Intensivtherapie bei Schwangerer mit irreversiblem Hirnfunktionsausfall

Zusammenfassung

Eine 29-jährige Frau erlitt durch einen Verkehrsunfall ein schweres Schädel-Hirn-Trauma mit im Verlauf infauster zerebraler Prognose. Es stellte sich heraus, dass die Patientin in der 9. Woche schwanger war. Nach Diagnose eines irreversiblen Hirnfunktionsausfalls in der 10. Schwangerschaftswoche (SSW) wurde die Patientin für insgesamt 5 Monate intensivmedizinisch weiterbehandelt bis zur assistierten vaginalen Entbindung eines gesunden Kindes auf der Intensivstation in der 31. SSW. Im Anschluss erfolgte, gemäß dem mutmaßlichen Willen der Patientin, eine Multiorganentnahme bei der Mutter. Der Artikel stellt die Details der intensivmedizinischen Therapie dar und diskutiert die notwendigen medizinischen Maßnahmen. Diese Maßnahmen dienten in erster Linie der Erhaltung der Schwangerschaft und Förderung einer gesunden Entwicklung mit dem Ziel der Entbindung des Fetus, erst in zweiter Linie der organerhaltenden Therapie mit dem Ziel der Organspende. Notwendig waren Maßnahmen zur Erhaltung der Vitalfunktionen, Elektrolythomöostase, Ernährung, Behandlung von Infektionen, Vermeidung fruchtschädigender Einflüsse, Substitution von Hormonen und Vitaminen und die Vorbereitung einer geplanten oder ungeplanten Entbindung.

Die Aufrechterhaltung der Intensivtherapie bei einer schwangeren Patientin mit einer schweren Hirnschädigung, bei der schließlich ein irreversibler Hirnfunktionsausfall diagnostiziert wird, ist eine intensivmedizinische und multidisziplinäre Herausforderung. Dieser Fallbericht schildert die Intensivtherapie über 5 Monate bis zur Entbindung und Organspende.

Abstract

A 29-year-old woman suffered major traumatic brain injury caused by a car accident. As diagnostic measures had revealed an early pregnancy (9th week), treatment on the intensive care unit was continued for 5 months, after unfavourable cerebral prognosis was followed by an irreversible loss of brain function in the 10th week of pregnancy. After assisted vaginal delivery of a healthy child in the 31th week of pregnancy on the critical care unit, organ procurement took place according to the presumed will of the patient. The article presents the details of the critical care therapy and discusses the supportive medical measures. Those measures served primarily to uphold the pregnancy und support the healthy development and delivery of the fetus and only in second instance the organ preservation aiming on organ donation. Necessary measures included maintenance of vital functions, hemostasis of electrolytes, nutrition, treatment of infection, prevention of adverse effects on the fetus, substitution of hormones and vitamins as well as the preparation of a planned or an unplanned delivery.

Schlüsselwörter

Schwangerschaft - Hirntod - Intensivtherapie - Organspende - Entbindung

Key words

pregnant women - brain death - intensive care - organ donation - parturition

• Literatur

• 1 Esmaeilzadeh M, Dictus C, Kayvanpour E. et al. One life ends, another begins: Management of a brain-dead pregnant mother – A systematic review. BMC Med 2010; 8: 74
• 2 Said A, Amer AJ, Masood UR. et al. A brain-dead pregnant woman with prolonged somatic support and successful neonatal outcome: A grand rounds case with a detailed review of literature and ethical considerations. Int J Crit Illn Inj Sci 2013; 3: 220-224
• 3 Kinoshita Y, Kamohara H, Kotera A. et al. Healthy baby delivered vaginally from a brain-dead mother. Acute Med Surg 2014; 2: 211-213
• 4 Wawrzyniak J. Continuation of pregnancy in a woman with critical brain injury. Anaesthesiol Intensive Ther 2015; 47: 40-44
• 5 Burkle CM, Tessmer-Tuck J, Wijdicks EF. Medical, legal, and ethical challenges associated with pregnancy and catastrophic brain injury. Int J Gynaecol Obstet 2015; 129: 276-280
• 6 Gopcevic A, Rode B, Vucic M. et al. Ethical and medical management of a pregnant woman with brain stem death resulting in delivery of a healthy child and organ donation. Int J Obstet Anesth 2017; 32: 82-86
• 7 Holliday S, Magnuson-Woodward B. Somatic support following cardiac arrest for 90 days leading to a healthy baby boy: A case report. Heart Lung 2017; 46: 397-400
• 8 Pikto-Pietkiewicz I, Okninski A, Wojtowicz R. et al. The management of a thirteen weeks pregnant woman rendered brain-dead following a ruptured aneurysm. J Crit Care Med (Targu Mures) 2019; 5: 111-114
• 9 Brauer M, Gunther A, Pleul K. et al. Wie viele potenzielle Organspender gibt es wirklich? Retrospektive Analyse zu nichterfolgter Diagnostik des irreversiblen Hirnfunktionsausfalls bei verstorbenen Patienten mit relevanter Hirnschädigung. Anaesthesist 2018; 68: 22-29
• 10 Anstotz C. Should a brain-dead pregnant woman carry her child to full term? The case of the “Erlanger baby”. Bioethics 1993; 7: 340-350
• 11 Reinhold AK, Kredel M, Markus CK. et al. Vaginal delivery in the 30 + 4 weeks of pregnancy and organ donation after brain death in early pregnancy. BMJ Case Rep 2019; 12: e231601
• 12 Reinhold AK, Markus CK, Kredel M. et al. Ethische, psychosoziale und legale Aspekte der Behandlung hirntoter Schwangerer. Anästhesiol Intensivmed Notfallmed Schmerzther 2021; 56: 536-543
• 13 Akhyari P, Lichtenberg A, Boeken U. Successful transplantation of a heart donated 5 months after brain death of a pregnant young woman. J Heart Lung Transplant 2019; 38: 1121
• 14 Sim KB. Maternal persistent vegetative state with successful fetal outcome. J Korean Med Sci 2001; 16: 669-672
• 15 Bugge JF. Brain death and its implications for management of the potential organ donor. Acta Anaesthesiol Scand 2009; 53: 1239-1250
• 16 Powner DJ, Bernstein IM. Extended somatic support for pregnant women after brain death. Crit Care Med 2003; 31: 1241-1249
• 17 SAFE Study Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group; Australian Red Cross Blood Service, George Institute for International Health et al. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 2007; 357: 874-884
• 18 Cooper DJ, Myburgh J, Heritier S. et al. Albumin resuscitation for traumatic brain injury: is intracranial hypertension the cause of increased mortality?. J Neurotrauma 2013; 30: 512-518
• 19 Executive Committee of the German Medical Association on the Recommendation of the Scientific Advisory Board. Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives: Chapter 5 Human Albumin – Revised. Transfus Med Hemother 2020; 43: 223-232
• 20 Hauksson A, Akerlund M, Melin P. Uterine blood flow and myometrial activity at menstruation, and the action of vasopressin and a synthetic antagonist. Br J Obstet Gynaecol 1988; 95: 898-904
• 21 Akerlund M. Vascularization of human endometrium. Uterine blood flow in healthy condition and in primary dysmenorrhoea. Ann N Y Acad Sci 1994; 734: 47-56
• 22 Robba C, Fossi F, Citerio G. Organ donation: from diagnosis to transplant. Curr Opin Anaesthesiol 2020; 33: 146-155
• 23 Greiss jr. FC. Pressure-flow relationship in the gravid uterine vascular bed. Am J Obstet Gynecol 1966; 96: 41-47
• 24 Banhidy F, Acs N, Puho EH. et al. Hypotension in pregnant women: a population-based case-control study of pregnancy complications and birth outcomes. Hypertens Res 2011; 34: 55-61
• 25 Magee LA, von Dadelszen P, Rey E. et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med 2015; 372: 407-417
• 26 Sifakis S, Pharmakides G. Anemia in pregnancy. Ann N Y Acad Sci 2000; 900: 125-136
• 27 Pavord S, Daru J, Prasannan N. et al. UK guidelines on the management of iron deficiency in pregnancy. Brit J Haematol 2020; 188: 819-830
• 28 Jung J, Rahman MM, Rahman MS. et al. Effects of hemoglobin levels during pregnancy on adverse maternal and infant outcomes: a systematic review and meta-analysis. Ann N Y Acad Sci 2019; 1450: 69-82
• 29 Executive Committee of the German Medical Association on the Recommendation of the Scientific Advisory Board. Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives. Chapter 5 RBC Concentrates. Transfus Med Hemother 2009; 36: 362-370
• 30 Embryotox – Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie der Charité-Universitätsmedizin Berlin. Hydrochlorothiazid. Im Internet (Stand: 30.04.2021): http://www.embryotox.de/arzneimittel/details/hydrochlorothiazid/
• 31 Bundesinstitut für Arzneimittel und Medizinprodukte (BfArM). Rote-Hand-Brief Hydrochlorothiazid. 17.10.2018. Im Internet (Stand: 30.04.2021): http://www.bfarm.de/SharedDocs/Risikoinformationen/Pharmakovigilanz/DE/RHB/2018/rhb-hydrochlorothiazid.html
• 32 McAuliffe F, Kametas N, Krampl E. et al. Blood gases in pregnancy at sea level and at high altitude. BJOG 2001; 108: 980-985
• 33 Prodromakis E, Trakada G, Tsapanos V. et al. Arterial oxygen tension during sleep in the third trimester of pregnancy. Acta Obstet Gynecol Scand 2004; 83: 159-164
• 34 Spiropoulos K, Prodromaki E, Tsapanos V. Effect of body position on PaO2 and PaCO2 during pregnancy. Gynecol Obstet Invest 2004; 58: 22-25
• 35 Terragni PP, Antonelli M, Fumagalli R. et al. Early vs. late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA 2010; 303: 1483-1489
• 36 Hosokawa K, Nishimura M, Egi M. et al. Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials. Crit Care 2015; 19: 424
• 37 Durbin jr. CG. Tracheostomy: why, when, and how?. Respir Care 2010; 55: 1056-1068
• 38 Gramm HJ, Meinhold H, Bickel U. et al. Acute endocrine failure after brain death?. Transplantation 1992; 54: 851-857
• 39 Williams GR, Franklyn JA, Neuberger JM. et al. Thyroid hormone receptor expression in the “sick euthyroid” syndrome. Lancet 1989; 2: 1477-1481
• 40 Dimopoulou I, Tsagarakis S, Anthi A. et al. High prevalence of decreased cortisol reserve in brain-dead potential organ donors. Crit Care Med 2003; 31: 1113-1117
• 41 Scholtens DM, Kuang A, Lowe LP. et al. Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (HAPO FUS): Maternal glycemia and childhood glucose metabolism. Diabetes Care 2019; 42: 381-392
• 42 Novitzky D, Mi Z, Videla LA. et al. Hormone resuscitation therapy for brain-dead donors – is insulin beneficial or detrimental?. Clin Transplant 2016; 30: 754-759
• 43 Bitzani M, Matamis D, Nalbandi V. et al. Resting energy expenditure in brain death. Intensive Care Med 1999; 25: 970-976
• 44 Hamaoui E, Hamaoui M. Nutritional assessment and support during pregnancy. Gastroenterol Clin North Am 2003; 32: 59-121
• 45 Riggs KW, Rurak DW, Taylor SM. et al. Fetal and maternal placental and nonplacental clearances of metoclopramide in chronically instrumented pregnant sheep. J Pharm Sci 1990; 79: 1056-1061
• 46 Embryotox – Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie der Charité-Universitätsmedizin Berlin. Metoclopramid. Im Internet (Stand: 30.04.2021): http://www.embryotox.de/arzneimittel/details/metoclopramid/
• 47 Lang C, Behnke H, Wulf H. et al. Plazentapassage von Anästhetika und Adjuvanzien. Anaesthesist 2002; 51: 409-417
• 48 Bates SM, Rajasekhar A, Middeldorp S. et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Adv 2018; 2: 3317-3359
• 49 Kiefer RT, Ploppa A, Dieterich HJ. Aortocaval compression syndrome. Anaesthesist 2003; 52: 1073-1083
• 50 Robinson AM, Bucci DJ. Physical exercise during pregnancy improves object recognition memory in adult offspring. Neuroscience 2014; 256: 53-60
• 51 Rodriguez A, Wang Y, Ali Khan A. et al. Antenatal corticosteroid therapy (ACT) and size at birth: A population-based analysis using the Finnish Medical Birth Register. PLoS Med 2019; 16: e1002746