Articles Posted in Hypoxic Ischemic Encephalopathy

At the end of her pregnancy, Ms. Doe experienced bleeding and pain. She went to the triage unit of Grove Hospital where she was seen by a midwife and first-year resident.

Ms. Doe was attached to a fetal monitor system, which showed decreased variability and some deceleration.

Although allegedly called, Ms. Doe’s treating obstetrician did not initially come to the hospital. An hour later, a nurse summoned the physician who arrived at the hospital more than two hours after Ms. Doe first presented to the hospital.
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At three different obstetrics appointments during the 37th and 38th week of pregnancy, Ms. Doe’s blood pressure readings showed hypertension. When she returned for another appointment toward the end of her 38th week, she had severe hypertension and decreased fetal movement.

Ms. Doe was sent to a hospital where the fetal heart monitor showed the fetal heart rate of 140 beats per minute, minimal to absent variability, and late decelerations.

The attending obstetrician ordered diagnostic testing and then attended to another patient. By the time Ms. Doe underwent a Cesarean section about two hours later, the fetal heart rate had dropped to zero.
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Ms. Doe was pregnant with twins; they shared a placenta but had their own amniotic sacs. During her pregnancy, one of the twins, Twin B, had an abnormal velamentous cord insertion and exhibited persistent absent end-diastolic flow, which indicated underlying fetal vascular stress. Velamentous cord insertion is a complication of pregnancy in which the umbilical cord is inserted in the fetal membranes. In a normal pregnancy, the umbilical cord inserts into the middle of the placenta and is surrounded by the amniotic sac.

At 24 weeks, a Doppler ultrasound revealed reverse end-diastolic flow (REDF) in Twin B’s umbilical artery. Reversal of the umbilical artery end-diastolic flow or velocity can be an ominous sign when detected after 16 weeks of pregnancy. In extreme situations, such as severe intrauterine growth restriction, the arterial blood flow can reverse directions at the end of diastole. This is referred to as a reversed end-diastolic flow.

When this condition was recognized, Ms. Doe’s treating maternal-fetal medicine specialist did not hospitalize her but continued seeing her every week until 27 weeks gestation. Two weeks later, Twin B died.
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Ms. Doe, who had a history of preeclampsia, was admitted to New York-Presbyterian Hospital to deliver her baby. She was administered Pitocin but was discontinued on order by one obstetrician before another doctor restarted it.

Despite all of this, Ms. Doe’s labor failed to progress, and the fetal monitor showed persistent variable decelerations.

Ms. Doe’s baby, a son, was subsequently born in a depressed condition, with Apgar scores of 0 at one minute and 1 at five minutes.
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Anna Scott was admitted to Jefferson Healthcare to deliver her first child. She was at first attached to a fetal heart monitor, which showed that her baby was healthy. She was then taken off the monitor for a six-hour period until her treating physician performed an artificial rupture of the membranes, after which Scott was then reattached to the fetal heart monitor.

The fetal heart monitor revealed that Scott’s baby had developed a worrisome heart rate pattern of repetitive variable decelerations with intermittent minimal variability.

Several hours later, Scott began to push. Her daughter, Lana, was born almost four hours later in a depressed condition with the umbilical cord wrapped tightly around her neck. Lana required 30 minutes of resuscitation. Lana’s Apgar scores were 3 at one minute and 4 at five minutes.
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This case arose from the tragic set of events involving A.F., a baby born with severe respiratory problems who developed permanent brain damage. A.F.’s mother, Kayla Butts, brought this lawsuit claiming that A.F.’s brain damage was caused by the medical malpractice of Dr. Sarah Hardy. It was alleged that Dr. Hardy should have transferred Baby A.F. from the hospital where A.F. was born to a hospital with a neonatal intensive care unit that could have provided the care A.F. needed in the hours after her birth.

After a bench trial, the district court agreed and entered judgment in favor of Kayla Butts for over $7 million in damages. On appeal, the U.S. Court of Appeals considered whether she presented sufficient evidence to establish that Dr. Hardy violated the applicable standard of care.

Because the district court’s finding on that issue was clearly erroneous, the court of appeals reversed the district court’s order and vacated the judgment against Dr. Hardy.
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The use of fetoscopy was first developed in the 1990s. The process involves ultrasound-guided placement of a stethoscope – a small, fiber optic instrument – in the uterus to see the fetus and the placenta.

Fetoscopy as a surgical procedure can treat various fetal conditions including congenital diaphragmatic hernia and bladder outlet obstruction. Its most common use is the treatment of a rare condition, Twin-Twin Transfusion Syndrome (TTTS).

The condition of TTTS occurs when identical twins share a placenta with blood vessel connections that cause blood to flow unevenly between the two fetuses. According to the article, “Caught on Camera” by attorney Jeffrey B. Killino, one of the fetuses develops a small amniotic sac while the other sac becomes too large. Laser fetoscopy allows the laser to break up and collapse these blood vessel connections. Reportedly, if the condition is not treated, both of the fetuses can die. TTTS occurs in approximately 1 in 2,500 pregnancies. It is expected that there will be a rise in TTTS occurrences because of the increase in fertility-assisted pregnancies.
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More than a few studies have been conclusive showing that infants with hypoxic-ischemic encephalopathy have benefited when cooled to a temperature of 30 degrees Centigrade in a median time of 58 minutes. The cooling of newborns inspired oxygen requirements in a test involving six infants diagnosed with HIE.

Five of those infants required inotropic support during the cooling procedure. The cooling would be progressively reduced after 1-2 days. Inotropic support is the intensive care of newborns to stabilize circulation and to optimize oxygen supply.

Over the years, HIE has been recognized much more frequently. The onset of cases of HIE are caused by stroke, compressive forces or changes in oxygen circulating through the fetus before and immediately after delivery.
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In this lawsuit, the mother identified as Ms. Doe was admitted to a hospital to deliver her first child. Although the labor and delivery were prolonged, the treating obstetrician, Dr. Laura Fortner, advised Doe to keep pushing for another 30 minutes.

The obstetrician returned an hour later and used forceps and a vacuum extractor to deliver the baby who had become stuck in Doe’s birth canal. The baby’s Apgar scores were one at one minute and five at five minutes, requiring resuscitation.

The child, now age 16, has been diagnosed as having suffered hypoxic ischemic encephalopathy (HIE), which affects his cognitive, social and fine motor skills.
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Rebecca Kerrins, 38, was admitted to Palos Community Hospital in the Chicago suburb to deliver her second child. Following labor, she reported feeling a gush of blood. This was later diagnosed as a placental abruption.

Because of the placental abruption, her daughter lost up to 60% of her blood supply necessitating a blood transfusion at her birth.

Nurses paged the on-call neonatologist, Dr. Thomas Myers, every few minutes. Dr. Myers did not respond for almost an hour. He arrived at the hospital one hour and 12 minutes after the nurses first paged him.
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