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We present in detail a case of a 27-year-old primigravida who was maintained in viving infant 63 days after the diagnosis
a brain-dead state for nine weeks. An apparently normal and healthy male infant of brain death was made.
weighing 1440 g was delivered. The newborn did well and was found to be REPORT OF A CASE
growing and developing normally at 18 months of age. Although the technical On Jan 25,1983, a previously healthy
aspects of prolonged life support are demanding and the economic costs are 27-year-old grávida 1, para 0 woman
very high ($217 784), there are ample ethical arguments justifying the separa- presented to her local hospital at 22
tion of brain death and somatic death and the maintenance of the brain-dead weeks' gestation with a five-day history
mother so that her unborn fetus can develop and mature. of worsening headaches followed by
(JAMA 1988;260:816-822) several hours of vomiting and disorien¬
tation. Results of physical examination
were consistent with a 22-week gesta¬
BRAIN death, the unequivocal and ir¬ is generally considered unethical to tion and were otherwise unremarkable;
reversible loss of total brain function, is squander costly medical resources by normal vital signs and no focal neuro¬
a concept used to determine when death continuing to support vital functions logic deficits were noted. Results of a
has occurred in cases in which life-sup¬ using artificial means. lumbar puncture were normal except
port equipment obscures the conven¬ Maternal brain death during preg¬ for a slightly elevated opening pressure
tional cardiopulmonary criteria of nancy is one instance in which prolonged of 20 cm of water and the presence of
death.1,2 This concept has gained wide maintenance of the mother's vital func¬ four segmented neutrophils per cubic
acceptance in the medical and legal com¬ tions might be justified for the sake millimeter of cerebrospinal fluid. Four
munities, and most states have passed of the fetus. Tb our knowledge, Dillon hours after presentation, the patient
brain-death statutes specifying the cri¬ et al3 reported the first case in which had a generalized seizure and a respira¬
teria needed to make the diagnosis of prolonged support of a brain-dead tory arrest.
brain death and equating that diagnosis mother resulted in the birth of an infant After cardiopulmonary resuscitation,
with the pronouncement of death.2 who survived. Though they suggested ventilatory support was continued in
Despite meticulous supportive care, guidelines for the treatment of these the intensive care unit, where examina¬
brain death is usually followed by car¬ patients, the decision of whether to con¬ tion revealed no response to painful
diovascular collapse within a few days tinue maximum supportive care in these stimuli, fixed and dilated pupils, papil-
and, once such a diagnosis is made, it rare and tragic cases remains a contro¬ ledema, and absent doll's eye move¬
versial one.4 ments. A computed tomographic scan of
From the Department of Obstetrics, Gynecology, and
Reproductive Sciences (Drs Field, Gates, Creasy, and Fundamental to this controversy are the head showed marked dilatation of
Laros) and the Division of Ethics in Medicine (Dr Jon- ethical and economic issues as well as the lateral and third ventricles with a
sen), University of California, San Francisco. Dr Field is unanswered questions concerning the mass obstructing the fourth ventricle.
now with the Department of Obstetrics and Gynecolo-
physiologic consequences to both the A ventriculostomy was placed and
gy, Naval Hospital, Oakland, Calif. Dr Creasy is now
with the Department of Obstetrics and Gynecology, mother and fetus of prolonged support revealed clear cerebrospinal fluid that
University of Texas, Houston. Dr Jonsen is now with the of the organ systems most prone to fail¬ had an opening pressure of 50 cm of
Department of Medical Ethics, University of Washing- water. Dexamethasone sodium phos¬
ton, Seattle. ure after brain death. We will examine
Reprint requests to Department of Obstetrics, Gyne- these issues and questions using as a phate and mannitol were given, but the
cology, and Reproductive Sciences, M-1485, Universi- framework for our discussion the case electroencephalogram was again iso-
ty of California, San Francisco, CA 94143-0132 (Dr
Laros). report of a woman who delivered a sur- electric two days later. There was no