Premature Birth and Birth Injuries: Prematurity Increases a Baby’s Risk for Birth Injuries, Periventricular Leukomalacia (PVL), Brain Damage & Cerebral Palsy
Legal Help for Premature Birth and Birth Injuries in Michigan and the U.S.
Approximately 15 million premature babies are born annually, and this number is on the rise. Preterm babies die every year, and many are left with lifelong conditions such as infant brain damage, cerebral palsy (CP) and intellectual and developmental disabilities (I/DD). Currently, experts believe that 75% of infant deaths from premature birth are preventable. Essential care during pregnancy can help prevent many of the lifelong injuries associated with premature birth and birth injuries.
One of the main components of essential prenatal care is to identify factors in the mother that put her at risk of giving birth preterm. The physician should then implement strategies to help prevent a premature delivery. Other medical strategies can help a baby’s lungs mature and protect the brain when premature birth is imminent. When a premature baby is in the neonatal ICU, extra care must be given to help prevent the numerous complications associated with preterm birth.
Lifelong conditions that can occur when preterm birth isn’t prevented or when a premature baby’s medical care is mismanaged include the following:
- Periventricular leukomalacia. Although PVL can occur in term infants, it is most frequently found in premature babies.
- Hypoxic ischemic encephalopathy. HIE usually occurs in term infants, but sometimes premature babies can develop HIE. HIE usually involves damage to the basal ganglia and watershed regions of the brain, but sometimes also includes PVL.
- Neonatal encephalopathy
- Permanent brain damage
- Seizure disorders
- Cerebral palsy (CP)
- Intellectual disabilities
- Developmental delays
- Motor disorders
The Relationship between Premature Birth and Birth Injuries: How Does Premature Delivery Cause CP, PVL, HIE, and Other Birth Injuries?
Typically, a baby is considered preterm if the delivery occurs before 37 weeks of gestation. However, babies born before 39 weeks have higher neonatal morbidity and mortality. Thus, many experts consider birth prior to 39 weeks to be preterm or early term.
When a baby is born prior to term, certain organs aren’t fully developed, such as the liver, kidneys and lungs. In addition, blood vessels are fragile, making the baby more susceptible to brain bleeds, especially intraventricular hemorrhages (IVH). Due to immature organs and body systems, a premature baby is prone to prolonged high bilirubin levels (prolonged jaundice), infection, trauma and oxygen deprivation (hypoxia), all of which can cause birth injuries and lifelong conditions, such as cerebral palsy.
Due to the serious complications associated with premature birth, efforts should be made to prevent a baby from being born preterm. However, sometimes a premature birth is medically indicated, and when this occurs, very close monitoring and medical management of the mother and baby must take place.
Which Premature Birth Complications Can Cause Birth Injuries?
1. Intracranial Hemorrhages (Brain Bleeds), Periventricular Leukomalacia (PVL) & Cerebral Palsy
Premature babies are at a higher risk for intracranial hemorrhages, such as an intraventricular hemorrhage, which is bleeding into the brain’s ventricular system, where spinal fluid is produced. Preterm babies are susceptible to IVH because blood vessels in their brains are not fully developed and therefore are weak. IVH can also result from physical trauma during birth. If a baby is in a difficult position, such as a breech presentation, the head may get stuck in the birth canal, or the process of maneuvering the baby might injure the head and cause a bleed. In a difficult birth, physicians may utilize delivery instruments, such as forceps. When used improperly, these instruments can cause different types of brain bleeds, such as IVH, a subdural hematoma and a subgaleal hemorrhage. Indeed, a premature birth makes a breech more likely, and the difficulty of labor can cause the baby to have fetal distress, which can cause hypoxia, PVL and brain damage. Furthermore, bleeding in the baby’s brain can cause oxygen deprivation, PVL and cerebral palsy.
2. Infection, Meningitis, Sepsis, Brain Damage in the Baby & Cerebral Palsy
Certain conditions can cause a mother’s membranes to rupture (her water breaks) before labor begins. When this happens before term, it is called preterm PROM, or PPROM. Preterm Premature Rupture of the Membranes frequently is the result of an infection in the vagina or uterus, and when the membranes break, the infection travels to the baby during birth.
Infections that a baby can get when PPROM occurs include the following:
- Chorioamnionitis (infection of the amniotic fluid and membranes that surround the baby in the womb)
- Herpes Simplex Virus (HSV), which can cause neonatal herpes encephalitis
- Encephalitis (inflammation of the brain, most often caused by HSV)
- Group B Strep (GBS)
- Sepsis (most commonly from GBS)
- Meningitis (most commonly from GBS)
These infections can cause permanent brain injury in the baby and cerebral palsy, if not properly treated.
When prematurity is caused by PPROM, the baby is susceptible to fetal distress and umbilical cord prolapse. Cord prolapse can impede or completely cut the baby off from her only source of oxygen. A prolapsed umbilical cord and fetal distress can cause the baby to have periventricular leukomalacia (PVL), brain damage and cerebral palsy.
3. Newborn Respiratory Distress Syndrome (RDS) & Hypoxic Ischemic Encephalopathy (HIE)
Breathing problems are a common cause of issues that can leave a premature baby with permanent brain damage.
A baby born preterm often has difficulty breathing, and one of the common causes of this is respiratory distress syndrome (RDS). In RDS, the baby’s immature lungs don’t produce enough surfactant. Surfactant allows the inner surface of the lungs to expand properly. When a baby is born prematurely, the physician usually administers 3 doses of surfactant within 72 hours. The first dose is given immediately after birth, or shortly after breathing problems are revealed. Surfactant therapy has been shown to substantially reduce respiratory problems and mortality in premature babies.
Indeed, proper management of RDS typically includes giving the baby a breathing tube (called intubation) so that surfactant can easily be administered right into the baby’s lungs. If surfactant therapy is delayed or not given, or a premature baby is not given enough help to breathe, severe RDS can suddenly affect the baby, and this can even cause the baby to code (go into cardiac and/or pulmonary arrest). Sometimes, RDS is not properly managed, causing the baby to have chronic (long-term) breathing problems and hypoxia. Proper management of RDS means giving the baby the correct doses of surfactant in a timely manner and making sure the baby is adequately breathing. This means the baby needs appropriate assistive breathing devices, which may include a breathing machine (ventilator). Mismanaged RDS can cause a baby to have brain damage, hypoxic ischemic encephalopathy (HIE) and cerebral palsy.
4. Neonatal Hypoglycemia & Cerebral Palsy
Preterm babies are at risk of developing neonatal hypoglycemia (NH), which is a condition in which the baby’s glucose (blood sugar) falls to unsafe levels shortly after birth. Babies need glucose for energy, and the baby’s brain depends on a steady supply of it as its main source of fuel. When brain cells receive inadequate glucose, they start to die, which can cause brain damage and cerebral palsy. NH is easily diagnosed by drawing a small amount of the baby’s blood and testing it. The blood should be sent to a lab, but a quick bedside test can also be done in the meantime so that treatment can begin immediately, if necessary. The bedside result can later be compared to the more accurate lab result. For the majority of babies, treatment for NH is simple: a baby with NH needs extra feedings with breast milk or formula, or a glucose solution can be given through an IV if the baby is unable to be fed by mouth. In more serious instances of NH, the baby may need medication. In severe cases, surgery to remove part of the pancreas, thereby reducing insulin production, may need to be performed. Since diagnosis and treatment are usually very easy, there really is no reason for a premature baby to suffer from hypoglycemia.
5. Hyperbilirubinemia (Jaundice), Kernicterus & Cerebral Palsy in the Baby
Jaundice is one of the most common health problems in premature and term babies. Jaundice is the yellowing of skin and eyes that happens when red blood cells break down and bilirubin, a byproduct of this breakdown, floods the baby’s body. Most babies are able to metabolize (break down and utilize) bilirubin easily. In some babies, however, red blood cells break down faster than normal and the body can’t easily metabolize the bilirubin. In these babies, bilirubin builds up to dangerous levels in the blood, a condition that is called hyperbilurubinemia.
Hyperbilirubinemia can cause a type of serious brain damage called kernicterus. Kernicterus is primarily seen in premature or sick newborns because their liver and kidneys aren’t fully developed and cannot quickly remove extra bilirubin. Kernicterus is a brain toxin, and when it enters the brain, it causes damage to the gray matter, particularly that in the basal ganglia. Children with kernicterus usually have a dystonic or athetoid form of cerebral palsy.
Hyperbilirubinemia is easily diagnosed with simple blood tests. It also is easily treatable with phototherapy, a fiberoptic phototherapy blanket, and a blood exchange transfusion. The underlying condition that is causing the hyperbilirubinemia should also be treated, if possible. Infections and trauma that causes bleeding under a baby’s scalp are conditions that can cause elevated bilirubin levels.
6. Apnea of Prematurity, Hypoxic Ischemic Encephalopathy (HIE) & Brain Damage in the Baby
In many babies born preterm, the region of the central nervous system that controls breathing is not yet mature enough to allow non-stop breathing. This causes regular (or fast and deep) breathing followed by periods of shallow or stopped breathing. This is called apnea of prematurity (AOP). The pauses in breathing typically last for 15 – 20 seconds (sometimes longer), and are often accompanied by a drop in heart rate (bradycardia) and hypoxia, as well as pale or bluish color. Caffeine and theophylline have been used for decades to treat AOP. In addition, there are many different types of breathing devices that can help prevent apnea. With appropriate settings on a ventilator, apnea can be completely prevented. In many cases, the risks associated with being intubated and on a ventilator are much less than the risk of brain damage that can result if the baby has significant apnea and bradycardia that goes untreated. Indeed, untreated or improperly treated apnea can cause hypoxic ischemic encephalopathy (HIE), brain damage and cerebral palsy.
7. Anemia of Prematurity, Neonatal Brain Damage & Cerebral Palsy
Babies experience a decrease in circulating red blood cells after birth. Hemoglobin is the part of the red blood cell that carries oxygen, and anemia means that the hemoglobin level is below normal. Infants born at term have a response to anemia: their bodies produce more of a hormone called erythropoietin (EPO), which controls red blood cell production. This response is diminished in premature babies, so they often remain anemic for a much longer period of time. One of the most serious issues that anemia of prematurity can cause is hypoxemia / hypoxia, or a lack of oxygen in the blood stream to be carried to the tissues. Although babies have ways of compensating for anemia and hypoxia, reduced hemoglobin means there is a reduction in the ability to transport oxygen to the cells and tissues in the body. If hemoglobin becomes low enough and goes untreated, the baby will not be getting sufficient oxygen to the cells – including brain cells – and this could lead to brain damage and cerebral palsy. One treatment for anemia is a red blood cell transfusion, and this should be performed when the level of anemia becomes symptomatic or is thought to compromise adequate oxygen delivery.
8. Bronchopulmonary dysplasia (BPD), Infant Brain Damage & Cerebral Palsy
Bronchopulmonary dysplasia (BPD) is a common lung problem among premature babies. It is characterized by scarring on the lungs, primarily from the immaturity of the lung tissue coupled with improper ventilator settings. BPD is typically diagnosed when a preterm baby has been on ventilation /oxygen therapy long-term – more than 28 days. It is not known what causes this serious condition; however, being on a ventilator is known to worsen the condition due to increased pressure exerted on the lungs. It therefore is crucial that a baby’s lung pressures be carefully monitored while on the ventilator, and that time spent on a vent be minimized. When the medical team does not pay close attention to blood gases, chest x-rays, and pressures and other data on the ventilator, the baby’s lungs can become severely compromised, and this can cause oxygen deprivation, brain damage and cerebral palsy.
9. Blood Pressure & Blood Volume Issues in the Baby (Hemodynamic Problems) & Brain Damage
Premature babies may have low blood pressure (hypotension) due to RDS, heart dysfunction, capillary leak syndrome, and low blood volume (hypovolemia). Hypotension should be promptly treated. Maintaining a good blood pressure is extremely important because a low blood pressure can cause a decreased flow of blood to the vessels in the brain. Sometimes treatment is simple, and normal saline or blood is given to the baby. Medications such as Dopamine or Dobutamine may also be used to achieve adequate cardiac output, which is the amount of blood pumped out of the heart per minute. A side effect of these drugs is very high blood pressure, and it is important that this be avoided as well. Hypotension causes reduced blood flow in the brain, which can cause periventricular leukomalacia and hypoxic ischemic encephalopathy. If this is prolonged or severe, it can cause brain damage and cerebral palsy. Thus it is crucial that a baby’s blood pressure be closely monitored, and a low blood pressure must be treated right away.
Preventing Premature Birth and Birth Injuries
Indeed, premature birth puts a baby at risk of having numerous complications. There are, however, many treatments that can help prevent premature birth and associated birth injuries.
1. Preventing Premature Birth Through Cervical Cerclage
A short cervix is one of the biggest risk factors for premature birth. It is recommended that all pregnant women have their cervices measured between weeks 14 and 28 of pregnancy. If tests show that the mother’s cervix is incompetent or short, a surgical procedure, called cervical cerclage placement, should be performed. A cerclage helps reinforce the cervical muscle and can help prevent premature birth. During cerclage placement, the cervix is stitched closed with strong sutures (or a suture), which helps the cervix remain closed under the weight of the baby. The placement of a cerclage is an extremely effective treatment for prevention of preterm birth, and this treatment has been in use for about 60 years. Cerclage may also be recommended in other instances, such as when the mother previously had a preterm birth. Mothers with cervical incompetence based on a prior second trimester loss and / or a premature birth typically have “history-indicated” cerclages, and these are usually performed at 12 – 14 weeks of gestation.
2. Preventing Premature Birth with Progesterone
Progesterone helps prevent premature birth in mothers at risk of preterm labor due to a short cervix, and it can also be useful when other risk factors are present. Progesterone is a hormone that helps women remain pregnant. It helps keep the womb from contracting and the hormone helps the womb grow. If contractions occur too early, the mother may go into premature labor. Progesterone therapy is usually initiated around the 16th – 20th week of pregnancy, lasting until the 36th week. Progesterone is also given when the mother had preterm labor in the past and the physician thinks she is at risk for having preterm labor in her current pregnancy.
Some physicians give progesterone therapy to mothers who are having twins. Mothers pregnant with twins can have progesterone therapy if they have a short cervix or have had a previous preterm birth. In addition, mothers who have had previous PPROM appear to benefit from progesterone therapy in later pregnancies.
Preventing Brain Damage and Cerebral Palsy in Premature Babies
1. Preventing Premature Birth with Steroids
When a baby is born prematurely – or about to be born prematurely – physicians must take steps to prevent the serious problems associated with preterm birth, such as RDS, sepsis, brain bleeds and PVL. When a baby is about to be born preterm, corticosteroids should be given to the mother to help the baby. Betamethasone is the most commonly used steroid, and it has been shown to reduce the incidence and severity of RDS, intraventricular hemorrhages (IVH), sepsis and periventricular leukomlacia (PVL). When appropriately given to the mother, corticosteroids help the baby’s lungs mature before the baby is delivered. The drugs also help numerous tissues throughout the baby’s body mature.
2. Preventing Premature Birth with Magnesium Sulfate
Another drug that can be given when a baby is about to be born prematurely is called magnesium sulfate. This medication is given while the baby is in the womb, and it has direct and indirect effects on the baby’s brain. Premature babies are at an increased risk for brain injury and cerebral palsy. Magnesium sulfate has been shown to help protect the baby’s brain from injury, and it increases the chance that the baby will be born free of cerebral palsy.
Magnesium sulfate protects the baby’s brain by increasing cerebral (brain) blood flow, having antioxidant effects, reducing the damaging molecules (cytokines) that are released when inflammation is present, stabalizing membranes in the brain, and preventing large blood pressure fluctuations. The drug also helps stop a process called neuronal excitability (excitotoxicity), which is damaging to the brain and occurs when the brain experiences trauma, restricted blood flow and oxygen deprivation.
Award-Winning Lawyers Helping Children with HIE, Brain Damage, and Cerebral Palsy from Premature Birth and Birth Injuries
Reiter & Walsh, P.C. was established to focus exclusively on birth injury cases. Since the firm’s inception in 1997, our legal team has addressed the special needs of our clients in a variety of birth injury, pregnancy and newborn medical malpractice cases, many of which involve premature birth injuries and complications. Our attorneys and in-house medical staff determine the causes of our clients’ injuries, the prognoses of birth injured children and areas of medical negligence.
Our firm, which is based in Detroit, Michigan, has helped families across the United States in cases involving HIE (hypoxic ischemic encephalopathy), premature birth, cerebral palsy, periventricular leukomalacia (PVL), and other birth injuries and complications. Our clients have hailed from all over the United States, in places including Michigan, Ohio, Texas, Wisconsin, Washington D.C., Pennsylvania, Tennessee, Arkansas, Mississippi, and other states. The Reiter & Walsh, P.C. birth trauma team has also handled FTCA (Federal Tort Claims Act) cases involving military medical malpractice and federally funded clinics.
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