topic Re: Pitdakota - A Couple Of Questions in Community Chat

Pitdakota - A Couple Of Questions

Marp2 — Sat, 11 Jan 2014 06:16:51 GMT

In addition to the McMath case I've also been following the case of Marlise Munoz, the pregnant Texas woman on mechanical support. After some research I found this case study which raised a couple of questions I can't find definitive answers to.

http://www.ijciis.org/article.asp?issn=2229-5151;year=2013;volume=3;issue=3;spage=220;epage=224;aulast=Said

Is there a way to determine if the fetal heartbeat is due to the mechanical support of the mother or if it is independently beating?

Can EEG/neurological testing be done at this time to determine if the fetal brain is functioning and to what degree?

Would you know if the multi-disciplinary approach in the cited case study is routinely used in the U.S.?

Re: Pitdakota - A Couple Of Questions

pitdakota — Sat, 11 Jan 2014 06:19:41 GMT

Marp, let me take a look. I am way out of my league here though with specific fetal and perinatal issues. Let me read the article. I'll be back.

Re: Pitdakota - A Couple Of Questions

pitdakota — Sat, 11 Jan 2014 07:09:15 GMT

Okay, well at least when I started reading the article I felt "at home" since it was discussion of what happened in this particular case of a35 year old female w/a cerebral bleed.

#1 Fetal viability is more related to maturity of the lungs. And to be honest, I don't specifically know that unless there are significant congenital cardiac anomalies that independent cardiac function is a risk in these particular cases. Fetal circulation takes place fairly early and is dependent upon the umbilical cord of course to supply oxygenated blood. The heart does pump although fetal circulation moves via the foramen ovale from the right side of the heart to the left side; bypassing the lungs (because that the placenta & umbilical cord provide the oxygen inutero instead of the lungs. But basically, the heart continues to beat....but is certainly dependent on oxygen via the placenta and in this case then mechanical ventilation. Does that make sense?

#2 I don't know if they are able to perform an EEG inutero. Maybe some neonatal or NICU nurses here would know.

#3. I am going to take exception to the term "multi-disciplinary" are applied in this article/case. They are using it for medical specialties; exclusive of other necessary specialties such as nursing, respiratory therapy, social work, etc. Okay, now that I have that out of my system , we tend to use the term inter-professional collaboration here more often. At any rate, this is outside my pay grade; although to achieve the best outcome for the baby...it would be necessary.

There are so many challenges to providing support for brain dead individuals that require specialists and various professions to collaborate to attempt to achieve the best outcome for the baby. For example overseeing the vent and pulmonary support is best managed by a pulmonologist; whereas treating any diabetes insipidous, any other hormone regulation, & temperature control would be best managed by a critical care specialist or endocronologist. And of course a neonatalogist would be essential to do fetal monitoring, etc. Lots of people to successfully manage the patient to try and achieve the best possible outcome for the baby.

I will say one question I have after reading the article is while they discuss the lit review of 30 cases from 1982-2010 with a survival rate of 12 for the neonatal period, it doesn't specify whether any of those women had prolonged anoxic events. I think that is important information to also evaluate.

If you notice, this patient presents to the ER with a low GCS and is immediately intubated and placed on a respirator. She does not suffer a respiratory arrest. After aggressive management which fails, she appears to suffer the most significant decline on day 4 which leads to a diagnosis of brain death. But she doesn't experience an anoxic period at any time. I think that would be important to also evaluate in these cases as well.

Okay, just my 2 cents. I typed fast, so please excuse typos. No telling how many there are here!!

Re: Pitdakota - A Couple Of Questions

sylviahomeatlast — Sat, 11 Jan 2014 07:27:14 GMT

you really know your facts--I'm totally out of my field. thanks

Re: Pitdakota - A Couple Of Questions

Marp2 — Sat, 11 Jan 2014 07:37:27 GMT

Thank you for your input Pit, I really appreciate it. I opted to cite this particular case because it was most descriptive of the procedures involved.

The fetal heartbeat question arose from other sources reporting instances of the mother's heartbeat mistakenly being monitored and not the fetus. I'm sure you're familiar with the one comment/question leading to a dozen others syndrome.

Your response #1 makes complete sense but also makes me sad in relation to the Munoz woman as no one knows for sure how long she was oxygen deprived and therefore how long the fetus might have or have not been deprived. It sounds like the fetus could have a perfectly normal heartbeat but there is no way of knowing for sure if it is autonomic or the result of machines.

Hopefully someone will be able to answer the EEG question.

Thanks again.

P.S., if there are typos I didn't notice them. I get too busy missing my own.

Re: Pitdakota - A Couple Of Questions

betteb — Sat, 11 Jan 2014 07:37:38 GMT

Pit, that is an excellent assessment and explanation. Bravo.

Re: Pitdakota - A Couple Of Questions

pitdakota — Sat, 11 Jan 2014 07:47:36 GMT

On 1/10/2014 sylviahomeatlast said: you really know your facts--I'm totally out of my field. thanks

Hi Sylvia!! Well, this is what I do. Let me amend that though because fetal and neonate issues are not my area at all. I don't know "nothing bout birthin no babies".

You have your own areas of expertise Sylvia, everyone does. Good to see you.

Re: Pitdakota - A Couple Of Questions

pitdakota — Sat, 11 Jan 2014 07:56:39 GMT

Marp, I hope someone else can answer the EEG question as well. I know they can do some surgical procedures, but I just don't know about an EEG.

Oh I know too well the one question leads to another question, and then what about this? Happens to me all of the time.

I do think it is an important element to consider with brain death in this situation. Obviously there are many different clinical situations that can lead to brain death, but when looking at the viability of a fetus in this situation I think it is an important distinction as to whether the mother had an anoxic event. I also have concerns about the woman in Texas because of this.

It was an interesting article, also interesting to read about a case from the UAE, and I enjoyed reading it, so thanks!

Re: Pitdakota - A Couple Of Questions

BellaPaprika — Sat, 11 Jan 2014 08:00:41 GMT

It's interesting to note that unlike the McMath case where the hospital stated she was brain dead, the Texas hospital has never confirmed or denied reports of Mrs. Munoz being brain dead. Her husband and her parents say they were "told she was" but was this after a proper formal exam by at least 2 physicians or is she actually in a coma or vegetative state? Legal and ethical experts are puzzled by this. The hospital lists her as a patient in serious condition. Ethicists say if she is actually brain dead, then they feel the hospital is misinterpreting the law because she is a corpse and therefore cannot (or they believe should not) be a patient receiving treatment for "life support".

Strange that there should be two such cases in the news at the same time.

Re: Pitdakota - A Couple Of Questions

pitdakota — Sat, 11 Jan 2014 08:02:08 GMT

Thanks betteb! Sometimes we have to go back to what we learned in nursing school and hope that we remember things correctly, don't we?

Re: Pitdakota - A Couple Of Questions

rondell — Sat, 11 Jan 2014 08:06:31 GMT

Hey, pitdakota, I just want to say thank you so much for taking the time to share what you know in these matters. I find it very interesting.

Thank you Marp, for the questions that I never would've thought to ask. I've learned a lot and I'm grateful for it.

Re: Pitdakota - A Couple Of Questions

betteb — Sat, 11 Jan 2014 08:10:04 GMT

On 1/11/2014 pitdakota said:
Thanks betteb! Sometimes we have to go back to what we learned in nursing school and hope that we remember things correctly, don't we?

Yes we do. That was a very interesting report. Thanks to Marp for posting it.

Re: Pitdakota - A Couple Of Questions

Irshgrl31201 — Sat, 11 Jan 2014 08:39:11 GMT

I have really enjoyed Pitdakotas (and the other professionals) posts these last couple of weeks, I have learned a great deal.

Re: Pitdakota - A Couple Of Questions

Marp2 — Sat, 11 Jan 2014 15:54:09 GMT

On 1/11/2014 BlueCollarBabe said:
It's interesting to note that unlike the McMath case where the hospital stated she was brain dead, the Texas hospital has never confirmed or denied reports of Mrs. Munoz being brain dead. Her husband and her parents say they were "told she was" but was this after a proper formal exam by at least 2 physicians or is she actually in a coma or vegetative state? Legal and ethical experts are puzzled by this. The hospital lists her as a patient in serious condition. Ethicists say if she is actually brain dead, then they feel the hospital is misinterpreting the law because she is a corpse and therefore cannot (or they believe should not) be a patient receiving treatment for "life support".

Strange that there should be two such cases in the news at the same time.

I don't know if I will be able to find the specific article again, I can't even search for it right now because we are having horrendous weather and my Internet is at a snail's pace, but I read within the last couple of days that at least some of the confirmatory tests cannot be done because of danger to the fetus. I do not recall the source of that statement but do remember that it made sense to me.

Another case of hurry up and wait to get information. I think in the Munoz case it is the hospital that is refusing to release information not the family preventing it.

Re: Pitdakota - A Couple Of Questions

JustJazzmom — Sat, 11 Jan 2014 19:43:29 GMT

As a former RN who worked at the bedside, I am always appreciative of Pitdakota's posts on anything medical. Well thought out and well written posts all the time!! Bravo to you my friend.

Re: Pitdakota - A Couple Of Questions

pepes mom — Sat, 11 Jan 2014 22:19:31 GMT

Hi Pitdakota. What happened to the other thread? Last I read was when you asked the medical folk to opine on the apnea test. After reading the notes and then the court documents, I had a headache. I was going to respond today, but the thread is gone.

Marp: I would think that if they did an apnea test on the Texas mom, that would mean depriving the fetus of oxygen, therefore they won't do that.

Re: Pitdakota - A Couple Of Questions

151949 — Sat, 11 Jan 2014 22:28:05 GMT

Dr Gupta -who is a neuro doctor - was on CNN and he said there is no way to determine the fetuses brain function in utero but since the mother was brain dead as a result of anoxia the fetus has little chance it was not affected.

Re: Pitdakota - A Couple Of Questions

hyacinth003 — Sat, 11 Jan 2014 22:28:39 GMT

It will all hinge on oxygen getting to the baby and if they were able to manage the other complications of brain damage or death.

Of course, keeping the baby in utero until lung maturity is crucial too.

If the mother didn't have a period of anoxia, the baby might have a good chance.

I think medical technology is way ahead of the ethics of some situations - like this one.

Hyacinth

Re: Pitdakota - A Couple Of Questions

hyacinth003 — Sat, 11 Jan 2014 22:31:17 GMT

On 1/11/2014 happy housewife said: Dr Gupta -who is a neuro doctor - was on CNN and he said there is no way to determine the fetuses brain function in utero but since the mother was brain dead as a result of anoxia the fetus has little chance it was not affected.

I didn't think there was any way to determine brain function in utero, but since I have no experience with babies, I wasn't sure.

Dr. Gupta would be a good source on this one.

Hyacinth

Re: Pitdakota - A Couple Of Questions

Marp2 — Sat, 11 Jan 2014 23:06:11 GMT

On 1/11/2014 pepes mom said:
Hi Pitdakota. What happened to the other thread? Last I read was when you asked the medical folk to opine on the apnea test. After reading the notes and then the court documents, I had a headache. I was going to respond today, but the thread is gone.

Marp: I would think that if they did an apnea test on the Texas mom, that would mean depriving the fetus of oxygen, therefore they won't do that.

I haven't been on most of the day so I didn't even realize the other thread was gone. It doesn't really surprise me though. It was there this morning and the last couple of posts had taken a decidedly religious turn so that is probably why. Webbie was very generous with that thread by just removing individual posts but I guess it went to far today.

I wish I could find or recall the article but I do think the apnea test was specifically mentioned as not being done for the reason you state.