Briefly, this matter involves an infant born at 38 weeks gestation. His EDC was Feb 26, 2015. The mother was admitted on Feb 13, 2015 in labor, 3.5 cm dilated . Onset of labor prior to admission took place at 6 pm on February 13. Labor until dilation of 10 cm took 15 hours (stage 1), from 10 cm dilation to delivery took 12 minutes (stage 2). The labor and delivery was managed by nurses and house staff until about 2 am when a nurse midwife took over.
Mom had her PNC in Staten Island. It appears that much if not all of her pnc visits were undertaken by a Midwife. The midwife also delivered the baby. From a review of the L&D chart , while the patient was admitted under a Gyn doctor, he never appeared at the Hospital and it was the midwife who was called and took over the management of the labor from house staff at 2AM and delivered the baby an hour later. We have no cord blood gas studies as none were performed. There was no NICU team in the L&D and apparently the Apgar’s were assigned by a nurse or the midwife. Apgar’s were 9/9. The neonatal care was uneventful and there are no labs and no reference to AGB studies ever being performed. Additionally we have a negative MRI and EEG but nevertheless a diagnosis of ataxia CP.
We believed the strips are non-reassuring Cat III. The patient was managed by nurses and house staff from about midnight until 2AM when the midwife arrived.
The child’s treating Pediatric Neurologist diagnosed cerebral palsy at approximately one year of age.
We have had this file reviewed by a neurologist, whose opinion is that the delay in delivery caused the damage that resulted in cerebral palsy. He puts no stock in the APGAR scores.
We also had the L&D chart reviewed by an OB. He found that the FHMS were awful from the moment the monitor was placed on the mother and that the baby should have been delivered hours earlier. At one year of age the baby was seen by a ped neuro. He had an MRI performed. While the MRI was read as normal he nevertheless diagnosed CP and told the parents that sometimes the injuries are too subtle to show up on an MRI.
We had that initial MRI study and a later study taken at three years of age reviewed by a neuro-radiologist.
This doctor found the white matter was decreased in volume slightly posterior albeit subtle on the study taken at one year. On the second MRI taken at three years of age our reviewing radiologist found an area of brain tissue that is not yet myelinated. He stated that on that 3 year image the area appears lighter than the surrounding tissue. This would be normal for a child of his age but it should fade over time. If it does not fade it is the right location for PLV and hypoxic ischemic encephalopathy.
After we had these expert reviews we commenced the litigation. Subsequently, the parents advise that the child was having seizures. A genetic work-up at the hospital revealed that there was strong suspicion of Angelmans syndrome. Defense counsel will be claiming as a defense that the child’s condition is the result of a genetic disorder
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We want to advance a theory that the head studied are indicative of PVL as a result of a hypoxic injury during labor and delivery regardless of what the genetic studies suggest. The child might have Angelmans but our claim will be that he also suffered an insult during delivery.
It should also be noted that the official readings of both MRIs was “normal study”.
We will ask that based upon you review of the child’s records and head studies will we be able to advance an argument that the inconclusive genetic findings suggestive of Angelmans are secondary to a showing of hypoxic injury on the MRIs and that the child’s CP is the result of the poor management of Mom’s L&D as per our pediatric neurologist’s report and that further any findings on the MRI studies are not suggestive or typical of Angelmans syndrome.
Thank-you,
Files:
Q: whether or no this is a case of Angelman syndrome (AS) it does not matter if the initial scanner read as negative showed positive findings. Imaging findings of acute PVL are easily missed in the current clinical practice.
A: —
Do you believe there might have been medical error?
Based on what the neurologist said regarding clinical diagnosis of CP and also based on the OB's assessment of the heart strips. I will have to personally see the MRI to determine what it shows.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the OB commenting on the heart strips and stating that the baby should have been delivered earlier and the clinical diagnosis of CP.
What makes you a good expert for this case?
I am a neuroradiologist with fellowship training and a certificated of additional qualification (CAQ) in neuroradiology. I work at a major teaching hospital. I review both adult and pediatric neuroimaging cases regularly. I have seen and diagnosed cases of cerebral palsy and hypoxic ischemic injury. I have also consulted with an attorney on a CP case previously (it didn't make it to trial).
How often do you encounter cases similar to this one in your practice?
Occasionally. I will have to personally see the MRI to determine what it shows.
Do you believe there might have been medical error?
Cavitation and periventricular cyst formation are required for a definitive diagnosis of PVL. In other words the findings of PVL are not subtle. Based on your description, the MRI findings are subtle and can be easily explained by the given diagnosis of Angelman Syndrome or perhaps represent normal variation. There may be other factors at play. It's possible the patient has CP and that CP was caused by some event at or before birth. But by the sound of it, the MRIs are not definitive proof of PVL.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Hypoxic ischemic brain injury depending on the gestational age at the time of insult, can be severe and unmistakable on imaging, or if occuring closer to term, can be more subtle (as the brain is more mature then). This case describes a close to term infant and therefore it is theoretically possible that the subtle findings on the MRI could be sequela of hypoxic-ischemic brain injury. The problem is, if the imaging findings are subtle it will be difficult if not impossible to prove the diagnosis and to prove causation.
What makes you a good expert for this case?
I'm very experienced in neuroimaging. I am obsessed with fairness and am constantly checking and rechecking my opinions and being aware of my biases so as to guard against them.
How often do you encounter cases similar to this one in your practice?
I work mostly on adult outpatients so it would be rare that I encounter such a case. But the findings and diseases in question are well known to me and described thoroughly in the literature and the imaging findings and relevant anatomy are well within my purvue.
Do you believe there might have been medical error?
Angelman Syndrome presents in children who are one year old or younger. MRI findings are described in the literature, differing from chronic PVL. Acute PVL may be missed, particularly if pseudonormalization phenomenon is present. I would recommend reviewing the first MRI to determine if there is evidence to support the case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
it depends - if initial mri scanner was misinterpreted there is a good chance that the patient's Angelman Syndrome may have been aggravated by the hypoxic ischemic injury. If the initial MRI was completely negative, not showing any subtle sign of white matter injury, then the correlation may be more difficult to demonstrate from an imaging point of view
What makes you a good expert for this case?
20 years of clinical practice in the field of rare genetic disorders
How often do you encounter cases similar to this one in your practice?
very often, I have been reader for clinical trial in rare genetic disorders and I have been first reader in thousand of pediatric neuroimaging cases
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