on bothaccounts. More complex cases havearisen in which the father of the fetuswas not the next of kin of the deceased(New York Times, July 26, 1986, p 7;San Francisco Examiner, July 13,1986, p Bl; San Francisco Examiner,June

22,1986,p

Bl;San Francisco Ex

aminer, June 19, 1986, p Bl). In thesecases, requests by the father for somaticsupport over the objection of a woman'snext of kin have been upheld by thecourts. In most cases, it is ethically ap-

propriate to respect the wishes of thefather in decisions about somatic support after maternal death.

CONCLUSION

A case of pregnancy complicated bymaternal brain death has been presented. To our knowledge, it is the second reported case in which prolongedsomatic

supportof the mother resulted

in the birth of a baby who survived, andit represents the longest period suchmaternal support has been maintained.The medical and ethical issues involvedwith the prolonged support of a "beating

heart cadaver" for purposes of nurturing the fetus have been examined. Thetechniques for fetal evaluation as well asthe factors involved in deciding when todeliver were discussed. However, justbecause a successful neonatal outcomecan be arrived at in a case such asthis does not mean that prolongedsomatic support ofthe mother should beundertaken. Rather than

proposingstrict guidelines, we believe that whenthese rare cases appear, the decisionof whether to proceed with prolongedcardiorespiratory support should bebased on the particulars of each case.

References

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