Doctors at the University Hospital in Brno are celebrating an unprecedented success. In mid-August, they delivered a healthy baby girl 117 days after her mother was declared brain dead after suffering a brain haemorrhage. It is the longest artificially sustained pregnancy in a brain-dead mother ever recorded in medical history.
The 27-year-old woman from the Moravian town of Třebíč was just 15 weeks into her pregnancy when she suffered a stroke. She was found lying unconscious in her home by her husband and was immediately rushed to hospital.
The brain haemorrhage was caused by vascular malfunction, which was diagnosed during the woman’s previous pregnancy. Despite the expert care she received, the haemorrhage was so devastating that it completely destroyed her brain.
To save the baby inside her womb, doctors decided to sustain the woman’s pregnancy by maintaining her vital functions. They managed to do so for 117 days, which is a record for the longest artificially sustained pregnancy in a brain-dead mother. In the middle of August, a healthy baby girl was delivered by Caesarean section.
Petr Janků, head of the department of Obstetrics and Gynaecology at the University Hospital in Brno, described the case in detail to Czech Radio starting with the moment the woman was brought to the hospital in mid-April:
“The vital functions of the patient had been sustained already during her transport to the hospital. We were called to the case immediately after she was admitted to assess the state of the pregnancy.
“I should say that in cases such as this one, the life of the mother, which is in imminent danger, is always the doctors’ primary concern. We can only intervene if the situation allows.
“In this case, we carried out the ultrasound and other necessary examination to determine the state of the pregnancy.”
Although the woman was declared brain-dead shortly after reaching the hospital, examinations showed that the brain haemorrhage had caused no damage to the baby. Doctors immediately began the struggle to save her child.
It was clear that the foetus, at just 15 weeks of age, could not survive outside the woman’s body. To keep the pregnancy going, she had to be connected on artificial life support. Petr Janků admits the decision was not an easy one, and involved all kinds of issues, from medical to ethical ones.
“The decision was preceded by many debates, not only at our centre of Obstetrics and Gynaecology, but also at the department of Anaesthesiology, which was in charge of the patient. It is mainly thanks to them that we succeeded in prolonging the pregnancy.
“Of course we also discussed the case with lawyers and the hospital management. So we made the decision taking into account medical possibilities as well as the ethical aspects of the matter, and it was by mutual consensus.”
It was equally important to consider the rights of the patient, namely her right to a dignified death:
“Even a person in such a critical state has the right to die without unnecessary prolonging of his or her life. In this case, we had to respect that. So if we have a patient in such serious condition, we have to ask the family how to proceed.
“As a perinatologist, I usually deal with children that are born extremely prematurely. In such cases, we have to approach the parents and talk about the problem. Communication is crucial.”
But the most important thing, Mr Janků explains, was the cooperation with the husband and other relatives of the brain-dead mother. Before making any decisions, doctors had to make sure they all agreed with the proposed plan:
“The family had to be acquainted with the situation and all its possible outcomes. Their involvement was absolutely crucial for us and determined all the steps we took.
“We were in communication with the husband and other family members throughout the whole time to make sure that we always agreed on the next course of action.”
The family members also had to understand that the process was fraught with loads of potential complications and the doctors could in no way guarantee that the outcome would be successful.
“The outcome could have been very different. There could have been a premature birth at the time when the foetus is most vulnerable, which is sometimes between the 24th and 26th weeks of gestation. And there could have been other, very serious medical complications.”
“The first turning point was the 24th week of gestation, when the foetus is theoretically vital. Then there was the 26th week, when it has a very limited ability to survive outside the mother’s body and then there are several other milestones up until the 34th week.
“Our mission was to closely observe the pregnancy and say if anything was going wrong, based on the ultrasound of the foetus and the monitoring of its heart activity. Luckily, nothing like that happened.”
Most of the daily care for the patient was carried out by the doctors, nurses and other medical staff at the department of Anaesthesiology, where the patient was placed. The nurses would even regularly move the woman’s legs to simulate walking to help the child’s growth.
“It is something called basal stimulation. It involved the nurses massaging the pregnant belly or the grandmother coming to the hospital to read stories for the child.
“There were many things they did to ensure that the baby inside the womb could feel the surrounding world, and not just the hospital environment. There are many experts who believe this type of care has a very positive effect on the development of the baby.”
Despite the altogether smooth course of events, doctors did experience a few critical moments along the way, says Doctor Janků:
“There were several critical moments, most of them involving inflammation. But the biggest problem was the fact that we have two separate facilities. The Anaesthesiology clinic is located far away from the perinatology unit.
“We had to consider the possibility of a premature birth, between the 24th and 30th week. In that case, we would either have to transport the woman to our clinic to undergo C-section, or bring the baby here after the delivery.”
Luckily, doctors did not have to deal with such scenario. The baby girl, called Eliška, was delivered as planned, in the 34th week of gestation, when her lungs were already fully developed. She weighed 2.13 kilogrammes and measured 42 centimetres and turned out to be perfectly healthy. Petr Janků says that to prolong the mother’s pregnancy any further would be pointless.
After the delivery, with the husband and other family members present, the medical staff at the Anaesthesiology department disconnected the woman from life support systems and allowed her to die. At the end of the month, her daughter was released from the hospital and is now at home with her father and older brother.
One of the things that make the case at the Brno University Hospital so special is the close cooperation between the medical staff and the relatives of the patient, given the length of time the woman had spent in the hospital. Despite that, Petr Janků says he tried to maintain a certain distance until the very end:
“We have to be able to keep a certain distance from our patients, to be able to make hard decisions if needed. However, the case has of course made a strong impression on us, especially the reaction of the public.
“I would say we still feel a little shaky. Our primary concern never was to set any kind of record. We simply wanted to prolong the pregnancy and give birth to a healthy child.”
Although the case was truly unique, Doctor Janků points out that he and his colleagues from the department of Obstetrics and Gynaecology have to deal with equally dramatic situations from time to time.
Just three years ago, doctors at the University Hospital in Brno delivered a baby whose mother who in a coma after being involved in a traffic accident. In that case, however, the patient recovered to such an extent that she is now able to look after her child.
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