A 19-year-old female in her first intrauterine pregnancy was diagnosed with brain death following a suicide attempt by means of a gunshot wound to the right occipital level.
Ultrasonography confirmed the presence of a live product of 19.6 weeks' gestation with no macroscopic malformations. The patient's family requested to continue advanced life support manoeuvres in order to save the product and eventually consider the mother as a potential organ donor. The ethics committee of the institution decides to continue with basic and somatic life support.
Once haemodynamic stability was achieved, management was initiated by the Nutrition Service, emphasising the importance of nutritional support to promote the growth and development of the product. At 20.3 weeks of gestation, mixed nutritional and metabolic support was started, both enteral and parenteral. Resting Energy Expenditure (REE) was estimated using the Harris-Benedict prediction formula, adding the theoretical energy and protein component established for gestational age. The energy and protein intake was increased gradually and gradually according to biochemical monitoring in order to prevent refeeding syndrome behaviour. After 5 days of mixed feeding and once tolerance and nutritional adequacy by enteral route had been established, parenteral support was discontinued. Enteral intake was maintained at total macro- and micronutrient requirements using a mixture of standard polymeric formula, high protein formula and modular trace element formula.
A minimum gestational age of 24-26 weeks was established to consider the possibility of extrauterine life according to previous reports in the literature.
Gestational weight was monitored serially by weekly ultrasound and fetal well-being was monitored by biophysical profile measurement. The relationship between ultrasound weight gain and energy intake is shown in figure 1.

Haemodynamic, ventilatory and metabolic stability was maintained with the usual management measures without evidence of uterine activity or foetal distress by tocographic monitoring for 22 days.
Suddenly, on the 23rd day of ICU stay (22.4 weeks gestation, 12th day of nutritional support), she presented hypertensive dyscontrol with uterine activity and transvaginal bleeding. Obstetric ultrasound showed placental abruption and foetal death.
With the loss of the product and in accordance with the purposes established for continuing vital and somatic management in the ICU, the mother's organs were explanted for donation (liver, heart, kidney and cornea).
The foetal autopsy showed a male product weighing 450g. Macroscopic age of 23 weeks of gestation, with no evidence of malformations.