Critical Care Obstetrics part 68 pdf

The Organ Transplant Patient in the Obstetric Critical Care Setting 659 tion less than 500 mg per day, the pregnancy can be expected to progress normally until near term. Although the transplanted kidney usually functions satisfactorily during gestation, most patients do not have an increased glomerular fi ltration rate (GFR) seen in normal pregnant women. GFR, instead, characteristically decreased during the third trimester, although this has been reversible after delivery except in a few cases. Proteinuria also occurs in 40% of renal transplant patients in the third trimester, but this characteristically resolves postpartum. If there are no signs of pre - eclampsia, this proteinuria requires no specifi c treatment [35] . Pregnancy is almost always more complicated in patients with elevated creatinine levels and those with chronic rejection episodes. Deterioration of renal function, rejection and even maternal death has occurred. There is no evidence that pregnancy has a deleterious effect on the transplanted kidney. Rejection of the renal graft with irreversible impairment of renal function during pregnancy or postpartum occurs in 10 – 20% of women, a risk similar to non - pregnant patients [36] . The clinical hallmarks of rejection include fever, oliguria, deteriorating renal fuction, enlargement of the kidney and tenderness to palpation. The diagnosis can be diffi cult because the fi ndings overlap with other disorders, such as pyelonephritis, recurrent glomerulopathy, pre - eclampsia and nephrotoxicity from immunosuppressant drugs. It is crucial to establish the diagnosis of rejection before initating additional antirejection therapy, and the clinical situation of failing renal function demands prompt hospitalization. Imaging studies, such as ultrasound, are useful to detect changes in the renal parenchyma and an indistinct corticomedullary boundary indicative of rejection. If the diagnosis is still unclear, renal biopsy is sometimes necessary. Chronic hypertension and pre - eclampsia are the most promi- nent complications in these pregnancies and contribute to the increase in preterm births, fetal growth restriction and occasional fetal death (Table 46.2 ). Hypertension has been reported in any- where from 47 to 73 percent of patients with a kidney transplant [37] . Pre - eclampsia rates vary, but it is described that one - third of patients with a kidney or kidney/pancreas transplant will develop the syndrome. In women with a renal transplant, blood pressure greater than 140/90 mmHg should usually be managed pharmacologically. Most commonly used antihypertensive agents can be continued during pregnancy with little risk to the fetus, but ACE inhibitors and angiotensin receptor blockers should not be used because of adverse effects on the fetus such as oligohy- dramnios, pulmonary hypoplasia, long - lasting neonatal anuria and possible fetal cardiac defects [7] . Calcium channel blockers are the preferred agents, and they appear to be benefi cial in coun- tering the vasoconstrictive effect of cyclosporine. Pre - eclampsia should be anticipated, and the management is the same as that in the non - transplant patient. Patients with systemic disease require even closer surveillance, but successful pregnancies have occurred in recipients who received their renal allografts for diabetes, type I oxalosis, previ- ous urinary diversion, Favry ’ s disease, systemic lupus erythema- born to immunosuppressed mothers have had relatively uncomplicated courses. Respiratory distress syndrome (RDS), increased susceptibility to infection, hypoglycemia, hypocalcemia, adrenal insuffi ciency, thymic atrophy, bone marrow hypoplasia, transient leucopenia, reduced levels of IgM and IgG, and transiently elevated serum creatinine levels have all been reported, but these conditions are also commonly present in premature infants not exposed to these drugs. Most neonates have also progressed normally through infancy and childhood, [30] but as they reach adulthood there are concerns about the possibility of delayed adverse effects [31] . Fetal exposure to immunosuppressive agents could be associated with later development of fertility problems, autoimmune disease, and neoplasia [32 – 34] . With newer agents, it may be even more diffi cult to accurately identity a cause and effect. It is hoped that lower dosages now possible with drug combinations resulting in less exposure to each specifi c drug will decrease the potential for teratogenesis. However, potentiating effects among drugs as well as unknown interactions in multiple drug regimens could also result in as yet unrecognized adverse fetal effects. Thus, it is important that all offspring exposed to these agents have long - term follow - up. Renal t ransplantation Approximately 1 in 20 women of childbearing age with a functioning renal allograft become pregnant [2] , and it is estimated that more than 10 000 pregnancies have now occurred. Many women have now had more than one pregnancy, and some have successfully delivered twins and triplets. One patient has had fi ve live births and one spontaneous abortion with no evident deleterious effect on the kidney evident 25 years after transplantation [34] (Figure 46.1 ). If preconception graft function is adequate as evidenced by a plasma creatinine < 1.5 mg/dL and a rate of urinary protein excre- Figure 46.1 Two generations following renal transplantation. The patient is pictured with her fi ve children and recently born granddaughter. Chapter 46 660 the diabetogenic effects of pregnancy, corticosteroids, cyclosporine and other immunosuppressive drugs can all aggravate hyperglycemia, macrosomia and other sequelae in pancreas transplant patients. Euglycemia should be achieved preconception, and glucose tolerance testing (GTT) is warranted prior to 20 weeks, particularly in patients who receive a segmental graft. If hypoglycemia is present, diet and insulin therapy should be instituted at that time. If the GTT screen is normal, it should be repeated at 24 – 28 weeks as with any pregnant patient. In reality, most pancreas transplant patients will maintain euglycemia throughout pregnancy and labor [40] . Nevertheless, complications character- istic of diabetes have occurred in these patients including osteo- porosis, fractures, diabetic neuropathy, chronic vascular insuffi ciency, maternal death, stillbirth, neonatal hypocalcemia and hypoglycemia [24] . Liver Improvements in immunosuppressant drug therapy and surgical techniques have resulted in longer life expectancy and many pregnancies in women with liver allografts. Currently, 11% of all patients receiving liver transplants are women of reproductive age, and an additional 15% are younger patients who will survive to and beyond the childbearing age [41] . As in renal transplant patients, conception can be attempted approximately 2 years following liver allograft placement if the patient has a stable immunosuppressive regimen and no signs of liver rejection [42] . Clinical signs suggesting liver rejection are fever, right upper quadrant pain, leukocytosis, elevated serum bilirubin and amnio- transferase levels. Because these tests are non - specifi c, suspected graft rejection requires biopsy confi rmation. Most rejection episodes can be managed by adjustments in the drug regimen. Maternal complications have included elevated liver function tests, rejection, recurrent hepatitis, decreased renal function, urinary tract infection, adrenal insuffi ciency, and endometritis [22,41,43] . There are also increased rates of fetal growth restriction, pre - eclampsia, premature rupture of membranes, preterm birth, cesarean delivery, and neonatal infection (Table 46.4 ). These complications are in part dependent on maternal health before pregnancy and the immunosuppressive regimen employed. Management of these pregnancy complications is similar to those in renal transplant patients. tosus, cystinosis, sickle cell disease, and Wegener ’ s and Goodpasture ’ s syndrome [24] . Although renal transplantation allows diabetic women to become pregnant, immunosuppression adds to the complexity of management because of the risk of infection and potentially poor diabetic control. Maternal complications in diabetic transplant patients have included weight - bear- ing foot fractures, diabetic neuropathy, and vascular complications leading to maternal and fetal death. Neonatal hypocalcemia and hypoglycemia have also been reported in the offspring of these mothers [24] . The data regarding allograft survival following pregnancy are confl icting. However, in general, women with poor prepregnancy renal function (defi ned as a serum creatinine level greater than 1.5 mg/dL), the risk of irreversible loss of renal allograft function is increased. In addition, this increased risk is present during and after pregnancy. The risk is lower if there is good renal function prior to conception. The risk of allograft rejection with pregnancy is less in patients with renal transplant than those with lung or heart transplant. Other o rgan t ransplantation Pancreas The fi rst pancreas transplants were performed in humans in 1966 [38] . Whole or segmental pancreas transplantation is now a treatment option for certain patients with insulin - dependent diabetes mellitus. Based on the international pancreas transplant registry from 1998 to 2000, 1 - year survival rate is greater than 95%. Graft survival rates vary depending on treatment and were 95% when pancreas and kidney were transplanted simultaneously, 74% when pancreas was transplanted after kidney transplantation, and 76% when pancreas alone was transplanted. The 10 - year proba- bility of insulin independence is about 90% if the patient has a functioning graft at 5 years [39] . Findings of pancreatic rejection are pain at the graft site, elevated serum amylase, hyperglycemia, and histologic evidence. Most cases of pancreas transplantation are performed in patients who already have or will receive a kidney allograft at the same time as they receive the pancreas. Since many issues are the same, antepartum and intrapartum management is similar to kidney transplant patients. However, Table 46.4 Representative pregnancy outcome in organ allograft recipients reported to the NTPR . 37 Graft rejection Graft loss Pre - eclampsia Live born Mean GA (weeks) Mean BW (grams) Newborn complications Neonatal deaths Kidney 2 – 4% 4 – 13% 30% 75% 36 2439 48% < 1% Liver 8% 7% 35% 73% 37 2705 29% 0% Heart 21% 0% 10% 69% 37 2717 22% 0% Pancreas 6% 16% 34% 79% 34 2096 57% 2% Lung 27% 21% 13% 53% 35 2285 75% 0% The Organ Transplant Patient in the Obstetric Critical Care Setting 661 approach for care of these patients. Particular attention should address the involvement of an anesthesiologist during late second trimester to formulate a well - organized plan for labor and delivery. An important intrapartum consideration is the denervated heart ’ s increased sensitivity to hypovolemia and catecholamines. Cesarean delivery in these patients should be performed for usual obstetric indications. Antibiotic prophylaxis for subacute bacterial endocarditis is recommended [51] . Opiates can be used to relieve pain and anxiety. Lumbar epidural anesthesia, for either vaginal or cesarean delivery, is effective in controlling pain and lowering pain - induced elevations of sympathetic activity [52] . It is also important to remember that these patients remain at signifi cant risk postpartum secondary to increases in maternal blood volume. Careful attention to cardiac function and maternal immunosuppressive blood levels is crucial to good care [53] . Lung In North America, there are approximately 30 female heart – lung transplant procedures annually. The most frequent indications are congenital heart disease with Eisenmenger ’ s syndrome, primary pulmonary hypertension and less commonly, cystic fi brosis and emphysema. The 1 - year survival rate for heart – lung recipients is 63% and this decreases to approximately 40% at 5 years [50] . There are few cases of pregnancy following heart – lung transplantation in the literature [24,54 – 56] . In addition to the management issues related to heart transplant patients, there are specifi c issues to be considered in the heart – lung transplant recipient. Diagnosing chronic rejection of the lung allograft may be challenging, but one of the fi rst symptoms can be a mild cough with subsequent deterioration in pulmonary function. Very little is known about the changes that occur in the gravid heart – lung recipient. During the transplant, there is a loss of pulmonary innervation, bronchial arterial supply and pulmonary lymphatics. The denervation leads to compromise of the cough refl ex and diffi culty protecting the airway. Decreased lung compliance may result in a persistent alveolar – arterial oxygen gradient. Pulmonary edema is a defi nite possibility in these patients, and excess intra- venous hydration should be avoided. Two patients have died postpartum from complications of obliterative bronchiolitis [56] . Bone m arrow The use of stem cell transplantation for women of childbearing age with leukemia and other malignant and non - malignant hematologic disorders has increased steadily for the past 20 years. Pretransplant conditioning protocols include alkylating agents and irradiation which can cause germ cell injury, ovarian failure and infertility, but many normal children have been born to women after bone marrow transplantation (BMT). Clinically signifi cant acute graft - versus - host disease (GVHD) occurs in 9 – 50% of patients who receive an allogenic stem cell transplant. Immunosuppressive agents, such as methotrexate, cyclosporine, tacrolimus, corticosteroids, or antithymocyte glob- ulin are used for prophylaxis in an attempt to prevent GVHD. The skin, liver, gastrointestinal tract, and the hematopoietic It is also important to note that, although pregnancy does not increase the risk of maternal mortality in liver transplant recipients, there are implications for these patients related to long - term survival and ability to care for children. In one reported series of women undergoing liver transplantation from 1992 to 2002, fi ve of 29 patients died between 10 and 54 months postpartum [42] . Heart The fi rst successful pregnancy in a cardiac transplant patient was reported in 1988 [44] . Since then, more than 5000 women in North America have undergone heart transplants at a current rate of more than 500 per year. In the past, patients with a history of cardiac transplantation have been dissuaded from pregnancy by physicians. This is, in part, related to the risks to the prospective mother. In addition, one must consider long - term survival and implications for child rearing. However, many pregnancies have been managed successfully following cardiac transplantation. There are many cardiovascular changes that occur during pregnancy and the transplanted denervated heart must adapt to the physiologic changes. Arrhythmias may be present and the den- eravated heart may not respond to some vasopressors in a pre- dictable way. Only direct - acting vasoactive drugs will have an effect, and the transplanted heart may be more sensitive to β - adrenergic agonists due to an increase in β - receptors [45] . One - third of patients have tricuspid regurgitation 1 year post transplant, and it may worsen with the increased blood volume associated with pregnancy. Almost one - third of cardiac transplant patients have atherosclerotic coronary vessel stenosis by 3 years after the transplant and up to 50% have atherosclerosis at 5 years [46] . Chest pain from myocardial ischemia will not be present since there is no afferent innervation, and paroxysmal dyspnea may be the only presenting symptom. Many signs and symptoms observed in normal pregnancies, including fatigue, dyspnea, and peripheral edema, may be confus- ing in heart transplant recipients. However, many women have had heart transplants for peripartum cardiomyopathy which has not recurred with subsequent pregnancies [47] . The incidence of acute graft rejection is not increased during pregnancy. Maternal graft rejections episodes occur in 20 – 30% of pregnancies, but most are not clinically evident and are diagnosed by routine surveillance biopsies. Surveillance endomyocardial biopsies are performed most frequently in the fi rst 3 – 6 months after transplantation. Endomyocardial biopsies are generally performed in a specialized facility, with access obtained through the right internal jugular vein or, less commonly, through a femoral vein. A specialized cardiac bioptome is then guided into the superior vena cava and through the right atrium and tricuspid valve into the right ventricle using fl uoroscopy or occasionally echocardiog- raphy [48] . Biopsy specimens are taken from the right ventricle. Rejection episodes are usually successfully managed by increasing the immunosuppression regimen. The increased incidence of hypertension, pre - eclampsia, pre- maturity and low birth weights are similar to that for other transplant patients [24,49,50] . It is well to utilize a multidisciplinary Chapter 46 662 Delivery by cesarean is based on accepted obstetric indications. Operative deliveries in these patients are managed with prophy- lactic antibiotics and additional glucocorticoids, and require strict asepsis, careful attention to hemostasis and good surgical technique. A lower midline vertical incision provides the greatest exposure and avoids the region of the transplanted kidney. A low transverse uterine incision is almost always possible, but the obstetrician should be aware of the anatomic alterations associated with the transplanted kidney to avoid inadvertent damage to the blood supply or urinary drainage. Obstetric e mergencies Acute emergencies may arise in transplant patients during pregnancy with severe consequences that require aggressive management and intensive care. These patients are best managed in a tertiary setting where the transplant surgeon, obstetrician, nephrologists and other subspecialists and intensivists can work together. Most diffi cult is severe and chronic rejection or allograft vasculopathy with loss of graft function which threatens the life of the mother and fetus. In some cases, patients have deliberately stopped their immunosuppression drugs resulting in acute rejection episodes and even death [47,65] . Renal allograft patients with deteriorating function may have to be placed back on dialysis therapy for the remainder of the pregnancy, and other organ recipients need a variety of supportive measures or including re - transplantation. Sepsis and overwhelming infections are also a constant threat in these women, and patients have died of men- ingitis, pneumonia, gastroenteritis, hepatitis C and B and AIDS [24,47] . With the high incidence of hypertension and pre - eclampsia, it is not surprising the HELLP syndrome, stroke and eclampsia have occurred [3,24] . Other causes of morbidity that have required emergent surgery include rupture of renal vessel anastomosis, mechanical obstruction of the ureter, antepartum bleeding, uterine rupture, small bowel injury at cesarean delivery, severe postpartum hemorrhage, abdominal wound dehiscence, and pelvic abscess [3,24] . The b aby All immunosuppressive drugs cross the placental barrier and diffuse into the fetal circulation. Again, because there is no convincing evidence that prednisone, azathioprine, cyclosporine or tacrolimus produce congenital abnormalities in the human fetus, they are the drugs of choice during pregnancy. Other than fetal growth restriction and preterm birth, most offspring born to these mothers have had relatively uncomplicated neonatal courses. Mothers are usually empirically advised against breast- feeding since the immunosuppressive drugs are detected in breast milk [3] . However, the dosage delivered to the infant is generally small. If a woman decides to breastfeed, she should understand there is limited information available to make this decision. system are the organs typically targeted. Diagnosis of acute GVHD can be established clinically in a patient presenting with a classic rash, abdominal cramps with diarrhea, and a rising serum bilirubin concentration [59] . Histologic confi rmation, by biopsy of skin or GI tract, can also be useful. In a patient with acute GVHD, the fi rst and most effective treatment option is the use of corticosteroids with the most commonly used corticoste- roid being methylprednisolone [60] . As with solid organ transplant recipients, infection is a potentially important contributor to maternal morbidity and mortality. Immediately following engraftment (3 weeks to 3 months after transplant), risks include bacterial (listeria and legionella), fungal and viral (CMV, human herpetic viruses and enteric and respiratory viruses) infections. Parasitic infections and mycobac- teria are also a concern. Following this time period, infectious complications can be present as well. Encapsulated bacteria ( Streptococcus pneumoniae , Haemophilus infl uenzae , Neisseria meningitidis ) [61,62] , staphylococci and Gram - negative bacteria, such as Pseudomonas pose the greatest risk to these patients as do viral infections resulting from varicella zoster and Epstein – Barr [63] . In addition, there is concern for loss of immunity acquired early in life to diseases such as measles and environmental expo- sures. Because of the concern for infectious risk, all pregnant patients with a history of BMT with a fever should be treated empirically with broad - spectrum antibiotics and evaluated care- fully for source of infection. Miscarriage, pre - eclampsia, IUGR, and preterm birth are the most frequent complications in patients with a history of BMT and pregnancy, but most have had relatively uncomplicated pregnancies and deliveries [57,58,64] . One study evaluated pregnancy outcome among 113 women after stem cell transplant and found that 85% of pregnancies resulted in live births. Less than 1% of the pregnancies had an anomalous fetus; a rate similar to that of the general population. There was an increased risk for cesarean delivery, preterm delivery and low birth weight infant in those patients with a history of stem cell transplant [58,64] . Labor and d elivery The timing of delivery is often dictated by events such as premature labor, premature ruptured membranes, or severe pre - eclampsia. The extraperitoneal location of the transplanted kidney in the iliac fossa usually does not interfere with vaginal delivery. Obstructed labor from soft tissue dystocia due to the graft or pelvic osteodystrophy is very rare. If the fetal head is not engaged in the pelvis during labor, dystocia can be assessed by ultrasound and CT scan of the pelvis. There are no particular contraindications to induction, labor or vaginal delivery in organ graft recipients. Because of an increased susceptibility to infection, vaginal examinations should be kept to a minimum and artifi cial rupture of membranes and internal monitoring performed only when specifi cally indicated. Cultures and antibiotics are warranted with the earliest sign of infection. The Organ Transplant Patient in the Obstetric Critical Care Setting 663 17 National Institutes of Health . Antenatal Corticosteroids Revisited: Repeat Courses . NIH Consensus Statement. Bethesda, MD: National Institutes of Health, 2000 ; 17 : 1 – 18 . 18 Saarikoski S , Seppala M . Immunosuppression during pregnancy: transmission of azathioprine and its metabolites from the mother to the fetus . Am J Obstet Gynecol 1973 ; 115 ( 8 ): 1100 – 1106 . 19 Penn I , Makowski EL , Harris P . Parenthood following renal transplantation . Kidney Int 1980 ; 18 ( 2 ): 221 – 233 . 20 Registration Committee of the European Dialysis and Transplant Association. Successful pregnancies in women treated by dialysis and kidney transplantation . Br J Obstet Gynaecol 1980 ; 87 : 839 – 845 . 21 Rizzoni G , Ehrich JH , Broyer M , et al. Successful pregnancies in women on renal replacement therapy: report from the EDTA Registry . Nephrol Dial Transplant 1992 ; 7 ( 4 ): 279 – 287 . 22 Armenti VT , Moritz MJ , Radomski JS , et al. Pregnancy and transplantation . Graft 2000 ; 3 : 59 – 63 . 23 Davison JM , Dellagrammatikas H , Parkin JM . Maternal azathioprine therapy and depressed haemopoiesis in the babies of renal allograft patients . Br J Obstet Gynaecol 1985 ; 92 ( 3 ): 233 – 239 . 24 Bumgardner GL , Matas AJ . Transplantation and pregnancy . Transplant Rev 1992 ; 6 : 139 – 162 . 25 Miller J , Mendez R , Pirsch JD , Jensik SC . Safety and effi cacy of tacrolimus in combination with mycophenolate mofetil (MMF) in cadaveric renal transplant recipients. FK506/MMF dose ranging kidney transplant study group . Transplantation 2000 ; 69 : 875 – 880 . 26 Pirsch JD , Miller J , Deierhoi MH , Vincenti F , Filo RS . A comparison of tacrolimus (FK506) and cyclosporine for immunosuppression after cadaveric renal transplantation. FK506 Kidney Transplant Study Group . Transplantation 1997 ; 63 ( 7 ): 977 – 983 . 27 Winkler ME , Niesert S , Ringe B , Pichlmayr R . Successful pregnancy in a patient after liver transplantation maintained on FK 506 . Transplantation 1993 ; 56 ( 6 ): 1589 – 1590 . 28 Le Ray C , Coulomb A , Elefant E , Frydman R , Audibert F . Mycophenolate mofetil in pregnancy after renal transplantation: a case of major fetal malformations . Obstet Gynecol 2004 ; 103 ( 5 Pt 2 ): 1091 – 1094 . 29 Armenti VT , Radomski JS , Moritz MJ , et al. Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation . Clin Transpl 2002 ; 121 – 130 . 30 Lau RJ , Scott JR . Pregnancy following renal transplantation . Clin Obstet Gynecol 1985 ; 28 ( 2 ): 339 – 350 . 31 Scott JR . Development of children born to mothers with connective tissue diseases . Lupus 2002 ; 11 ( 10 ): 655 – 660 . 32 32C lassen BJ , Shevach EM . Evidence that cyclosporine treatment during pregnancy predisposes offspring to develop autoantibodies . Transplantation 1991 ; 51 : 1052 – 1057 . 33 Willis FR , Findlay CA , Gorrie MJ , Watson MA , Wilkinson AG , Beattie TJ . Children of renal transplant recipient mothers . J Paediatr Child Health 2000 ; 36 ( 3 ): 230 – 235 . 34 Scott JR , Branch DW , Holman J . Autoimmune and pregnancy complications in the daughter of a kidney transplant patient . Transplantation 2002 ; 73 ( 5 ): 815 – 816 . 35 Scott JR , Branch DW , Kochenour NK , Larkin RM . The effect of repeated pregnancies on renal allograft function . Transplantation 1986 ; 42 : 694 – 695 . 36 First MR , Combs CA , Weiskittel P , Miodovnik M . Lack of effect of pregnancy on renal allograft survival or function . Transplantation 1995 ; 59 ( 4 ): 472 – 476 . Most neonates have progressed normally through childhood [46,47] . Concerns have recently been raised about the possibility of delayed adverse effects in adulthood such as the later development of fertility problems, autoimmune disease and neoplasia [47 – 49] . Thus, it is important that all offspring exposed to these agents have long - term follow - up. References 1 Murray JE , Reid DE , Harrison JH , Merrill JP . Successful pregnancies after human renal transplantation . N Engl J Med 1963 ; 269 : 341 – 343 . 2 Alston PK , Kuller JA , McMahon MJ . Pregnancy in transplant recipients . Obstet Gynecol Surv 2001 ; 56 ( 5 ): 289 – 295 . 3 Norton PA , Scott JR . Gynecologic and obstetric problems in renal allograft recipients . In: Buchsbaum H , Schmidt J , eds. Gynecologic and Obstetric Urology , 3rd edn . Philadelphia : WB Saunders , 1993 : 657 – 674 . 4 Scott JR . Pregnancy in transplant recipients . In: Coulam CB , Faulk W P , M c I n t y r e J A , e d s . Immunology and Obstetrics . New York : WW Norton , 1992 : 640 – 644 . 5 McKay DB , Josephson MA . Pregnancy in recipients of solid organs – effects on mother and child . N Engl J Med 2006 ; 354 ( 12 ): 1281 – 1293 . 6 Davison JM . Towards long - term graft survival in renal transplantation: pregnancy . Nephrol Dial Transplant 1995 ; 10 ( Suppl 1 ): 85 – 89 . 7 Kasiske BL , Vazquez MA , Harmon WE , et al. Recommendations for the outpatient surveillance of renal transplant recipients. American Society of Transplantation . J Am Soc Nephrol 2000 ; 11 ( Suppl 15 ): S1 – 86 . 8 American College of Obstetricians and Gynecologists . Perinatal viral and parasitic infections. ACOG Practice Bulletin No. 20 . Int J Gynaecol Obstet 2002 ; 76 ( 1 ): 95 – 107 . 9 Brent L . The discovery of immunologic tolerance . Hum Immunol 1997 ; 52 ( 2 ): 75 – 81 . 10 Levitz M , Jansen V , Dancis J . The transfer and metabolism of corticosteroids in the perfused human placenta . Am J Obstet Gynecol 1978 ; 132 ( 4 ): 363 – 366 . 11 Scott JR . Fetal growth retardation associated with maternal adminis- tration of immunosuppressive drugs . Am J Obstet Gynecol 1977 ; 128 ( 6 ): 668 – 676 . 12 Baud O , Zupan V , Lacaze - Masmonteil T , Dehan M . Neurological adverse effects of early postnatal dexamethasone in very preterm infants . Arch Dis Child Fetal Neonatal Ed 1999 ; 80 ( 2 ): F159 . 13 Ballard PL , Ballard RA . Scientifi c basis and therapeutic regimens for use of antenatal glucocorticoids . Am J Obstet Gynecol 1995 ; 173 ( 1 ): 254 – 262 . 14 Cowchock FS , Reece EA , Balaban D , Branch DW , Plouffe L . Repeated fetal losses associated with antiphospholipid antibodies: a collabora- tive randomized trial comparing prednisone with low - dose heparin treatment . Am J Obstet Gynecol 1992 ; 166 ( 5 ): 1318 – 1323 . 15 Abbasi S , Hirsch D , Davis J , et al. Effect of single versus multiple courses of antenatal corticosteroids on maternal and neonatal outcome . Am J Obstet Gynecol 2000 ; 182 ( 5 ): 1243 – 1249 . 16 Esplin MS , Fausett M , Smith S . Multiple courses of antenatal steroids are associated with a delay in long term psychomotor development in children with birth weights < 1500 grams . Am J Obstet Gynecol 2000; 182 : 524 . Chapter 46 664 51 Durack DT . Prevention of infective endocarditis . N Engl J Med 1995 ; 332 : 38 . 52 Kim KM , Sukhani R , Slogoff S , Tomich PG . Central hemodynamic changes associated with pregnancy in a long - term cardiac transplant recipient . Am J Obstet Gynecol 1996 ; 174 ( 5 ): 1651 – 1653 . 53 Mendelson MA . Pregnancy after cardiac transplantation . In: Gleicher N , ed. Principles and Practice of Medical Therapy in Pregnancy , 2nd edn. Norwalk, CT : Appleton and Lange , 1992 : 841 . 54 Parry D , Hextall A , Banner N , Robinson V , Yacoub M . Pregnancy following lung transplantation . Transplant Proc 1997 ; 29 ( 1 – 2 ): 629 . 55 Troche V , Ville Y , Fernandez H . Pregnancy after heart or heart - lung transplantation: a series of 10 pregnancies . Br J Obstet Gynaecol 1998 ; 105 ( 4 ): 454 – 458 . 56 Rigg CD , Bythell VE , Bryson MR , Halshaw J , Davidson JM . Caesarean section in patients with heart - lung transplants: a report of three cases and review . Int J Obstet Anesth 2000 ; 9 ( 2 ): 125 – 132 . 57 Sanders JE , Hawley J , Levy W , et al. Pregnancies following high - dose cyclophosphamide with or without high - dose busulfan or total - body irradiation and bone marrow transplantation . Blood 1996 ; 87 ( 7 ): 3045 – 3052 . 58 Salooja N , Szydlo RM , Socie G , et al. Pregnancy outcomes after peripheral blood or bone marrow transplantation: a retrospective survey . Lancet 2001 ; 358 ( 9278 ): 271 – 276 . 59 Firoz BF , Lee SJ , Nghiem P , Qureshi AA . Role of skin biopsy to confi rm suspected acute graft - vs - host disease: results of decision analysis . Arch Dermatol 2006 ; 142 ( 2 ): 175 – 182 . 60 Bacigalupo A , van Lint MT , Frassoni F , et al. High dose bolus methylprednisolone for the treatment of acute graft versus host disease . Blut 1983 ; 46 ( 3 ): 125 – 132 . 61 Wessels , M , Nevill , T , Ford , K , et al . Late bacteremia after stem cell transplantation: incidence and risk factors analysis . Proceedings of the 25th Annual Meeting of the European Group or Blood and Marrow Transplantation and 15th Meeting of the Nurses Group, March 21 – 25 1999 , Hamburg, Germany. 62 Sheridan JF , Tutschka PJ , Sedmak DD , Copelan EA . Immunoglobulin G subclass defi ciency and pneumococcal infection after allogeneic bone marrow transplantation . Blood 1990 ; 75 ( 7 ): 1583 – 1586 . 63 Kawasaki H , Takayama J , Ohira M . Herpes zoster infection after bone marrow transplantation in children . J Pediatr 1996 ; 128 ( 3 ): 353 – 356 . 64 Carter A , Robison LL , Francisco L , et al. Prevalence of conception and pregnancy outcomes after hematopoietic cell transplantation: report from the Bone Marrow Transplant Survivor Study . Bone Marrow Transplant 2006 ; 37 ( 11 ): 1023 – 1029 . 65 Sims CJ . Organ transplantation and immunosuppressive drugs in pregnancy . Clin Obstet Gynecol 1991 ; 34 ( 1 ): 100 – 111 . 37 Armenti VT , Radomski JS , Moritz MJ , et al. Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation . Clin Transpl 2004 ; 103 – 114 . 38 Kelly WD , Lillehei RC , Merkel FK , Idezuki Y , Goetz FC . Allotransplantation of the pancreas and duodenum along with the kidney in diabetic nephropathy . Surgery 1967 ; 61 ( 6 ): 827 – 837 . 39 Sutherland DE , Gruessner A . Long - term function ( > 5 years) of pancreas grafts from the International Pancreas Transplant Registry data- base . Transplant Proc 1995 ; 27 ( 6 ): 2977 – 2980 . 40 Barrou BM , Gruessner AC , Sutherland DE , Gruessner RW . Pregnancy after pancreas transplantation in the cyclosporine era: report from the International Pancreas Transplant Registry . Transplantation 1998 ; 65 ( 4 ): 524 – 527 . 41 Casele HL , Laifer SA . Pregnancy after liver transplantation . Semin Perinatol 1998 ; 22 ( 2 ): 149 – 155 . 42 Nagy S , Bush MC , Berkowitz R , Fishbein TM , Gomez - Lobo V . Pregnancy outcome in liver transplant recipients . Obstet Gynecol 2003 ; 102 ( 1 ): 121 – 128 . 43 Armenti VT , Radomski JS , Moritz MJ , Philips LZ , McGrory CH , Coscia LA . Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation . Clin Transpl 2000 ; 123 – 134 . 44 Lowenstein BR , Vain NW , Perrone SV , Wright DR , Boullon FJ , Favaloro RG . Successful pregnancy and vaginal delivery after heart transplantation . Am J Obstet Gynecol 1988 ; 158 ( 3 Pt 1 ): 589 – 590 . 45 Camann WR , Goldman GA , Johnson MD , Moore J , Greene M . Cesarean delivery in a patient with a transplanted heart . Anesthesiology 1989 ; 71 ( 4 ): 618 – 620 . 46 Uretsky BF , Murali S , Reddy PS , et al. Development of coronary artery disease in cardiac transplant patients receiving immunosuppressive therapy with cyclosporine and prednisone . Circulation 1987 ; 76 ( 4 ): 827 – 834 . 47 Scott JR , Wagoner LE , Olsen SL , Taylor DO , Renlund DG . Pregnancy in heart transplant recipients: management and outcome . Obstet Gynecol 1993 ; 82 ( 3 ): 324 – 327 . 48 Kim KM , Sukhani R , Slogoff S , Tomich PG . Central hemodynamic changes associated with pregnancy in a long - term cardiac transplant recipient . Am J Obstet Gynecol 1996 ; 174 ( 5 ): 1651 – 1653 . 49 Wagoner LE , Taylor DO , Olsen SL , et al. Immunosuppressive therapy, management, and outcome of heart transplant recipients during pregnancy . J Heart Lung Transplant 1993 ; 12 ( 6 Pt 1 ): 993 – 999 ; discussion 1000. 50 Branch KR , Wagoner LE , McGrory CH , et al. Risks of subsequent pregnancies on mother and newborn in female heart transplant recipients . J Heart Lung Transplant 1998 ; 17 ( 7 ): 698 – 702 . 665 Critical Care Obstetrics, 5th edition. Edited by M. Belfort, G. Saade, M. Foley, J. Phelan and G. Dildy. © 2010 Blackwell Publishing Ltd. 47 Ethics in the Obstetric Critical Care Setting Fidelma B. Rigby Department of Obstetrics and Gynecology, MFM Division, MCV Campus of Virginia Commonwealth University, Richmond, VA, USA Introduction Ethical issues remain a relevant topic in the obstetric setting. This is especially true when one considers that obstetrics often deal with the care of two or more individuals at any one moment. In essence, ethics is “ the determination of what ought to be done, all things considered ” [1] . This defi nition, a form of ethics in action, requires differentiating “ what could be done ” from “ what ought to be done ” and calls for special thought regarding non - professional factors [1] . Chervenak and McCullough [2] describe medical ethics as the “ disciplined study of morality in medicine regarding obligations of physicians and institutions to patients and the obligations of patients. ” They note that medical ethics calls for examining concrete and clinically applicable accounts of how physicians ought to conduct themselves with patients. Tools for answering ethical dilemmas derive from ethical principles that assist practitioners in interpreting and implementing their general moral obligations to protect and promote the interest of the patient [2] . This chapter fi rst introduces four ethical principles that form the framework for ethical decision - making, i.e. autonomy, non - malefi cence, benefi cence, and justice. Boxes 47.1 and 47.2 provide a glossary of ethical terms and review of important legal cases. The doctrine of informed consent and the relative status of the fetus are then examined in relation to the mother. Applications to the critical care setting are then made. Issues involving competency, critically ill patients, and maternal – fetal confl ict are addressed. Specifi c concerns regarding Jehovah ’ s Witness cases are reviewed, and fi nally letters of condolence are discussed. With the aid of this chapter the reader should have an understanding of how to apply ethical principles to the care of the critically ill obstetric patient. Ethical p rinciples Four principles frame the values of the underlying common morality in the community formed by the patient – physician relationship: benefi cence, non - malfi cence, patient autonomy and justice. These principles should guide the approach to the patient in medical ethics [3] . Until the 1960s, the Hippocratic tradition served as the basis for medical ethics discussion in the United States [1] . Physicians were expected to be benefi cent, thereby promoting patient well - being. Benefi cence obligates the physician to act in a manner that produces the greater good for the patient. The coinciding ethical principle of non - malefi cence obli- gated the physician to do no harm [1,3] . The technological advances and cultural change that accompanied the 1960s expanded the framework to include respect for autonomy. This principle emphasizes the decision - making capacity of the competent person [3] . The prior assumption that the physician is the main decision - maker came to be shunned as paternalism. The emphasis shifted from the physician making decisions “ in the patient ’ s best interests ” to the patient ’ s right to self - determination. Patient autonomy rose to the foremost of the ethical principles and tended to overpower other ethical considerations [1] . More recently, limitations on a patient ’ s absolute autonomy have been raised in light of affi rmation of the physician ’ s autonomy, consideration for the physician ’ s character, and efforts to protect physicians from compromising their own principles. The fi nal ethical principle which should be considered is justice. Justice is the principle which involves weighing the obligation to the patient with the physician ’ s obligation to society as a whole. Justice obligates the physician to consider the allocation of limited resources in the community [4] . These varied emphases merged into a model of shared decision - making. Informed c onsent The legal right to informed consent is well summarized in Justice Benjamin Cardozo ’ s ruling in the 1914 case of Schloendorff vs Society of New York Hospital: “ Every being of adult years and Chapter 47 666 Box 47.1 Glossary of ethical and legal terminology Battery Harmful or offensive touching of another person: physicians may commit battery if they operate without patient ’ s consent. Benefi cence The physician ’ s obligation to act in the patient ’ s best interest. Competence Capacity to understand and appreciate the nature and consequences of one ’ s actions. Dependent moral status A moral status which is dependent on someone else ’ s actions. Ethical principles Guidelines for ethical behavior (i.e. benefi cence, autonomy, non - malefi cence). Independent moral status Having a moral status in and of one ’ s self. Justice Consideration of risks and benefi ts to society as a whole. Negligence Breach of duty to the patient from which the patient suffers harm. Non - malefi cence The physician ’ s obligation to do no harm. Paternalism Overriding the patient ’ s wishes to act in a way the physician feels would most benefi t the patient. Respect for autonomy Respect for the patient ’ s wishes and right to self - determination. Substituted judgment When a surrogate decision makes attempts to determine what a patient would have decided. Adapted from Chervenak & McCullough [63] , Annas & Densberger [10] , Pinkerton [44] , ACOG Patient Choice, 2004 [62] . sound mind has a right to determine what shall be done with his body, and a surgeon who performs an operation without his patient ’ s consent commits an assault for which he is liable in damages ” [5] . The original concept of informed consent centered on the legal doctrine regarding battery: the harmful or offensive touching of another person [6] . This concept of battery for unau- thorized surgery applies even if the surgery is appropriately and skillfully done [6] . This point was underscored in the classic case of Mohr vs Williams in which the consent was obtained for surgery on the patient ’ s right ear (Mohr vs Williams, 1905 [87] ). However, increased disease was noted in the patient ’ s left ear at the time of surgery. Although appropriate surgery was done on the more severely affected left ear, the courts ruled that the patient had not consented to the surgery and held the physician liable (Mohr vs Williams, as presented in Beauchamp & Childress, 2001 [3] ). The breach of informed consent in today ’ s legal setting is more commonly interpreted as a form of negligence [6] . Negligence involves a breach of duty to the patient from which the patient suffers harm. In the case of informed consent, negligence occurs when the physician has not disclosed a risk of the surgery and this risk occurs, causing harm to the patient. The patient could then claim that she would not have consented to the surgery if the risk had been disclosed. Exceptions to this concept of informed consent do occur. In an emergency setting, where the patient is incapable of providing informed consent and there is not time to fi nd a proxy decision maker, doctors may provide lifesaving procedures (as long as they do not go against any known beliefs of the patient) [6] . In the case of minors, parental consent is usually needed except when state laws provide for emancipation of minors. Pregnancy is generally one of the conditions that allows minors to consent to procedures on their own behalf. The essence and interpretation of these laws can vary from state to state. Other exceptions to informed consent occur. One of these rare exceptions may include a waiver of informed consent [7] . In this case, a patient with a serious illness specifi cally requests that the physician make decisions regarding treatment options the patient does not feel capable of making (such as surgery vs radiation treatment). As Lo points out, self - determination is undermined when reluctant patients are forced to engage in decision - making against their wishes. Shared decision - making is a goal but not an absolute requirement in this particular setting [6] . In fact, accepting the patient ’ s decision to waive her right to decide can be seen as respect for her autonomy to make such decisions [7] . Physicians should be aware that such patients can change their minds and choose to actively participate in a later phase of their therapy [6] . The American College of Obstetrics and Gynecology was among the fi rst specialty societies to establish an ethics committee [1] . The concept of informed consent evolved in the 1970s when the central concern for the medical well - being of the patient evolved to include increasing concern for the autonomy of the patient in making medical decisions [8] . In the 1980s, the concept of shared decision - making evolved [8] . The issue of informed consent is addressed by ACOG in its 2004 document Informed Consent . In this document, two main aspects of informed consent are addressed: free consent and comprehension. Free consent is defi ned as an act that is intentional and voluntary by which the individual is authorized to act in certain ways. For medicine, free consent means the patient freely authorizes a medical interven- tion [7] . “ Consent ” implies that no coercion is present. “ Free ” implies that the person is choosing among alternatives. The document also emphasizes the element of comprehension, i.e. an awareness and understanding of the information regarding one ’ s care and the possibilities that surround it [7] . The ideal of informed consent works best in a relationship of mutual respect and is best seen as a process, as opposed to a task of getting the patient to sign the consent form. In the critical care setting, decisions are often made under periods of stress with limited time. Special effort must be made to allow the patient (or the desig- nated surrogate) to help in the decision process as much as possible. Competency Informed consent presupposes the patient ’ s competency. Competency questions lead to ethical dilemmas when the patient refuses life - sustaining interventions. In Lane vs Candura, a Ethics in the Obstetric Critical Care Setting 667 Box 47.2 Summaries of important medical – legal cases Informed Consent Mohr v. Williams (1904) [87] Physician was held accountable for operating on opposite ear without consent. Schloendorff v. Society of New York Hospital (1914) [5] Judge Cardozo ’ s classic case where patient was not properly informed re nature of surgery. In the Matter of Karen Quinlan (1976) [12] Court permitted withdrawal of respirator in fi rst “ right to die ” case, introduced “ substituted judgment ” stand and spurred development of ethics committees. Lane v. Candura (1987) [9] Case affi rmed competency of woman who declined amputation of her gangrenous leg. Superintendent of Belchertown v. Bouvia (1983) [88] Court granted right of patient with cerebral palsy to refuse nutrition. Cruzan v. Missouri Department of Health (1990) [13] Courts permitted parents to withdraw feeding tube from patient with persistent vegetative state: spurred development of living wills. Maternal – Fetal Confl ict Smith v. Brennan (1960) [47] Court permitted neonate to sue for damages infl icted during gestation. Jefferson v. Griffer Spalding Hospital Authority Court ordered cesarean section for patient (1981) [46] with complete previa at term. Re: Maydun (1986) [49] Court ordered cesarean after 60 hours of ruptured membranes. Re: A.C. (1990) [39] Patient with terminal cancer underwent court - ordered cesarean with subsequent demise of mother and neonate. Appeals Court overturned decision. Baby Doe v. Mother Doe (1999) [43] Court declined to order cesarean section for placental insuffi ciency, citing re: A.C. as precedent Supreme Court Case. Rowland Case (2004) [55] Pregnant woman charged in stillborn birth of one twin. She accepted plea bargain for child endangerment charge. Supreme Court Cases Roe v. Wade (1973) [38] Landmark decision permitting abortion in fi rst trimester with regulation in second and third trimesters. Calauttiv v. Franklin (1979) [45] Supreme Court invalidated statute that required post - viability termination using least destructive techniques. Webster v. Reproductive Health Services (1989) [50] Court permitted ultrasounds of fetus above 20 weeks undergoing termination. Planned Parenthood v. Casey (1992) [51] Court permitted restrictions on abortions after viability. Jehovah ’ s Witness Raleigh - Fitkin (1964) [77] Court gave permission for forced transfusion of pregnant woman but she left hospital before transfusion. Georgetown Hospital Case (1964) [80] Court ordered transfusion to prevent abandonment of young child. Application of Jamaica Hospital (1985) [79] Court ordered transfusion at 18 weeks gestation in pregnant women with esophageal varices. 77 - year - old widow with diabetes refused amputation of a gangrenous lower leg [9] . She was considered competent when she consented to the earlier amputations of her toe and then a portion of her foot. When she initially vacillated and then fi rmly and repeatedly declined the further amputation, her competency was called into question. Although the lower court ruled against her, the appeals court ruled in her favor, stating, “ Mrs. Candura ’ s decision may be regarded by most as unfortunate but … it is not the uninformed decision of a person incapable of appreciating the nature and consequence of her act. ” (Lane vs Candura in Annas, 1984 [10] ). Thus the mere fact that she was declining a life - saving operation did not in itself make her incompetent. Ethical guidelines must allow for decision - making to proceed when the patient is judged to be incompetent. The Karen Quinlan case in 1976 was pivotal in the evolution of the substituted judgment standard in these cases. Karen Quinlan was a 22 - year - old woman in a persistent vegetative state. She was initially intubated and placed on a respirator using consent to treatment implied by the emergency doctrine [11] . As the vegetative state continued without hope of recovery, her father petitioned to be named her legal guardian so that he could ask that she be taken off the respirator. The court ruling discussed the right to privacy, which includes a right to decline treatment. The court decided the father could exercise this right on his daughter ’ s behalf. The question Chapter 47 668 follows that such a patient has the right to refuse any medical treatment, even that which may save or prolong her life ” [15] . Thus the Bouvia case permitted withdrawal of nutrition from a competent patient with a non - terminal illness. We will consider how these cases and ethical principles should infl uence our approach to critically ill obstetric patients after fi rst addressing the status of the fetus. Status of the f etus One of the special aspects of obstetric medical ethics is that there are two patients involved: the mother and fetus. The status of the fetus can signifi cantly infl uence the approach to ethical issues surrounding the pregnancy. The debate regarding the moral/ legal/political status of the fetus as a person has been going on since antiquity [1] . Many authors have addressed this issue during the last two decades [16 – 29] ). Three main views can be distinguished in much of today ’ s debate regarding fetal status: the fetus never has moral status, has independent moral status, or has dependent moral status. One view is that the fetus never has moral status. Annas argues that there is no justifi cation for considering forced treatment of pregnant women because the fetus has no independent moral status and maternal autonomy concerns should therefore prevail in any situation [30,31] . Problems with this view have become more evident as knowl- edge of fetal status and benefi cial prenatal fetal interventions have become more common. The expanding ability to treat the fetus has encouraged viewing the issue of the fetus as a patient. The idea of a graded moral status for the fetus has been introduced as a way to relieve this dilemma. Brown and Elkins credit Fletcher with introducing the concept of the fetus as a patient [1,18] . In this 1981 editorial in JAMA, he identifi ed several important ethical dilemmas in the emerging fi eld of fetal therapy. Central to his analysis was the pressure to consider the fetus as a separate entity in that specifi c interventions were becoming possible on its behalf. Many authors have addressed this issue of fetal status [17 – 29] ). McCullough and Chervenak have developed a framework to discuss the issue of fetal status by presenting the concepts of independent and dependent moral status of the fetus [32] . They argue that the fetus is a being who can be reliably linked to later “ achieving ” independent moral status as its development pro- gresses. Knowing when to confer “ independent moral status ” is the problematic issue. They hold that the fetus does not have subjective interests per se due to the immaturity of its central nervous system. Therefore, there can be no autonomy - based obligations to the fetus [32] . They conclude that there are, therefore, no fetal rights in the sense that the fetus itself can “ generate ” these rights. This conclusion leads McCullough and Chervenak to propose a dependent moral status for the viable fetus in that viability is the fi rst important step the fetus achieves in progressing towards an independent moral status [32] . The age at which the fetus achieves independent moral status could vary in different that needed to be addressed was, “ What would the patient decide if the patient were able to decide? ” [12] . Decision - makers for the patient were expected to “ render their best judgment ” [6] . This expectation became known as the “ substituted judgment standard ” [6] . The complications surrounding this case spurred the development of ethics committees [6] . This case in particular made clear the limitations of medicine in predicting the outcome of critically ill patients, as Karen Quinlan lived for years after being removed from the respirator [6] . Further evolutions in the ethical and legal response to critically ill patients occurred in the Cruzan, Brophy, and Bouvia cases. Cruzan was a young woman in a persistent vegetative state following a 1983 motor vehicle accident. In 1986, her parents asked that her gastrostomy feeding tube be discontinued because she had previously stated that she “ didn ’ t want to live ” as a “ vegetable ” (Cruzan vs Missouri Dept of Health, 1990 [13] as presented in Lo, 2000 [6] ). In 1990, the Supreme Court affi rmed the Missouri court ruling that states may require life - sustaining interventions in cases where there is no clear convincing evidence that the incompetent patient would refuse such. Many states allow the family to make decisions on the patient ’ s behalf, but the Supreme Court ruled that states could intervene on the patient ’ s behalf to continue life - sustaining measures if there were no clear indications of the patient ’ s preferences [6] . Ironically, the court was repetitioned after more evidence of Cruzan ’ s wishes was discovered. In this phase of the proceedings, the State of Missouri withdrew from the proceedings and Cruzan ’ s attending physician no longer challenged the removal of the feeding tube. The Court then ruled that the tube could be removed (Cruzan vs Missouri Dept of Health adapted from Lo, 2000 [6] ). This case was a landmark case involving the refusal of treatment and spurred the development of living wills and advance directive statutes. The Brophy case in 1986 also confi rmed the right for patients ’ families to allow the removal of feeding tubes in patients in persistent vegetative states [14] . Brophy was a fi refi ghter who fell into a persistent vegetative state following a ruptured aneurysm in 1983. In 1985 his wife petitioned the court to remove his feeding tube, and in 1986 a four to three decision by the Supreme Judicial Court of Massachusetts affi rmed that the tube could be removed ( [14] adapted from Beauchamp, 2001 [3] ). The Bouvia case presented the judicial system with the issue of removing a feeding tube from a competent patient who was not terminally ill [15] . Elizabeth Bouvia was a 26 - year - old woman with cerebral palsy. Her disease left her with only limited use of her right hand such that she could operate an electric wheelchair but could only eat when fed by another person. In 1983 the courts originally upheld the hospital ’ s right to feed her due to the onerous effect her refusal to eat would have had on the staff and other patients [10] . She went to court again 2 years later and lost again. However, this decision was overturned by the appeals court which held “ a person of adult years and in sound mind has the right, in the exercise of control over his own body, to determine whether or not to submit to lawful medical treatment … It . . 665 Critical Care Obstetrics, 5th edition. Edited by M. Belfort, G. Saade, M. Foley, J. Phelan and G. Dildy. © 2010 Blackwell Publishing Ltd. 47 Ethics in the Obstetric Critical Care Setting. 53% 35 2285 75% 0% The Organ Transplant Patient in the Obstetric Critical Care Setting 661 approach for care of these patients. Particular attention should address the involvement of an anesthesiologist. signifi cant risk postpartum secondary to increases in maternal blood volume. Careful attention to cardiac function and maternal immunosuppressive blood levels is crucial to good care [53] . Lung

Định dạng
Số trang	10
Dung lượng	169,05 KB