Care for a Pregnant Woman in a Persistent Vegetative State After a Hypoxic Event From 22 Weeks to Birth at 33 Weeks Gestation

Abstract

Caring for a pregnant patient in a persistent vegetative state (PVS) is very challenging. Our hospital admitted a 24-year-old woman who suffered sudden cardiac arrest, resulting in hypoxia and central nervous system (CNS) damage. She transferred to our facility at 22 weeks gestation with a tracheostomy, gastrostomy tube, and an indwelling urinary catheter. Her previous birth was a cesarean twin birth. The antepartum staff was overwhelmed with the complexity and higher skill level required for this nonresponsive patient. Education was provided for staff using mannequins. The patient required continuous tracheotomy and feeding tube care, assessment for autonomic dysreflexia (AD) episodes, and physical care. AD episodes could be triggered by pain from uterine contractions, discomfort from constipation, a full bladder, or positioning, resulting in agitation, sweating, and tachypnea. The antepartum team was challenged in identifying preterm labor, uterine rupture, maternal chorioamnionitis, thrombus, and assessment of the fetus in a nonresponsive patient. A detailed daily patient care plan and return-demonstration staff education were provided. The successful outcome was due specifically to effective communication and care that were maintained through weekly multidisciplinary patient conferences (NICU, antepartum, labor and delivery staff, physical therapy, respiratory therapy, nutrition, social services, neonatology, internal medicine, neurology, anesthesiology, and perinatology). Weekly topics included complications of immobility, nutrition, continuous physical care of the patient and her fetus, ethical issues such as maternal code status after delivery, timing of full fetal intervention, child custody, and estimated delivery date. It was also important for the staff to have empathy and be realistic with the family due to the poor neurologic patient prognosis. It was especially difficult for the family during the patient’s nonpurposeful movements and blinking, as they hoped she would eventually wake up. There is no standardized management plan for obstetric care of women in a persistent vegetative state. This case illustrates a successful multidisciplinary approach that may be useful as a template in similar situations to provide optimal outcomes for the patient and her fetus. The patient never had a catheter-associated urinary tract infection or pressure sores, and she and her newborn thrived with the help of a collaborative multidisciplinary health care team.