Ethical and medical management of a pregnant woman with brain stem death resulting in delivery of a healthy child and organ donation.

Maternal brain death during pregnancy remains an exceedingly complex situation that requires not only a well-considered medical management plan, but also careful decision-making in a legally and ethically delicate situation. Management of brain dead pregnant patients needs to adhere to special strategies that support the mother in a way that she can deliver a viable and healthy child. Brain death in pregnant women is very rare, with only a few published cases. We present a case of a pregnant woman with previously diagnosed multiple brain cavernomas that led to intracranial hemorrhage and brain stem death during the 21st week of pregnancy. The condition that can be proven unequivocally, using tests that do not endanger viability of the fetus, is brain stem death, diagnosed through absence of cranial reflexes. The patient was successfully treated until delivery of a healthy female child at 29weeks of gestation. The patient received continuous hormone substitution therapy, fetal monitoring and extrinsic regulation of maternal homeostasis over 64days. After delivery, the final diagnosis of brain death was established through multi-slice computerized tomography pan-angiography. This challenging case discusses ethical and medical circumstances arising from a diagnosis of maternal brain death, while showing that prolongation of somatic life support in a multidisciplinary setting can result in a successful pregnancy outcome.

Ovarian vein thrombosis--a case report.

OBJECTIVE AND IMPORTANCE: Ovarian vein thrombosis is a rare condition usually seen in the puerperium. The incidence is 0.05-0.18% of pregnancies. Possible complications of ovarian vein thrombosis are sepsis, thrombus extension into the inferior vena cava or renal veins and pulmonary embolism. CLINICAL PRESENTATION: A 31-year-old puerpera complained about abdominal pain in the right lower quadrant and right inguinal region. INTERVENTION: Ultrasonographic examination and multislice computed tomography (MSCT) revealed the right ovarian vein thrombosis. Patient was treated with low-molecular weight heparin and antibiotics for 2  weeks. She was discharged with oral anticoagulants for 6  months. CONCLUSION: Ovarian vein thrombosis should be taken under consideration in the post-partum period.

Ovarian cancer and ovulation induction drugs--is there a link?

Screening for ovarian cancer in a group of women with induced ovulations was encouraged by recently reported controversies about a possible association between the use of ovulation induction drugs and the increased risk of ovarian carcinoma. Transvaginal color Doppler ultrasonography was applied in screening for early stage ovarian malignoma in 110 asymptomatic women who received an ovulation induction therapy for infertility. Already reported standard parameters for discriminating malignant from benign flows, such as resistance index RI < 0.40, pulsatility index PI < 1 and morphological score (borders, cyst quality, septate areas, papilla and ovarian tissue echogenicity) were used. Screening included 110 women and was carried out from April 1, 1198 to March 31, 1999. Seven examinees had abnormal ovarian findings. The finding spontaneously regressed in five of them, one underwent surgery for a persistent cyst with a benign pathohistologic diagnosis, and one was diagnosed with early stage ovarian malignoma. RI < 0.40 was reported in one patient (0.9%) with a morphologically suspect finding and a pathohistologically confirmed malignoma, PI < 1 was found in 40 subjects or 36.4%, while malignoma was demonstrated in one case alone. The results showed the advantage of RI over PI in discriminating malignant from benign structures. The association between the use of ovulation stimulation drugs and the increased risk of ovarian carcinoma remains unproved and also challenges new dilemmas. The paper cautions against undesirable, potentially serious long-term effects of the use of ovulation induction agents. Additional trials should therefore be performed including a long-term prospective follow-up of women with induced ovulations.

Screening for Down's syndrome and neural tube defect in Croatia. A regional prospective study.

OBJECTIVE: The purpose of this study was to investigate the efficiency of second-trimester maternal serum screening for Down's syndrome and open neural tube defects using alpha-fetoprotein and free beta-human chorionic gonadotropin as serum markers. METHODS: 3, 188 women underwent testing between 14th and 22nd week of pregnancy. Of all tested patients, 25.4% were >/=35 years old. A cut-off risk of >/=1:250 for Down's syndrome and MS-AFP >/=2.0 MoM for open neural tube defect were considered screen-positive. RESULTS: The detection rate for Down's syndrome was 77.8% (7/9) with 8.2% screen-positive rate (7.9% false-positive rate). When evaluated separately, in patients younger than 35 and in those >/=35 years old, the screen-positive rates were 3.1 and 23.3%, respectively. A total of 52 (1.6%) were found screen-positive for open neural tube defect; 2 cases of encephalocela and 1 case of gastroschisis were confirmed prenatally. CONCLUSION: The respectable number of cases with trisomy 21 identified in this study confirms that routine mid-trimester screening for Down's syndrome including MS-AFP, free beta-hCG and maternal age is useful in identifying pregnancies at increased risk.

[The effect of the presence of the husband during childbirth]. / Ucinak nazocnosti muza pri porodu.

In the course of 1994 a particular number of deliveries were examined in the maternity ward of the Clinical Hospital "Sestre milosrdnice". Randomly a hundred pregnant women were chosen whose husbands were present at the childbirth. The same number of women delivered their babies without their husband's presence. The duration of labor was examined as well as APGAR score, threatening intrauterine asphyxia, uterine inertia, prolonged labor, induced labor, medical analgesia, and the frequency of cesarean section and vacuum extraction. In the group, in which the husband was present, the labor was shorter, the number of threatening intrauterine asphyxia cases and cesarean sections was smaller, but there were more induced deliveries. Contrary to all expectations, the uterine inertia with the administration of oxytocin was comparably present in both groups, the same as medical analgesia. Other above mentioned parameters were also comparably present in both groups. The level of labor analgesia was not examined in particular to avoid the subjective factor, and besides, the aim was to achieve the maximal possible analgesia. The results suggest the importance of husband's presence at childbirth. Apart from being a very important psychosocial factor, reducing the duration of labor as well as the frequency of threatening intrauterine asphyxia and cesarean section, it also directly affects the course and result of labor.