The normal brain is composed of a complicated network of healthy cells. Normal brain function depends on a steady supply of glucose and oxygen, carried from the maternal blood to the placenta and, then, from the placenta-via the umbilical cord and the fetal circulation-to the brain. Because the placenta is essential for the transfer of nutrients and gases from the mother to the fetus and for removal of fetal waste products, when maternal, fetal, or placental conditions prevent normal blood flow from the mother to the placenta, or from the placenta to the brain, the decreased delivery of glucose and oxygen can cause cells to become irreversibly injured and die.
Pregnancy complications that affect normal placental development and function and can also lead to histological changes in the placenta. These changes are referred to as lesions or abnormal findings. Some lesions can be observed on gross examination, while others are detected microscopically
The Examination of the Placenta
An examination of the placenta after birth consists of a two-step procedure. First, the pathologist performs a visual inspection referred to as a gross examination. It usually enables the pathologist to identify disorders affecting placental weight, size, shape, and thickness. A gross examination should indicate whether the placenta is stained with meconium - a dark-green material released from the fetus's intestine. Sometimes, the presence of meconium in the amniotic fluid is used by attorneys as evidence that the baby's oxygen supply was compromised. The gross report should also include a description of the umbilical cord. A cord typically has a median length of 57.5 centimeters and has three blood vessels (two arteries and one vein). A short cord (30 centimeters or less) or a long one (110 centimeters or more) can be associated with neonatal problems.
After performing a gross examination, the pathologist selects specimens of the placenta and prepares slides containing this tissue. The pathologist should select tissue from both the fetal and the maternal sides of the placenta, and from sections of the placenta that appear to have an abnormal appearance. The slides are then examined under a microscope. This examination can identify abnormalities that cannot be seen with the naked eye. For example, while some infarcts (areas of dead tissue) may be visible on the maternal surface, many infarcts can only be detected with a careful microscopic examination.
The Use of the Placenta Examination in Litigation
An important step in the evolution of placental pathology in contemporary obstetrical practice occurred in 1991 at a conference held in Atlanta. Under the leadership of nationally known placental pathologists, and with the support of the College of American Pathologists, several working groups tried to reach a consensus about the appropriate circumstances and procedures for performing an examination of the placenta and about the significance of abnormal findings in explaining a fetal death or injury. The meeting resulted in the publication of a series of articles relating placental findings to adverse pregnancy outcomes.
College of Am. Pathologists Conference XIX, The Examination of the Placenta: Patient Care and Risk Management, 115 ARCHIVES PATH. & LAB. MED. 641-732 (1991).
Yet the obstetrical community has been slow to recognize the purported virtues of placental pathology. In 1992, the American College of Obstetricians and Gynecologists published a committee opinion that acknowledged the possible value of examining the umbilical cord and the placenta. But, it cautioned that "the benefit of securing specimens on a routine basis is as yet unproven".
AMERICAN COLLEGE OF OBSTETRICIANS & GYNECOLOGISTS, COMMITTEE OPINION NO. 125 (1993) (replacing OPINION NO. 102 (1991).
It is beyond the scope of this discussion to point out all of the placental abnormalities that may be significant in birth trauma litigation. If placental tissue has been saved and slides are available, it may be helpful to discuss the gross and microscopic findings with the pathologist who performed the examination. If the pathologist is not available, or has little experience in placental pathology, the attorney may request recut slides and consider consulting with a placental pathologist, who will usually have more training and experience in identifying abnormal placental findings and linking them to specific genetic, infectious, chemical, hypoxic, ischemic or other factors that may have caused the fetal injury or death.
Remember!
It is impossible to make any sweeping statements about the ability of pathologists to pinpoint the cause and timing of antepartum or intrapartum events, leading to an infant's irreversible brain damage or death, solely from an examination of the placenta. Many placentas will demonstrate some pathologic changes that can be referred to as abnormal. Abnormal findings are of little importance in most cases, however, because such findings are compatible with many maternal or fetal conditions which occur in normal pregnancies with good outcomes. Thus, abnormal gross or microscopic placental findings often have questionable value in determining the timing and etiology of the infant's brain damage. Each case has to be evaluated on its own merits.
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.
