Dov Apfel.

Birth Injury Information
Dov Apfel.
Maternal Infection in Pregnancy and Perinatal Brain Damage
When a pregnant woman develops an infection, it does not mean that the fetus will be infected, it does not mean that the infant will suffer permanent brain damage, and it does not excuse negligent obstetric care. Yet in birth trauma litigation, defense experts often try to link a newborn's cerebral palsy or other neurologic disabilities to maternal infection during pregnancy.

Defense experts routinely testify that when a pregnancy is complicated by maternal infection, the infant's adverse neurological outcome could not have been prevented. Plaintiffs' lawyers must be prepared to prove either that infection did not cause the brain injury or that infection would not have caused the injury if it had been timely diagnosed and properly treated.

To satisfy this burden, counsel must determine whether

  • the clinician failed to timely diagnose and properly treat the infection,
  • the clinician performed antepartum testing to assess fetal well-being,
  • the clinician recognized and properly managed fetal distress, and/or
  • the brain damage could have been prevented with earlier delivery or proper treatment of the infection or other conditions that contributed to the infant's adverse outcome.

Several conditions other than infection can lead to brain injury during pregnancy or at birth. An important question for the lawyer is whether the injury was caused by asphyxia. Asphyxia is a series of events that begins with hypoxia (reduced oxygen delivery to the brain despite adequate blood flow), hypoxemia (a diminished amount of oxygen in the blood), or ischemia (diminished blood flow to the brain) and culminates with acidosis (blood gas and pH abnormalities). Physicians often refer to the brain injury that is caused by asphyxia as a "hypoxic-ischemic brain insult."

In many birth trauma cases in which the defense claims that infection isto blame for the injuries, the plaintiff's attorney may prove that the true cause was asphyxia. The attorney must show that the hypoxic-ischemic brain injury could have been prevented if the physician had performed fetal testing before labor began (antepartum testing) or during labor and delivery (intrapartum testing), detected fetal distress, and performed an earlier delivery.

Types of Infection

When a pregnant woman develops an infection, the infant's neurological outcome depends on the type of organism involved, the gestational age of the fetus at the time of the infection, the route of infection, and the quality of obstetric and neonatal care. There are two major types and routes of maternal infection.

Hematogenous viral infection. Generally, maternal viral organisms originate in the mother's blood. They are transmitted to the fetus via the maternal blood bathing the villi (the tiny, fingerlike projections of the placenta through which the mother and baby exchange nutrients, gases, and fetal wastes) in the intervillous space.

Viral infections can attack a fetus's brain cells and precipitate a metabolic disorder that inhibits their normal growth and development. Physicians may conduct a series of tests of the mother during a pregnancy to screen for toxoplasmosis, other viruses, rubella, cytomegalovirus, and herpes symplex. This is known as TORCH testing. Also, neuroimaging studies performed after the infant is delivered may reveal a pattern of congenital brain lesions that is characteristic ofinfection.

Ascending bacterial infection. Maternal bacterial agents usually ascend through the cervix, penetrate the placental membranes, and infiltrate the amniotic fluid. This can occur even when the membranes are intact. These infections may cause changes in the placenta that interfere with its capacity to deliver oxygen and nutrients to the fetus and/or to eliminate wastes and carbon dioxide. The fetus also may be exposed to bacteria during vaginal delivery and develop an infection after birth, known as sepsis.

The most significant obstetric complications of an untreated, prolonged bacterial infection in the mother are premature rupture of the membranes(PROM), chorioamnionitis (CA) (inflammation of the fetal membranes known as the chorion and the amnion), preterm labor, prematurity, and neonatal sepsis.

Chorioamnionitis ("CA"). CA is believed to have an indirect effect on brain development by reducing the normal blood flow and oxygenation of the brain. This presumably occurs due to inflammation in the placental membranes or in the umbilical cord, which may also cause abnormal fetal heart rate patterns. Another risk associated with CA is that the fetus will aspirate amniotic fluid tainted with the bacteria and become infected.

After delivery, a microscopic examination of the placenta may reveal clusters of inflammatory cells characteristic of CA or funisitis (inflammation of the umbilical cord, which can result from a severe ascending bacterial infection). Additionally, women experiencing PROM tend to have a higher incidence of CA, but it also can occur in patients with intact membranes.

Defense experts routinely place too much weight on the role of CA as a cause of permanent brain damage. Only in rare cases does the condition cause fetal death or permanent brain injury. Even when CA is accompanied by funisitis, most infants are normal. This is because most bacteria are of low virulence and have no harmful effects on the fetus.

Infection is only one of many potential complications that an obstetrician must properly diagnose and manage to prevent irreversible brain damage or death. In cases involving maternal infection, lawyers and parents should

  • look for clinical evidence revealing the time when maternal infections should have been suspected or diagnosed;
  • determine whether timely treatment was initiated;
  • confirm whether antepartum testing was performed and was properly interpreted;
  • look for clinical evidence of fetal distress or delayed delivery;
  • review the placental pathology report, if available, and determine whether chorioamnionitis was present in the placenta; and
  • evaluate the neuroimaging studies to ascertain whether they reveal the cause or timing of the permanent brain injury.

Taking these steps will ensure that all of the relevant medical issues will be considered and help to overcome the argument that the infant's brain injury could not have been prevented by timely and proper obstetric care.

Please Note:
This web site is not intended as legal advice on cerebral palsy, and is not a substitute for obtaining guidance from your own legal counsel about cerebral palsy litigation. It provides general educational information about the standards of care and causation issues that can arise in obstetrical malpractice and cerebral palsy litigation. Readers of the articles contained within this web site should not act upon the cerebral palsy information without first consulting with a lawyer who is experienced in evaluating and litigating cerebral palsy and obstetrical malpractice cases. Mr. Apfel is admitted to practice law in Maryland and the District of Columbia. When Mr. Apfel is asked to participate in cerebral palsy litigation filed in other states, he will associate with, and act as co-counsel with, an attorney licensed in that state who is familiar with the local laws and procedures.
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