PREGNANCY TERMINATION IN BRAIN INJURED PATIENTS
Kathryn Kenny MD, BSc, MSc Candidate
Departments of Obstetrics & Gynecology and Medical Science, University of Calgary
Background
► Catastrophic neurological events can occur in
otherwise healthy pregnant woman. Cerebral
vascular events (stroke) can occur in the
antepartum period, sometimes before the fetus
reaches viability.
►Most pregnant woman do not anticipate
catastrophic events occurring – no prior
discussion of personal values regarding
pregnancy continuation if there is loss capacity
during pregnancy.
►Few case reports published with respect to
women with serious brain injury and pregnancy
termination.
Case Presentation – Patient JA
► 36 yr old woman, 2 previous children from
different partners
► 9 weeks gestation at time of massive cerebral
vascular accident from thrombosis –
secondary hemorrhagic stroke and seizures –
required urgent neurosurgical decompression
with skull removal
► Patient sedated and intubated in ICU at time
of Obstetrics Consult for discussion of
pregnancy continuation. Following simple
commands with right side of body and no
speech ability.
► Substitute decision maker (patient’s mother)
requested pregnancy termination. Termination
opposed by partner and remainder of patient’s
family
Ethical Considerations in the Case of JAThe
Non-Malifecence
►Does continuing the pregnancy risk harm to
the patient?
►Is termination medically indicated?
►Is termination appropriate in this patient if
requested by the partner and/or family?
Autonomy - Substitute Decision Maker
►What defines capacity?
►No available personal directive – who should
be the substitute decision maker for this
patient?
►Substitute decision maker is elderly and
physically disabled and unable to care for
infant – does her request for termination
reflect the values of the patient or herself?
Autonomy - Confidentiality
► How should the family be incorporated in
discussions normally held in confidence
between OB and the patient?
► What role should the father of the baby play
in decision making for this patient given he is
not the substitute decision maker?
►Substitute decision maker feared retaliation
from family when requesting information on
termination – how should she be protected?
Moral Distress of Care Providers
►Concerns from health care providers infant
may need involvement of social work and
foster care as no one physically able to meet
basic needs of infant (extended family did not
initially offer to care for infant)– does this
justify performing a pregnancy termination?
Multidisciplinary Support
►When should a formal capacity
assessment be performed in a patient with
brain injury?
►Who should perform the capacity
assessment? Who should be permitted to
comment on capacity in a patient’s chart?
► Who from the Obstetrical Department be
involved? General Gynaecology, Maternal
Fetal Medicine?
► What should be the role of the hospital
ethicist and ethics committee and when
should they be involved in discussions?
Support in the Literature?
Society of Obstetricians and
Gynaecologists…
“The physician must make sure that the
woman understands the nature and the
potential complications of the procedure
and that she has the necessary information
to make an informed decision.” – a
discussion of mature minor follows but not
comment is made about adults with loss of
capacity
Future Directions
►Development of hospital based guidelines
outlining both the steps and key team
players who should be involved when
pregnancy termination is considered in a
brain injured pregnant patient
► Improved education of the public about
the benefit of advance personal directives in
ensuring the values of a patient are
respected by decision makers and
healthcare teams