Asignaturas del Tercer Curso

1. Brain injury in a pregnant woman most commonly results from either trauma or intracranial abnormalities such as an aneurysm that ruptures, causing hemorrhage or stroke. These casualties may lead to maternal brain death.

2. Brain death implies absolute and incontrovertible cessation of total brain function, including brain stem function. Supportive interventions are mandatory if somatic functions are to be preserved, in particular ventilation and circulation. A pregnant woman who has been diagnosed as brain dead is considered dead, and somatic support is justified only to design appropriate strategies for the sake of the fetus, if it is expected to be generally normal at birth and free from severely disabling physical and/or mental handicap.

3. Pregnancy adds considerable complexity to these rare conditions. Maternal supportive care may last as long as 15 weeks, far longer than the hours or days required for supportive care for organ donation. Once continuation of pregnancy has been decided after maternal brain death, systemic vital functions must be actively supported to maintain a maternal milieu as close as possible to the physiological state of pregnancy. The justification of such a perilous endeavour is not only to allow the woman to give birth to a viable neonate, but also to secure the neonate’s own brain integrity. 4. Neurogenic maternal pulmonary consequences may occur, requiring

positive end-respiratory pressure and high concentration of inspired oxygen whose prolonged effect on the fetus is unknown. Hypotension develops in the vast majority of brain dead patients

requiring vasopressors which may cause dramatic decrease in placental perfusion.

5. Loss of central thermoregulation may lead to either hyperthermia or hypothermia, which are potential causes of fetal death or severe fetal growth retardation. Total parenteral nutrition through a subclavian line, required to ensure adequate caloric supply and normal fetal growth, may risk maternal sepsis. All of these may have deleterious effects on fetal growth and survival.

6. The decision about whether attempts to maintain pregnancy are likely to be successful depends first on the gestational age of the fetus. For brain death in early pregnancy, supportive care may lead to the birth of a desperately premature neonate. However, starting at 12–14 weeks of gestation, fetal survival has been successfully prolonged for 15 weeks, bringing the fetus beyond the threshold of viability. 7. During pregnancy, medical care may suddenly fail to support organ

survival, for instance because of an irremediable cardiovascular instability. Pregnancy must then be interrupted, entailing the questions of potential fetal damage and the justification of an emergency delivery.

8. Pregnant brain dead women are diversely perceived by medical care givers as pregnant patients, terminally ill patients, dead persons, cadavers, or cadaveric incubators. They are not out of range of any harm or wrong, such as indignity, that could, consciously or unconsciously, be inflicted on them.

9. Just after delivery, brain dead women are disconnected from life support. Dying is a continuous process that culminates in brain and body function death. When life functions are artificially maintained by supportive care, death of individual persons can precede their physical dying. Prevented from dying, the brain-dead pregnant woman is not supported for her own good, but for the sake of someone else, her fetus. Therefore, her body is at risk of being used as a means to an end, as an object, or as an instrument.

10. For brain death during pregnancy, advance directives concerning the future of the fetus are rarely available, and a substitute has to decide according to their best understanding of the likely decision the brain-

dead person would have made. In the absence of an appointed substitute decision-maker, the person thought to be the most relevant substitute is a next of kin; that is, the spouse or the companion, an adult child, one or both parents, or other relative. Only when the choice of a substitute among the relatives seems insoluble, e.g. the father of the child is neither the spouse nor the companion, or when substitutes of equal standing disagree concerning the prolongation of pregnancy, a court may be asked to decide, or a guardian may be legally appointed to be a substitute decision maker for the woman. 11. The cost of maintaining a brain dead pregnant woman in order to deliver a child is expensive, and availability and proper allocation of resources may be questioned. Public and private health insurance plans do not usually cover services after death is determined.

Recommendations

1. Women have the right to die in dignity. The goal of fetal rescue does not exonerate health care givers from the duty to respect this right of the primary patient, the woman.

2. Questions regarding maintaining pregnancy must be answered in consultation with the remaining family. In the absence of any expressed wish of the woman, her preference for the future of her fetus, to be kept alive or not, must be discussed. A substitute must act in the interests of the woman’s respectful treatment.

3. When brain-death occurs during pregnancy, whether or not to deliver the fetus must be decided in light of fetal viability. As long as the maternal condition is stable, all efforts should be made to prolong pregnancy and improve fetal maturity, provided proper fetal evaluation has ensured that no irremediable damage has occurred to the fetus at the time of maternal brain death. Appropriate surveillance of fetal well being should be implemented.

4. No mandatory lower gestational age limit should be set for the onset of fetal rescue after maternal brain death.

5. After maternal wishes and best interests are considered, the best interests of the fetus must also be considered, even where the fetus is in law not yet a person. Among the issues to be considered are: the

viability of the fetus and its probable health status before and after birth. All reasonable efforts should be made to promote the birth of an adequately mature, brain-intact neonate.

6. Allowing the fetus to die naturally in utero is appropriate if an irremediable maternal complication or acute fetal distress calls for an immediate delivery that carries the likely prospect of a severely compromised outcome. For the sake of a pregnant braindead woman and her fetus, it is advisable not always to strive to achieve conspicuous technical performance, nor always to try to wrest life from death.

Goa, March 2011

ETHICAL ASPECTS REGARDING CAESAREAN DELIVERY