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

Abstract Background Brain death (BD) during pregnancy might justify in select cases maternal somatic support to obtain fetal viability and maximize perinatal outcome. Objective To evaluate by systematic review of literature all cases of BD during pregnancy with attempt at prolonging pregnancy with the aim of assessing perinatal outcomes. Data Sources We performed a systematic review of the literature using Ovid Medline, Scopus, and PubMed (including Cochrane database), CINHAIL from the inception until April 2020. Study Eligibility Criteria Relevant articles describing any case report of maternal BD were identified from the above databases without any time, language, or study limitations. Studies were deemed eligible for inclusion if they described at least one case of maternal BD. Study Appraisal and Synthesis Methods: Only BD in pregnancy cases with desired somatic support to maximize perinatal outcome were included. Maternal management strategy, diagnosis, clinical course, fetal monitoring, delivery, fetal and neonatal outcome data were collected. Mean, range, standard deviation, and percentage calculations were used as applicable. Results After exclusion, 35 cases of BD in pregnancy were analyzed. BD diagnosis occurred at a mean gestational age of 20.2 ±5.3 weeks, usually associated with intracranial hemorrhage / subarachnoid hemorrhage/ hematoma (68%). The most common complications were infections (69%) (e.g. pneumonia, urinary tract infection, sepsis), circulatory instability (63%), diabetes insipidus (DI) (56%), thermovariability (41%), and panhypopituitarism (34%). The most common indications for delivery were maternal cardiocirculatory instability (38%) and non-reassuring fetal testing (35%). Mean gestational age at delivery was 27.2 ±4.7 weeks and differed depending on gestational age at BD. Delivery occurred mostly (89%) by cesarean. There were 8 (23%) IUFDs in the second trimester (14-25 weeks), and 27 babies (77%) born alive. Of the 35 total cases of BD in pregnancy, 8 (23%) babies were just described as ‘healthy’ at birth, 15 (43%) had normal longer term follow-up (>1 month to 8 years, mean 20.3 months), 2 (6%) had neurologic sequelae (born at 23 and 24 weeks), and 2 (6%) were neonatal deaths (born at 25 and 27 weeks). Mean birth weight was 1,229 grams, and small for gestational age was present in 17% of neonates. Live birth rate by BD at diagnosis differed by gestational age: Conclusions In 35 cases of BD in pregnancy at a mean of about 20 weeks, maternal somatic support to maximize perinatal outcome lasted a mean of 7 weeks, with 77% of babies born alive, and 85% of these having normal outcome at a mean of 20 months of life. These data are helpful in counseling families and practitioners faced with these rare and complex cases.s