Intraventricular haemorrhage and maternal brain death associated with antepartum cocaine abuse

Brain death in pregnancy: a systematic review focusing on perinatal outcomes

OBJECTIVE

Brain death (BD) during pregnancy might justify in select cases maternal somatic support to obtain fetal viability and maximize perinatal outcome. This study is a systematic review of the literature on cases of brain death in pregnancy with attempt to prolong pregnancy to assess perinatal outcomes.

DATA SOURCES

We performed a systematic review of the literature using Ovid MEDLINE, Scopus, PubMed (including Cochrane database), and CINHAIL from inception to April 2020.

STUDY ELIGIBILITY CRITERIA

Relevant articles describing any case report of maternal brain death were identified from the aforementioned databases without any time, language, or study limitations. Studies were deemed eligible for inclusion if they described at least 1 case of maternal brain death.

METHODS

Only cases of brain death in pregnancy with maternal somatic support aimed at maximizing perinatal outcome were included. Maternal management strategy, diagnosis, clinical course, fetal monitoring, delivery, and fetal and neonatal outcome data were collected. Mean, range, standard deviation, and percentage calculations were used as applicable.

RESULTS

After exclusion, 35 cases of brain death in pregnancy were analyzed. The mean gestational age at diagnosis of brain death was at 20.2±5.3 weeks, and most cases (68%) were associated with maternal intracranial hemorrhage, subarachnoid hemorrhage, and hematoma. The most common maternal complications during the study were infections (69%) (eg, pneumonia, urinary tract infection, sepsis), circulatory instability (63%), diabetes insipidus (56%), thermal variability (41%), and panhypopituitarism (34%). The most common indications for delivery were maternal cardiocirculatory instability (38%) and nonreassuring fetal testing (35%). The mean gestational age at delivery was 27.2±4.7 weeks and differed depending on the gestational age at diagnosis of brain death. Most deliveries (89%) were via cesarean delivery. There were 8 cases (23%) of intrauterine fetal demise in the second trimester of pregnancy (14-25 weeks), and 27 neonates (77%) were born alive. Of the 35 cases of brain in pregnancy, 8 neonates (23%) were described as "healthy" at birth, 15 neonates (43%) had normal longer-term follow-up (>1 month to 8 years; mean, 20.3 months), 2 neonates (6%) had neurologic sequelae (born at 23 and 24 weeks of gestation), and 2 neonates (6%) died (born at 25 and 27 weeks of gestation). Mean birth weight was 1,229 grams, and small for gestational age was present in 17% of neonates. The rate of live birth differed by gestational age at diagnosis of brain death: 50% at <14 weeks, 54.5% at 14 to 19 6/7 weeks, 91.7% at 20 to 23 6/7 weeks, 100% at 24 to 27 6/7 weeks, and 100% at 28 to 31 6/7 weeks.

CONCLUSION

In 35 cases of brain death in pregnancy at a mean gestation age of 20 weeks, maternal somatic support aimed at maximizing perinatal outcome lasted for about 7 weeks, with 77% of neonates being born alive and 85% of these infants having a normal outcome at 20 months of life. The data of this study will be helpful in counseling families and practitioners faced with such rare and complex cases.

Assessment of Somatic Support Process for Pregnant Brain Death Patients Occurring in a Transition Country Between Asia and Europe from Medical, Ethical, Legal and Religious Aspects

In spite of the fact that brain death during pregnancy is not a common occurrence, it is an important ethical problem for all cultures and religions can have a significant influence on the donation decision after brain death. Therefore, this study aimed to present the case of a pregnant patient developing brain death which occurred in our intensive care unit and to compare the medical, ethical and legal problems relating to pregnant cases developing brain death with 24 cases in the literature. A 21-year-old 19-week pregnant case with gestational diabetes was monitored in the anesthesia intensive care unit and developed brain death due to intracranial mass and intraventricular hemorrhage. Though brain death is a situation well understood by organ transplant professionals, brain death developing in pregnant patients still involves many medical, ethical and legal problems.

Management of prolonged epistaxis in pregnancy: case report

OBJECTIVES

To report a case of life-threatening epistaxis in a pregnant patient, describe the links between pregnancy and epistaxis, and discuss the management of such cases. Life-threatening epistaxis in pregnancy is rare, and there are no specific evidence-based guidelines regarding the management of these patients.

CASE REPORT

A 31-year-old primigravida presented with severe epistaxis in the second trimester of her pregnancy. Conservative measures failed, thereby necessitating surgical intervention.

CONCLUSION

This case illustrates the importance of a multidisciplinary approach in the management of a pregnant patient presenting with severe epistaxis, and highlights the surgical challenges presented in such a situation.

Cocaine-induced intracerebral hemorrhage in a patient with cerebral amyloid angiopathy

Intracerebral hemorrhage (ICH) is a well-recognized complication of recreational cocaine use. The precise mechanism of the cocaine-induced hemorrhagic event is unclear, although multiple factors have been implicated. We report a case of a 62-year-old woman who suffered left parieto-occipital ICH with herniation and death, following a cocaine binge. Microscopic examination also revealed extensive cerebral amyloid angiopathy (CAA) in the vicinity of the hemorrhage. We additionally studied brain tissue in eight subjects between ages of 60 and 80 who were positive for cocaine metabolites at autopsy; of these, none had vascular amyloid-β deposits by immunohistochemistry. Whereas we found no evidence that chronic cocaine use is a risk factor for CAA, given the age-associated nature of CAA and the aging population using cocaine, CAA-induced hemorrhage in the setting of cocaine use may be more common than recognized. This is the first reported case of CAA-associated ICH precipitated by cocaine.

One life ends, another begins: Management of a brain-dead pregnant mother-A systematic review-

BACKGROUND

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 supporting therapy.

METHODS

To obtain information on brain-dead pregnant women, we performed a systematic review of Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). 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.

RESULTS

In our search of the literature, we found 30 cases reported between 1982 and 2010. A nontraumatic brain injury was the cause of BD in 26 of 30 mothers. The maternal mean age at the time of BD was 26.5 years. The mean gestational age at the time of BD and the mean gestational age at delivery were 22 and 29.5 weeks, respectively. Twelve viable infants were born and survived the neonatal period.

CONCLUSION

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.

Maternal brain death and somatic support

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.

Cardiac arrest in pregnancy and somatic support after brain death

OBJECTIVE

To review the important causes of cardiopulmonary arrest during pregnancy and the recommended modifications to resuscitation protocols when applied to pregnant patients, including the indications for perimortem cesarean section and the expected fetal outcomes, and to review the literature regarding extended somatic support after brain death during pregnancy.

DATA SOURCES

MEDLINE review of publications relating to cardiac arrest and resuscitation in pregnancy, physiologic changes after brain death, and attempted somatic support of brain-dead pregnant women.

CONCLUSIONS

Cardiac arrest during pregnancy is rare, but it is important to recognize the causes, which may be either unrelated to pregnancy or unique to the pregnant woman. For the most part, the resuscitation protocol is the same as for nonpregnant victims of cardiac arrest, with a few important modifications, including especially the need for relieving aortocaval compression by the gravid uterus, the need for rapid intubation, and the importance of rapid perimortem cesarean delivery when indicated. In those rare cases of brain death occurring in a pregnant patient, continued somatic support of the mother may be possible, even for prolonged periods, to extend the pregnancy and further fetal maturation. The expected physiologic changes after brain death, challenges to successful somatic support, and specific recommendations regarding organ support of the brain-dead pregnant woman are reviewed.

Cardiopulmonary resuscitation and somatic support of the pregnant patient

Cardiopulmonary arrest during pregnancy is a rare event that critical care clinicians must be prepared to manage. The causes of cardiopulmonary arrest during pregnancy, recommended modifications to cardiopulmonary resuscitation protocols that are specific to pregnancy, indications for and timing of perimortem cesarean delivery, and the expected fetal outcomes are reviewed. Rarely, brain death of a pregnant patient may occur in which continued support of the mother is possible to prolong the pregnancy and improve fetal outcome. Prolonged somatic support of pregnant patients who are brain dead presents specific management challenges, but has been accomplished. The physiologic changes that occur after brain death and recommendations for somatic support of the brain dead pregnant patient also are reviewed.

Pregnancy in a persistent vegetative state: case report, comparison to brain death, and review of the literature

Severe maternal neurologic injury during pregnancy has the potential for fetal demise without advanced critical care support to the mother. Brain death is the unequivocal and irreversible loss of total brain function, whereas patients in a vegetative state, by contrast, have preserved brain stem function but lack cerebral function. They can appear to be awake, have sleep-wake cycles, be capable of swallowing, and have normal respiratory control, but there are no purposeful interactions. These conditions have different maternal prognoses, but both have resulted in near-normal neonatal outcomes with long latencies from maternal injury to delivery in previously published cases. This article compares and contrasts the 11 cases of brain death with 15 cases of persistent vegetative state in pregnancy. We found that the mean latency between maternal brain injury and delivery was significantly shorter in the brain-dead patients as compared with those in a vegetative state (46 days vs. 124 days, P </=.001). Correspondingly, the gestational ages at delivery (29.7 weeks vs. 33.2 weeks, P </=.01) and the birth weights (1380 g vs. 2145 g, P </=.01) were shorter in duration and smaller in size in the brain-dead group. We also present a case of persistent vegetative state in pregnancy at our institution with both maternal and neonatal death in the context of previously published literature with a focus on obstetric and ethical management. We hope this information will help elucidate the issues for providers confronted with these unique and challenging cases.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state the difference between coma, persistent vegetative state and brain death, to describe the neurologic aspects of a patient in a persistent vegetative state, and to list the fetal effects of maternal brain injury.

Extended somatic support for pregnant women after brain death

OBJECTIVE

To review case reports of pregnant women who have been supported after brain death until successful delivery of their infants. From these reports and other literature about brain death, normal physiologic changes of pregnancy, and specific needs for fetal development, recommendations were made to assist in supporting pregnant women after brain death until delivery of a mature fetus who is likely to survive.

DATA SOURCES

Personal files and experiences, MEDLINE review of case reports and publications about physiologic changes present during normal pregnancy and after brain death, and the critical needs for fetal development were included.

DATA EXTRACTION

Eleven reports of ten patients comprise the accumulated clinical experience. Hypotension, requiring fluid administration and inotropic/vasopressor therapy, occurred in all the mothers, and in six cases, was the reason for urgent delivery. The longest period of support was 107 days, from 15 to 32 wks of gestation. Two mothers also became organ donors. Recurrent infections, thermolability, and other complications common to prolonged ICU care were encountered. All infants survived. One had congenital abnormalities caused by phenytoin use by the mother. When followed, all others developed within normal growth and mental variables. These cases plus literature citations noted above were used to develop recommendations for maternal/fetal care.

CONCLUSION

Preservation of uterine/placental blood flow is the most important priority during somatic support. Imprecise autoregulation of the uterine vasculature during maternal hypoxemia or hypotension makes this goal a significant challenge. Special considerations for nutrition; medication use; cardiovascular, respiratory, or endocrine therapy; fetal monitoring; hormone replacement; and ethical concerns are discussed.

Fetal effects of cocaine: an updated meta-analysis

BACKGROUND

A very large number of women in the reproductive age group consume cocaine, leading to grave concerns regarding the long term health of millions of children after in utero exposure. The results of controlled studies have been contradictory, leading to confusion, and, possible, misinformation and misperception of teratogenic risk.

OBJECTIVE

To systematically review available data on pregnancy outcome when the mother consumed cocaine.

METHODS

A meta-analysis of all epidemiologic studies based on a priori criteria was conducted. Comparisons of adverse events in subgroups of exposed vs. unexposed children were performed. Analyses were based on several exposure groups: mainly cocaine, cocaine plus polydrug, polydrug but no cocaine, and drug free.

RESULTS

Thirty three studies met our inclusion criteria. For all end points of interest (rates of major malformations, low birth weight, prematurity, placental abruption, premature rupture of membrane [PROM], and mean birth weight, length and head circumference), cocaine-exposed infants had higher risks than children of women not exposed to any drug. However, most of these adverse effects were nullified when cocaine exposed children were compared to children exposed to polydrug but no cocaine. Only the risk of placental abruption and premature rupture of membranes were statistically associated with cocaine use itself.

CONCLUSIONS

Many of the perinatal adverse effects commonly attributed to cocaine may be caused by the multiple confounders that can occur in a cocaine using mother. Only the risk for placental abruption and PROM could be statistically related to cocaine. For other adverse effects, additional studies will be needed to ensure adequate statistical power.

Recombinant tissue plasminogen activator for the treatment of spontaneous adult intraventricular hemorrhage

BACKGROUND

Intraventricular hemorrhage (IVH) has a poor prognosis with mortality rates of between 80 and 100% when all four ventricles are involved. Fibrinolytic therapy has been reported to improve overall outcome.

METHODS

Patients with severe primary IVH were treated by direct intraventricular injection of recombinant tissue plasminogen activator (rt-PA) into the lateral ventricles, followed by cerebrospinal fluid (CSF) drainage if the intracranial pressure rose above 20 mm Hg.

RESULTS

Over a 15-month period from 1995 through 1996, 10 patients were treated, (4 male and 6 female, mean age 35 years; range, 21-55 years). The mean Glasgow Coma Scale score on admission was 6 (range, 4-8) and the mean Graeb score for severity of IVH on the first CT scan was 10 (range, 8-12). Angiography was negative in five cases but identified arteriovenous malformations in three, a post-traumatic pseudoaneurysm in one, and Moya-moya disease in one. The mean total dose requirement of rt-PA was 8.25 mg (range, 6-12 mg) with a significant reduction in the mean Graeb score after 7 days to 3.9 (range, 2-7, p<0.0001). Outcome at 3 months was death in one case (mortality 10%), severe disability in two (20%), moderate disability in three (30%), and good result in four (40%). Four patients (40%) required subsequent CSF shunting. No complications of rehemorrhage, infection, or catheter obstruction were encountered.

CONCLUSION

Intraventricular fibrinolysis with rt-PA seems to be safe and effective for the treatment of severe IVH.

Cardiopulmonary resuscitation: pregnant women are different

Although cardiopulmonary arrest rarely occurs in the pregnant woman, it is important that the health care team know the appropriate actions to take in such an event, to promote positive outcomes for both mother and fetus. Specific techniques, personnel, and equipment are required to manage this grave situation. The principles of airway, breathing, and circulation are used as with any client in cardiopulmonary arrest; however, modifications must made because of the physiologic changes that normally occur during pregnancy. If the pregnant woman does not respond to treatment, a cesarean delivery must be attempted within 5 minutes of the arrest if uterine size indicates gestational age of at least 20 weeks. This article describes the adaptations of traditional cardiopulmonary arrest procedures required to treat the pregnant woman who sustains a cardiopulmonary arrest, protocols for managing the communication of the emergency code, emergency equipment that must be available, and the importance of teams in managing mother and neonate.

Cocaine's lethality increases during late gestation in the rat: a study of "critical periods" of exposure

OBJECTIVE

Cocaine-associated morbidities in pregnant women (e.g., abruptio placentae, hypertension, seizures) occur mostly during the final stages of gestation. The purpose of our study was to determine whether cocaine's toxicity and blood levels varied as a function of "critical periods" of exposure during gestation.

STUDY DESIGN

To evaluate mortality rates, pregnant Long-Evans rats received subcutaneously 30, 40, or 50 mg/kg cocaine hydrochloride twice daily (C30, C40, and C50 groups) either during gestational days 7 to 13 (midgestation) or gestational days 14 to 20 (late gestation) (n 9 to 20 per group). Serum levels of the cocaine metabolite benzoylecgonine were examined in other groups of rats on either gestational day 13 (mid) or day 20 (late) in the C30 treatment condition (n = 5 and 10 per group).

RESULTS

There were no maternal mortalities in the midgestation groups at any dose. In contrast, the late-gestation groups showed a dramatic dose-dependent effect, with maternal mortality rates of 0%, 40%, and 72% in the C30, C40, and C50 groups. The late-gestation group had higher benzoylecgonine levels than the midgestation groups did.

CONCLUSIONS

Late gestation was associated with higher maternal mortality rates and higher benzoylecgonine levels, indicating that some underlying physiologic change enhanced cocaine's toxicity as pregnancy progressed. This increased sensitivity to cocaine may be mediated by estrogen or progesterone, suggesting that the cocaine-abusing woman is at increased risk for cocaine-induced morbidities whenever levels of these hormones are elevated, such as during the final stages of pregnancy or possibly when taking oral contraceptives.