A 19-year-old female with her first intrauterine pregnancy diagnosed with brain death after a suicide attempt by a occipital firearm projectile wound.
Median ultrasound corroborated the presence of live product of 19.6 weeks of gestation without macroscopic malformations.
The patient's family asks to continue advanced life support maneuvers in order to save the product and eventually consider the mother as a potential organ donor.
The institution's ethics committee decided to continue with basic life support and isolation.
Once hemodynamic stability was achieved, management was initiated by the Nutrition Service, highlighting the importance of nutritional support in order to promote the growth and development of the product.
In the 20.3 week of gestation, enteral and parenteral nutrition and mixed metabolic support were initiated.
Rest Energy Expenditure (REE) was estimated using the Harris-Benedict prediction formula, adding the theoretical energy and protein component established for gestational age.
Energy and protein intake was gradually increased and paulatin was gradually increased according to biochemical monitoring in order to prevent behaviour of realisation syndrome.
parenteral nutrition was discontinued after 5 days of mixed feeding and enteral nutrition tolerance and adequacy were established.
Enteral intake was maintained at total macro requirements such as micronutrients by a mixture of standard polymeric formula, high protein formula and trace element modulators.
A minimum gestational age of 24 to 26 weeks was established to consider the possibility of extrauterine life according to previous reports in the literature.
The weight of the gestational product was serially monitored by weekly ultrasound and monitoring of fetal well-being by measuring the biophysical profile.
The relationship between ultrasound profit and energy supply is shown in Figure 1.
1.
Hemodynamic, ventilatory and metabolic stability was maintained with usual management measures without evidence of uterine activity or fetal distress by tocographic monitoring for 22 days.
Suddenly, on day 23 of ICU stay (22.4 weeks of gestation, day 12 of nutritional support), she had uncontrolled hypertension with uterine activity and transvaginal bleeding.
Obstetric ultrasound showed placental detachment and fetal death.
With the loss of the product and in accordance with the established goals to continue life management and ICU care, the mother's organs were explanted for donation purposes (liver, heart, kidney and cornea).
Fetal autopsy showed a male product weighing 450 g.
Macroscopic age of 23 weeks gestation, with no evidence of malformations.
