The brain death of a young pregnant woman is an event which poses several ethical and clinical  criticalities for  health professionals.  During the first wave of COVID-19 pandemia in 2020, a 23-year old woman at 24+3 weeks of gestation was admitted in our Neurointensive Care Unit, for  intracranial bleeding. At the admission the patient met the criteria for the diagnosis of brain death. On  the  arrival, the foetus was vital. Therefore, we proceeded to maintain the vital functions of the mother, aiming to provide the foetus with a chance for survival. The clinical treatment was performed around the following key concepts:

• Maintaining hormonal/metabolic functions:

1. thyroid: Levothyroxine 150 mcg firstly, raised to 200 mcg to sustain foetal growth;
2. steroid therapy with hydrocortisone which was first provided intravenous  and then in a second phase  via enteral nutrition as cortisone acetate 25 + 12,5 mg;
3. diabetes insipidus: firstly we use intravenous of desmopressin  boluses of 2 mcg x 3, which were then changed to continuous infusion with variable dosing 0.05-0.03 mcg/h (4-1 mcg/die), adjusted according to the polyuria level.

• Maintaining cardiovascular functions: the very early hormonal substitution and the correct fluidic management allowed to interrupt the aminic support within the first 72h of hospitalization, mitigating its impact on placental circulation.
• Nutritional support suitable to the growing organism at25 Kcal/kg (plus vitamins, iron and other nutrients) and, after 10 days, at 30 Kcal/kg.
• Management of healthcare-associated infections: to reduce  the risk of  pulmonary  infections an early tracheostomy (on day 2 of hospitalization) was performed; manoeuvres of bronchial de-obstruction were routinely performed. The patient developed a Ventilatory Acquired Pneumonia by Meticilline-Resistant Staphilococcus Aureus, which was treated with a short cycle of linezolid. The patient also developed a urinary tract infection by Escherichia Coli, which was treated with clavulanic-amoxicilline. Strictly antibiotic stewardship and infection monitoring were performed.
• Meticulous nursing and mobilization of the patient to prevent decubitus and thrombosis: the patient was routinely mobilized on alternated decubiti, including the left hip.
• Monitoring foetal well-being and intrauterine growth: the gynecologists monitored placental circulation constantly and never found any abnormality.

The treatment, described above allowed the foetus to develop within the standards and  a caesarean section was  performed at 30 weeks of gestation (after 39 days of hospitalization); the child was born with weight of 1670 grams (90° percentile) and of length 44 centimeters (97° percentile). Following the birth, the child required intubation and respiratory support for 36 hours and surfactant administration, after which he was successfully extubated. As of the date of this abstract, the child shows a standard psychomotor development.