The placenta in the litigation process

Article Abstract:

The tense medical-legal climate has changed the practice of obstetrics, and the fear of litigation has driven medical students to choose other medical specialties over obstetrics. The most common type of obstetrical litigation is those cases involving a poor infant outcome, such as cerebral palsy or death during or immediately after delivery. In some cases, it is difficult to recreate the standards of practice when an adverse effect of delivery, such as a neurological deficit, appears in the child many years later. Furthermore, it is difficult to ascertain whether other factors, such as a viral or bacterial infection, played a role in causing the neurological damage. Courtroom cases may focus on the best medical judgments of a witness rather than the actual facts of the case, when evidence is lacking. Perinatal medicine is a complicated science which has been well-served by advances in neonatal care and resuscitation methods. Despite these medical advances, children are still born with cerebral palsy, resulting in a range of neurological deficits. Some studies have shown that damage to the fetus may occur before labor. In this article, the role of the placenta, the organ of fetal nutrition and the source of oxygen from the mother, in the litigation process is evaluated. The cells of the placenta can be examined fairly rapidly, preferably immediately after delivery (otherwise it can be refrigerated until the outcome of the fetus has been established). An examination of the placenta is particularly useful when litigation proceedings involve multiple pregnancies, prolonged pregnancies, premature deliveries, and small-for-gestational-age infants. Cases involving multiple pregnancies usually include examination of the placenta to determine the presence of twin-to-twin transfusion, blood clots and abnormal blood vessel connections. When meconium (the first fetal stool) is released before delivery, it may indicate fetal complications. However, meconium more often relates to fetal maturity than to fetal distress. Chorioamnionitis, swelling in the placenta caused by infection, is commonly reported in premature deliveries. Other complications showing up in placental examinations are those in which the blood supply to the placenta becomes blocked with blood clots, compromising the blood supply to the fetus; this results in fetal growth retardation. As the number of obstetrical malpractice cases increases, the value of placental examination becomes more apparent. (Consumer Summary produced by Reliance Medical Information, Inc.)

Evaluation, Laws, regulations and rules, Medical examination, Practice, Obstetrics, Forensic pathology, Forensic obstetrics

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Antenatal origin of neurologic damage in newborn infants: 2. Multiple gestations

Article Abstract:

Neurological complications such as cerebral palsy, small head size or abnormal brain lesions occur more often among premature twins than among premature singletons. Although the origin of these brain lesions is unknown, it is thought that blood clots from one twin dislodge, travel and enter the blood circulation of the co-twin to land in the brain, causing brain tissue death (necrosis). In an earlier study, there was an association between twins sharing the same gestational sac (monochorionic) who had blood vessel connections in the placenta (such as artery to artery, artery to vein, vein to vein), swelling of the umbilical cord and pus in the amniotic fluid, and tissue death within the brain's white matter. To see if there is a connection between necrosis of the white matter and vascular connections, 89 twins and 12 triplets whose gestational age was less than 36 weeks were studied. Echoencephalographic studies, which use high frequency sound to study the hollows and tissue inside the brain, were used to determine brain necrosis. Necrosis was apparent when hollows in the brain's white matter were present by the third day of life. White matter necrosis was diagnosed in 14 infants (13.8 percent), with a higher incidence among monochorionic twins (30 percent) than in twins having individual gestational sacs (3.3 percent). Necrosis occurring during pregnancy developed more often if the pregnancy was complicated by increased fluid surrounding the fetus, death of the other twin, fetal swelling (hydrops) and multiple blood vessel connections in the placenta. The factor predicting brain necrosis was artery-to-artery, vein-to-vein and artery-to-vein connections and death of the co-twin. Vein-to-vein connections were found in 89 percent of the infants with white matter necrosis. Since cavities in the brain develop two weeks after initial acute tissue death, the lesions must have occurred during pregnancy and not after birth. White matter injury, which occurs more often in multiple pregnancies, is associated with blood vessel connections in the placenta. (Consumer Summary produced by Reliance Medical Information, Inc.)

Causes of, Diseases, Twins, Brain damage, Diseases in twins

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Lack of specific placental abnormality associated with cocaine use

Article Abstract:

Several complications of cocaine use during pregnancy are known; these include fetal growth retardation, abruptio placentae (premature detachment of the placenta), preterm delivery, preeclampsia, and changes in fetal skeletal and urinary structures. Changes have also been found in placentas of cocaine-complicated pregnancies, and additional knowledge regarding these effects was sought by examining 13 such placentas. The placentas studied were from mothers who reported using only cocaine, and whose urine tests did not reveal the presence of other illicit drugs besides cocaine. Nine infants in this group were born preterm. Five infants had growth retardation; two women had preeclampsia; five had premature rupture of the fetal membranes ('bag of waters'); and two fetuses had other complications. However, no specific abnormalities in the placentas were noted at either the gross or microscopic levels. Thus it appears that the effects of maternal cocaine use on the fetus are a consequence of the drug's effect on physiological, rather than morphological (structural), variables. (Consumer Summary produced by Reliance Medical Information, Inc.)

Complications and side effects, Physiological aspects, Cocaine, Drug abuse in pregnancy

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