Archive for the ‘Birth Injuries’ Category

Fibroids during pregnancy increases risk of stillborn birth.

February 9, 2010

Fibroids, which occur in an estimated 5% to 20% of women, have been reported by researchers at Washington University in St. Louis, Missouri  to increase the risk of stilborn birth. The study was presented Saturday, February 6th,  at the annual meeting of the Society for Maternal-Fetal Medicine in Chicago.

It is known that many women who have fibroids are without any symptoms.  What is of importance is that women typically undergo sonography at 16 to 22 weeks.  It is at this time that such asymptomatic fibroids can be detected.

This study looked retrospectively at over 64,000 births.  After numerous other factors were excluded and a subgroup identified, the investigators found that women with  fibroids and in whom there was evidence of intrauterine growth restriction (IUGR) were at a relative increased  risk of having a stillbirth (fetal death in utero – FDIU).

“Our results showed that women with a combination of fibroids and fetal growth restriction were at two-and-a-half times the risk of having a stillbirth, though the absolute risk remained rare,” said Dr. Alison G. Cahill, one of the study’s authors. “This may lead to a future recommendation for serial growth scans to monitor fetal growth in women with fibroids.”

One related question remains: will the cost-effectiveness of serial sonograms for this group at risk drive the decision-making on setting a new standard for surveillance?

If you are pregnant and know you have fibroids, this is a subject for discussion with you obstetrician.  If you are unaware of the presence of fibroids and undergo the usual 16-22 week sonogram, it might not be a bad idea to inquire about the presence of asymptomic fibroids when this test is interpreted.  We have been involved in a number of cases of FDIU and the emotional devastation it causes a family when it occurs is simply awful.

Should you be interested in more information about fibroids, the US Department of Health and Human Services has a good FAQ on this topic.

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Autism: Is advance maternal age a true risk factor? New study suggests link.

February 8, 2010

The newswires, blogs and tweets abound today with stories about a new study by the UC Davis M.I.N.D. Institute, which is reported to link advanced maternal age with increased risk of having a child with autism.  See the Institute’s Newsroom release on this study.                                            

The researches obtained the birth records for all births occurring in California from January 1, 1990 through December 31, 1999, which included demographics such as the parents’ ages.  Additionally, the researchers obtained the electronic records identifying children born during the study period who later received an autism diagnosis from the state Department of Developmental Services.  After certain exclusionary criteria were applied, the total study sample was approximately 4.9 million births during the study period of the 1990’s.  It was also determined that there were 12, 159 cases of autism, as that condition was defined “as a diagnosis of full-syndrome autism at a California Regional Center.”

The press release reports as follows:

The study found that the incremental risk of having a child with autism increased by 18 percent —  nearly one fifth — for every five-year increase in the mother’s age. A 40-year-old woman’s risk of having a child later diagnosed with autism was 50 percent greater than that of a woman between 25 and 29 years old.

Advanced parental age is a known risk factor for having a child with autism. However, previous research has shown contradictory results regarding whether it is the mother, the father or both who contribute most to the increased risk of autism. For example, one study reported that fathers over 40 were six times more likely than fathers under 30 to have a child with autism.

“This study challenges a current theory in autism epidemiology that identifies the father’s age as a key factor in increasing the risk of having a child with autism,” said Janie Shelton, the study’s lead author and a doctoral student in the UC Davis Department of Public Health Sciences. “It shows that while maternal age consistently increases the risk of autism, the father’s age only contributes an increased risk when the father is older and the mother is under 30 years old. Among mothers over 30, increases in the father’s age do not appear to further increase the risk of autism.”

Dr. Irva Hertz-Picciotto, a member of the Institute and the senior author of the report, in an interview with the Los Angeles Times said, “There is a long history of blaming parents for the development of autism.  We’re not saying this is the fault of mothers or fathers. We’re just saying this is a correlation that will direct research in the future.”

Another member of the research team, Janie E. Shelton, noted that while the data shows that the recent trend toward delayed childbearing contributed about a 4.6% increase in autism diagnoses over the decade –

Five percent is probably indicating that there is something besides maternal age going on because we are seeing a rise in every age group of parents.  We don’t know what the biology is. . . . We can’t say if it is age or something that is a proxy for age,” such as lifetime exposure to environmental pollutants, which accumulate in the body over the years.

The senior author, Hertz-Picciotto, added the following comment( as summarized by the LA Times reporter) for those who may prematurely  read too much into this report:

Older women are more likely to have problems with fertility and require intervention. They may be followed more closely during pregnancy, which would mean more ultrasounds. They are more likely to suffer gestational diabetes and to develop autoimmune disorders, which have been shown to play a role in autism. All are fertile areas for further research.

“We still have a real long way to go” in determining the causes of autism, she concluded.

RISKY BUSINESS: NEJM — Outcomes after Internal versus External Tocodynamometry for Monitoring Labor

January 30, 2010

In December 2003, ACOG, the American College of Obstetricians  and Gynecologists, issued a Practice Bulletin (#49) for its members, in which it recommended the use of intrauterine monitoring of contractions during augmentation or induction of labor in select patients, such as those suffering from obesity.  There were some obstetrical organizations who were recommending the routine use of internal contraction monitoring to assess contractions more accurately.

Of course, the intent behind such recommendations was ostensibly to provide the attending obstetrician with better/more accurate information with which to make clinical decisions regarding the need for an operative birth (i.e. C-section or instrument assisted birth), dosing effectively with oxytocin nad avoidance of complications in such labor situations – the common end-result being to improve fetal and maternal outcomes in such deliveries.

On the other side of the risk/benefit equation, it is only common sense that the use of an internal monitor would increase certain risks – the medical literature speaks of the most common of these as being placental and/or fetal vessel damage, infection and anaphylactic reaction.

A new study by the Academic Medical Center in Amsterdam, led by Jannet J. H. Bakker, MSc, and reported by The New England Journal of Medicine on January 28, 2010 – NEJM — Outcomes after Internal versus External Tocodynamometry for Monitoring Labor raises serious questions about the use of such monitoring when one applies a science-based risk/benefit analysis.

The study reports in pertinent part:

In summary, the results of our trial do not support the routine use of internal tocodynamometry for monitoring contractions in women with induced or augmented labor.

In this multicenter, randomized trial we found no significant difference in rates of operative delivery with internal tocodynamometry as compared with external monitoring of uterine contractions among women in whom oxytocin was used for induction or augmentation of labor. On the basis of the lower boundary of the confidence interval around the observed relative risk of the primary outcome, our data are plausibly consistent with no more than a 9% reduction and up to a 20% increase in the risk of operative delivery associated with internal tocodynamometry. For cesarean section alone, plausible results range from a 17% reduction in risk to a 30% increase in risk with internal tocodynamometry. These results are in concordance with those of three previous small trials that compared internal and external uterine monitoring (each including between 127 and 250 patients), all of which showed a nonsignificant increase in the frequency of cesarean sections in the internal-tocodynamometry group.

Our trial also showed no significant difference between the two types of monitoring in the rates of adverse neonatal outcomes, rates of use of analgesia or antibiotics, or time to delivery. Similarly, none of the earlier studies showed significant benefits in terms of other maternal or neonatal outcomes with the use of an intrauterine pressure catheter.

For a full review of the patient population, the limitations of the study, please refer to the NEJM article.

Medical News: Survival Rates Vary with Congenital Anomalies – in Pediatrics, General Pediatrics from MedPage Today

January 23, 2010

Over the course of my career in litigating  catastrophic newborn injury cases, a rather common  ‘defense tactic’ involves trying to prove a limited life expectancy for these catastrophically injured children.  Essentially, defense lawyers attempt to convince a jury that such children have a very limited chance of survival for more than 8 to 15 years of life.  The reason for this approach is  quite simple – the shorter the period of time that such children survive, the lower the potential damage award for future care needs and future pain and suffering.

Lawyers for the inured child and family, on the other hand, contend that with appropriate medical care, such children will live a relatively normal life expectancy – therefore, there is an absolute need for a substantial amount of money for future care needs.

The issue often becomes:  given a certain type of injury, what is the ‘probable’ life expectancy for such children?

A recent study published in the British medical journal, The Lancet, and reported in MedPage Today on January 19, 2010,  provides some further insight into this issue.   Medical News: Survival Rates Vary with Congenital Anomalies – in Pediatrics, General Pediatrics from MedPage Today.

It has long been suspected that if a child is unable to protect his/her airway because of an inability to roll-over and clear secretions, that child is at increased risk for breathing complications – potentially leading to early death.  A number of limited studies are cited for other ‘factors’ leading to limited life expectancy.

This new study offers some interesting insights into various types of anomalies and the probability of survival for children suffering from them.

Just a sampling of the data (see the article for more details) gives a sense of the ‘predictability’ of survival based on specific defects:

The investigators analyzed survival among specific subtypes of anomalies and found rates of 20-year survival exceeding 95% for the following:

  • Ventricular septal defects, 98.3% (95% CI 96.6 to 99.1)
  • Pulmonary valve stenosis, 98.1% (95% CI 96.1 to 99.1)
  • Cleft lip and palate, 97.7% (95% CI 94.6 to 99.1)
  • Atrial septal defects, 96.3% (95% CI 93.3 to 98)
  • Cleft palate, 96.3% (95% CI 92.8 to 98.1)
  • In contrast, subtypes with less than 50% one-year survival included arhinencephaly/holoprosencephaly, common arterial trunk, and hypoplastic left heart.

    What the study also goes on to say, however, is that certain conditions, survivability is contingent on the quality of care being provided to these children.

    What is obvious and beyond any argument is that funding is desperately needed for further long-term studies to clarify this issue for not only the physicians rendering care to these children, but also for the parents seeking a clearer picture of what the future holds for their families in terms of financial needs and planning.

FDA announces research program for prescription drugs in pregnancy

January 2, 2010

On December 30, 2009, the FDA announced that a new collaborative research program to study the effects of prescription medications taken by women during pregnancy.  This program is called the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP) and will be a collaborative effort among the FDA, and researchers at the HMO Research Network Center for Education and Research in Therapeutics (CERT), Kaiser Permanente’s multiple research centers and Vanderbilt University.

The FDA references in its announcement an article in the American Journal of Obstetrics and Gynecology, which states  that it estimates that two-thirds of women who are pregnant take at least one prescription medication during their pregnancy.

One might think that there had been a number of clinical trials relating to medications taken during pregnancy prior to this collaborative effort; however, this appears not to be the case since there were too many concerns about the health of the mother and fetus preventing such a study in the past.

For more details  on this long-overdue research study, see the FDA’s announcement.

Choosing a Lawyer – A How-To Guide

December 24, 2009

One of the most important things you can do if you are considering a lawsuit is to spend time doing a proper search for the lawyer, who will be handling your case.

Just because a law firm or a lawyer has a fancy webpage or an eye-catching ad in your local phone directory or even a professional looking TV commercial does not mean that this lawyer has a clue what he/she is doing in the specialized areas of medical malpractice or catastrophic personal injury.

We invite you to read and consider the issues and questions raised in our White Paper – “How to Choose a Lawyer.”

If you have other ideas or questions that you believe would be helpful to our readers in their search for a lawyer, post your reply on this topic so others may benefit by your insights.

Nash And Associates Announces a Free New White Paper – “Statute of Limitations”

December 10, 2009

In the broadest sense, the statute of limitations is a period of time within which you are allowed to file a lawsuit against someone else. Another way to think about it is a deadline by which you must file your lawsuit. Why is there any time limitation at all on filing a lawsuit? The courts and legislature have reasoned that it is beneficial to society to have disputes resolved in a timely fashion. Also, as more and more time elapses after an incident, memories fade, important records get lost or destroyed, and it becomes more difficult to prove what actually happened. Therefore, the law imposes a time limit on when an injured party may file a lawsuit.

When you contact Nash and Associates to discuss your case, one of the first questions we will ask you is when did the incident take place and where it took place. The reason is simple—we need to know when the statute of limitations, or deadline, will expire in your specific case. The statute of limitations can vary widely depending on what state you live in and what specific legal claim you are asserting. Many states have a unique statute of limitations for medical negligence cases, including birth injuries, surgical errors, or other doctor mistakes. In some states (Ohio, for example) the statute of limitations can be as little as one year from the date of negligence. In Virginia, it is usually two years. In Maryland, it is generally three years, but even this seemingly simple rule can have a number of variables that can affect the deadline in your case