Anaesthetic management of a pregnant patient in a persistent vegetative state

B. T. Ayorinde1, I. Scudamore2 and D. J. Buggy1,*

1University Department of Anaesthesia and 2Department of Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK

Accepted for publication: April 14, 2000


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Pregnancy in a patient in a persistent vegetative state presents challenging therapeutic questions about the level of supportive management required, the assessment of fetal well-being, the timing and mode of delivery and the anaesthetic management of labour and delivery. We report the case of a 29-yr-old woman who had a favourable fetal outcome despite suffering hypoxic brain damage after a suicide attempt by a drug overdose. She was managed until the onset of labour on an intensive care unit and had a spontaneous vaginal delivery assisted by epidural anaesthesia.

Br J Anaesth 2000: 85; 479–81

Keywords: brain, injury; persistent vegetative state; anaesthesia, epidural; pregnancy


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
The term persistent vegetative state (PVS) describes a state of continuing ‘wakefulness without awareness’ that is usually due to a severe brain insult from a variety of possible causes.1 PVS involves damage to the central nervous system, other systems being essentially normal. A pregnancy may be viable, creating an unusual scenario requiring difficult clinical and ethical decisions. In this report, we discuss the anaesthetic and intensive care management of a 29-yr-old patient who suffered hypoxic brain injury after a failed suicide attempt at 12 weeks gestation.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
A 29-yr-old lady was 12 weeks pregnant with her second pregnancy. She had a history of depressive illness. There was also a history of marital discord. While abroad with her family, she attempted suicide and overdosed on a cocktail of antihypertensives (which belonged to her father-in-law), anxiolytics and antidepressants. The patient was found unconscious, and after admission to an intensive care unit (ICU) a computer tomographic (CT) scan of her brain showed gross ischaemic changes in the cerebral cortex consistent with severe hypoxic brain damage.

After air transfer to our ICU, 4 weeks after the suicide attempt, she had a Glasgow Coma Score (GCS) of 7 (spontaneous eye opening, no verbal response and an extensor response to pain). She responded to distressing situations by becoming increasingly agitated, sweaty and tachypnoeic. A tracheostomy had been performed at the referring hospital. The tracheostomy tube was changed to a fenestrated type to facilitate spontaneous ventilation, an enterostomy feeding tube was sited and a central venous catheter (CVP) was inserted to aid fluid management. She was treated for multiple respiratory, urinary and gastrointestinal infections with appropriate antibiotics, but continued to demonstrate intermittent pyrexia and persistent tachycardia.

A fetal ultrasound scan showed that the fetus was intact and small for date at 16 weeks, but did not appear to have any anatomical abnormality. A plan to manage the pregnancy expectantly was made. This involved weekly clinical assessment supplemented by regular ultrasound assessment of fetal growth, liquor volume and umbilical artery waveforms. In the absence of fetal or maternal indications, a requirement for early delivery or Caesarean section was not anticipated. These findings were discussed extensively with the family, who were particularly concerned about fetal survival. Arrangements were made initially to transfer the patient to a rehabilitation unit once her condition had stabilized. However, this decision was reversed after careful consideration of the risks to the patient and the fetus. She therefore remained in the ICU until delivery. Whilst in the ICU she required substantial nursing care, although she was not artificially ventilated.

The ICU nursing staff were instructed in the palpation of uterine contractions and encouraged to request midwifery support if in doubt. At 35 weeks gestation, the patient developed regular uterine contractions, which seemed to be causing considerable distress. A lumbar epidural catheter was sited in the lateral position and an infusion of 0.25% bupivacaine commenced at a rate of 6–10 ml h–1, which was adjusted according to the patient’s agitation and the cardiovascular parameters. She was transferred to the delivery suite after spontaneous rupture of the membranes occurred. Continuous fetal heart rate monitoring identified a baseline rate of 140 beats min–1 with normal variability.

Taking into account the patient’s previous normal delivery and the small size of the fetus, it was decided to allow a trial of labour and to anticipate vaginal delivery. However, it was felt that there should be a low threshold for operative delivery. As the patient was not in established labour, the fetal heart rate decelerations, the need for maternal analgesia and the suspected rupture of membranes prompted a decision to induce labour by artificial membrane rupture with oxytocin augmentation. The patient appeared comfortable with the epidural solution being infused at a rate of 8 ml h–1. Four hours after admission to the delivery suite, she delivered a healthy 2.2 kg boy by spontaneous vaginal delivery, who had an Apgar score of 10 at 5 min. She was transferred to a rehabilitation unit 2 days later.


    Discussion
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
This is the first report, to our knowledge, of a pregnancy in which the fetus survived maternal PVS during the entire second and third trimesters, thus presenting a therapeutic dilemma during the pregnancy and at delivery of the fetus. PVS is a state of eyes-open unconsciousness with sleep–wake cycles in which patients are incapable of awareness of themselves or their environment.2 3 The use of the term PVS usually implies that the vegetative state has continued for more than 1 month.4 A patient in this state is not expected to recover, although this is the subject of controversy. There have been rare documented cases of late recovery of patients who had been diagnosed as being in a PVS.5 Hence the diagnosis should be considered carefully before it is made because of the enormous financial, emotional and social implications of the management of these patients. Apart from establishing lack of awareness, the cause and irreversibility of the syndrome must be obvious.6 The differential diagnosis includes prolonged coma (a state of unconsciousness in which the eyes are closed and sleep–wake cycles are absent) and the locked-in syndrome (resulting from brainstem lesions which disrupt the voluntary control of movement without abolishing either arousal or the content of awareness), both of which can also result from severe brain injury.7

Patients with PVS usually breathe spontaneously, although a tracheostomy may be necessary to ensure airway protection. Patients may exhibit a bizarre variety of neurological signs, including arousal to painful stimuli, grimacing, limb movement, spontaneous head movements, chewing, and grinding the teeth.4 Most of these features were present in our patient, but with the additional feature that she was pregnant, exposing her to the potential risk of obstetric complications such as aortocaval compression, pregnancy-induced hypertension and premature labour. Termination of the pregnancy was not considered appropriate as the fetus had survived the hypoxic insult of a suicide attempt and had a good chance of survival as long as the mother was alive.

The choice of an appropriate place to manage the patient was a contentious issue. Managing her in a side room in the delivery suite would have been considered as a cheaper alternative to high-dependency or intensive care. However, this would not have provided optimal patient care in view of the presence of a tracheostomy tube and the lack of appropriate expertise in airway management among the labour ward staff. The potential requirement for artificial ventilation, the degree of nursing and physician input required and the obstetric and fetal risks indicated that the intensive care unit, rather than the high-dependency unit, was the most appropriate place to optimize her management. Once the fetus had been delivered without any maternal complications, the patient was deemed to present a risk profile similar to a non-pregnant patient in a PVS, who would usually be managed safely in a rehabilitation unit.

Assessment of pain and the provision of safe and effective analgesia during labour and delivery in a patient in a PVS is challenging because the patient cannot communicate. Physiological parameters such as tachycardia, hypertension and tachypnoea are commonly used as indicators of inadequate analgesia, but all lack specificity. The safety and efficacy of epidural analgesia for the management of labour pain is well documented.8 Despite the absence of reports describing the use of epidural analgesia for a similar case, we could not find any justifiable reason for withholding epidural analgesia in our patient. We decided to use a plain bupivacaine infusion to avoid the further neurological depression that may have been induced by opioids. A continuous infusion, rather than bolus doses of epidural local anaesthetic, was chosen to minimize cardiovascular compromise, especially since dermatomal sensory levels of the block could not be assessed. The medical condition of the patient, the fetal heart rate decelerations in the intrapartum period and the anaesthetic considerations indicated a low threshold for emergency Caesarean section. Although regional anaesthesia is now established as the preferred technique for Caesarean section,9 this requires a dense sensory block extending from the fourth thoracic dermatome to the fifth sacral dermatome.10 However, we could not establish the extent of the block in this patient. Therefore, our anaesthetic plan in the event of emergency Caesarean section was to administer a general anaesthetic. Provision was made for a cuffed tracheostomy tube and antacid prophylaxis, as for any obstetric patient undergoing general anaesthesia. The epidural could also have been used for postoperative analgesia.

In conclusion, this unusual case illustrates that pregnant patients in a PVS may receive low-dose epidural analgesia in labour, but general anaesthesia would be indicated for Caesarean section. Nursing support, medical management, fetal assessment and deciding the optimum time for delivery are challenging decisions requiring a multidisciplinary approach to this clinical situation.


    Footnotes
 
* Corresponding author Back


    References
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 Jennett B, Plum F. Persistent vegetative state after brain damage. Lancet 1972; i: 734–7

2 Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (Part 1). N Engl J Med 1994; 330: 1499–508[Abstract/Free Full Text]

3 Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (Part 2). N Engl J Med 1994; 330: 1572–9[Free Full Text]

4 Zeman A. Persistent vegetative state. Lancet 1997; 350: 795–9[ISI][Medline]

5 Childs NL, Mercer WN. Late improvement in consciousness after post-traumatic vegetative state. N Engl J Med 1996; 334: 24–5[Free Full Text]

6 Wade TW, Johnston C. The permanent vegetative state: practical guidance on diagnosis and management. Br Med J 1999; 319: 841–4[Free Full Text]

7 Plum F, Posner JB. The diagnosis of stupor and coma. Philadelphia: FADC, 1980

8 Yancey MK, Pierce B, Schweitzer D, Daniels D. Observations on labor epidural analgesia and operative delivery rates. Am J Obstet Gynecol 1999; 18: 353–9

9 May AE. Epidurals for Childbirth. Oxford: Oxford University Press, 1994

10 Morgan BM. ‘Walking’ epidurals in labour. Anaesthesia 1995; 50: 839–40[ISI][Medline]





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