Hypoxic ischemic encephalopathy (HIE), sepsis and intracranial hemorrhages (brain bleeds) are common causes of brain damage in babies. In a recent study published in Pediatrics, researchers discussed the causes of neonatal morbidity and mortality in the neonatal intensive care unit (NICU). Researchers examined the records of 641 NICU babies to determine the factors that led to their deaths
In this article, we review the study and discuss common medical errors that can cause a baby to have birth injuries such as HIE, intracranial hemorrhages and sepsis.
PREVENTING BIRTH INJURIES & DEATH CAUSED BY HYPOXIC ISCHEMIC ENCEPHALOPATHY (HIE), BRAIN BLEEDS & SEPSIS
The study in Pediatrics was undertaken so that researchers could understand factors associated with neonatal mortality by determining potentially preventable causes of infant death in the NICU. Issues associated with newborn deaths changed with gestational age. Babies born at an early gestational age usually died from extremely low birth weight, intracranial hemorrhages and sepsis. Deaths in late preterm and term infants were primarily caused by hypoxic ischemic encephalopathy (HIE).
Thirty-one percent of neonatal deaths were due to potentially preventable factors. The most common hospital error identified as a risk factor for death of a newborn was the hospital having inadequate medical staff and support. The author of the study, Dr. Reese Clark, said that the intervention most likely to reduce mortality in premature babies is preventing or delaying preterm birth and optimizing therapies that decrease intraventricular hemorrhages, respiratory distress syndrome (RDS) and sepsis. For older babies, mortality can be decreased by preventing and properly managing hypoxic ischemic encephalopathy (HIE).
HOW DO NEWBORNS GET HYPOXIC ISCHEMIC ENCEPHALOPATHY (HIE), BRAIN BLEEDS & SEPSIS, & HOW CAN THESE CONDITIONS BE PREVENTED?
Hypoxic Ischemic Encephalopathy (HIE)
Hypoxic ischemic encephalopathy is a brain injury caused by a lack of oxygen in the baby’s blood and tissues (hypoxia) and a decreased flow of blood in the brain (ischemia). There are many conditions that can occur during or near the time of birth that can deprive a baby of oxygen and cause HIE. These conditions usually involve problems with the uterus (womb), placenta and/or umbilical cord.
When the baby is in the womb, she receives all her oxygen from oxygen-rich blood being delivered to her from her mother. The placenta is attached to the inside of the womb, and the umbilical cord arises from the placenta. The blood travels from the mother, through blood vessels that run between the uterus and placenta, and then into the baby through the umbilical cord. Blood flow to the baby takes the following path: maternal circulation –> uteroplacental circulation –> umbilical cord –> fetal circulation.
Problems that commonly cause reduced blood flow to the baby and oxygen deprivation (birth asphyxia) include a ruptured uterus, placental abruption and umbilical cord compression. Although these conditions are very dangerous for the baby, birth asphyxia can usually be prevented if the mother and baby are properly monitored so the baby can be delivered at the first signs of distress or when distress is impending. It is especially important to monitor the fetal heart rate. When a baby is experiencing a lack of oxygen to her brain, it will be evident on the fetal heart rate monitor by nonreassuring heart tracings. When these tracings occur, the baby must be delivered right away by emergency C-section, in most cases. Failure to deliver a baby who is in distress can cause the newborn to develop hypoxic ischemic encephalopathy and permanent brain damage. HIE also makes a baby more susceptible to brain bleeds, and brain bleeds can cause or worsen HIE.
Listed below are some common conditions that can cause birth asphyxia and HIE if not properly managed. Proper management includes a prompt C-section delivery if the baby is in distress.
Conditions that can cause HIE
- Umbilical cord problems, such as a nuchal cord (cord wrapped around baby’s neck), umbilical cord prolapse, short umbilical cord and cord in a true knot
- Ruptured uterus
- Preeclampsia / eclampsia
- Placental abruption
- Placenta previa
- Anesthesia mistakes, which can cause blood pressure problems in the mother, including a hypotensive crisis. This can greatly decreases the supply of oxygen-rich blood going to the baby.
- Oligohydramnios (low amniotic fluid)
- Premature rupture of the membranes (PROM) / premature birth
- Prolonged and arrested labor
- Intracranial hemorrhages (brain bleeds), which can be caused by a traumatic delivery. Forceps and vacuum extractors can cause brain bleeds. Sometimes intense contractions (hyperstimulation) caused by labor induction drugs (Pitocin and Cytotec) can cause head trauma. Mismanagement of cephalopelvic disproportion (CPD), abnormal presentations (face or breech presentation), and shoulder dystocia also put a child at risk of having a brain bleed.
- Hyperstimulation caused by Pitocin and Cytotec can also cause oxygen deprivation that gets progressively worse.
- Fetal stroke
- Postmaturity syndrome
- Failure to quickly deliver a baby when fetal distress is evident on the fetal heart rate monitor (delayed emergency C-section)
Treatment for HIE
First and foremost, the medical team should closely monitor the mother and baby and quickly deliver the baby if she is in distress in order to prevent birth asphyxia and HIE. However, if the baby does develop HIE, it must be diagnosed right away. Prompt diagnosis is critical because the treatment for HIE has to be given within 6 hours of the time the baby experienced birth asphyxia, which usually means treatment must be initiated within 6 hours of birth. The more severe the HIE, the sooner the treatment should be given.
Hypothermia treatment (brain cooling) is the only treatment available for HIE. During brain cooling, the baby’s core body temperature is cooled to a few degrees below normal for 72 hours. The cooling is accomplished with either a cooling blanket or cool cap. Hypothermia treatment halts almost every damaging process that starts to occur when the brain experiences an oxygen-depriving insult. Research shows that when a baby has HIE, brain cooling can decrease the likelihood of – and even prevent – cerebral palsy.
INTRACRANIAL AND EXTRACRANIAL HEMORRHAGES (BRAIN BLEEDS)
Brain bleeds in a baby have numerous causes. Premature babies are more susceptible to bleeding in the brain, especially intraventricular hemorrhages (IVH), because their blood vessels are fragile. This is one of the many reasons premature birth should be prevented, if possible.
Brain bleeds in a baby can cause many conditions, including the following:
- Hypoxic ischemic encephalopathy (HIE). HIE usually involves damage to the basal ganglia and watershed regions of the brain, but sometimes also includes periventricular leukomalacia (PVL)
- Neonatal encephalopathy
- Permanent brain damage
- Seizure disorders
- Cerebral palsy (CP)
- Intellectual disabilities
- Developmental delays
- Motor disorders
- Periventricular leukomalacia (PVL)
Listed below are types of brain bleeds that commonly occur in newborn babies.
Subarachnoid hemorrhage (SAH) and subdural hemorrhage (SDH). A subarachnoid hemorrhage is the second most common neonatal brain bleed and it is caused by the rupture of veins in a space or spaces near the skull. Hydrocephalus can develop after SAH because the bleeding causes too much cerebral spinal fluid (CSF) to build up in the brain’s ventricles, which can cause brain swelling. SAH can also cause oxygen to be cut off in certain parts of the brain, which can cause brain tissue to die.
A subdural hemorrhage is the most common type of neonatal brain bleed. SDH occurs when there is rupture of the blood vessels in the area between the surface of the brain and the thin layer of tissue that separates the brain from the skull. Sometimes SDH causes an increase in intracranial (brain) pressure, which can cause an increase in head size, apnea (periods of not breathing), bradycardia (slow heart rate) and coma.
Causes of subarachnoid and subdural hemorrhages include the following:
- Use of forceps or vacuum extractors to facilitate delivery
- A vaginal delivery when the baby is in breech presentation. Research shows that a C-section delivery is the safest way to deliver babies in this position.
- Improperly managed face or brow presentation
- Macrosomic (large) baby
- Cephalopelvic disproportion (mother’s pelvis is too small for the size of the baby)
- Precipitous delivery. This is very fast delivery, often accompanied by strong contractions. Drugs used to start or speed up labor and delivery, such as Pitocin (oxytocin) and Cytotec, can cause contractions that are so fast and strong (called hyperstimulation) that they deprive the baby of oxygen. Hyperstimulation can also cause head trauma.
- Prolonged labor and delivery. Prolonged labor can be very traumatic for a child. This can occur when a baby is very large, when the baby is not in the normal position in the birth canal (e.g., breech or face presentation), and when the mother’s pelvis is too small for the baby. Many conditions can cause prolonged labor, and oftentimes, physicians fail to move on to C-section delivery when it is medically necessary. During the extended vaginal labor and attempted delivery, the physician may use Pitocin or Cytotec to try and speed up delivery, or vacuum extractors and forceps may be used to try and facilitate delivery. All of these actions can cause a traumatic injury to the head with resultant brain bleeding.
Intraventricular hemorrhage (IVH). The brain has four ventricles at its center. IVH is bleeding inside the ventricles, and it is most common in preterm babies, although term babies can have IVH as well.
IVH can be caused by the same factors that cause SAH and SDH. IVH can also be caused by hypoxia. Thus, conditions such as umbilical cord prolapse, nuchal cord, uterine rupture, placental abruption, delayed delivery, Pitocin, Cytotec and preeclampsia all can cause IVH. HIE is also a significant cause of IVH.
Very close monitoring of infants with IVH is crucial due to the potential for the bleeding to extend into the tissue around it and cause hydrocephalus.
Subgaleal hemorrhage. This is a potentially deadly type of bleed that is strongly associated with head trauma and forceps and vacuum extraction delivery, with vacuum extraction being the biggest risk factor. In fact, subgaleal hemorrhages are almost always caused by vacuum extractors. This type of hemorrhage is caused by rupture of veins that are very close to the scalp. When these veins rupture, blood builds up just beneath the scalp, and the baby will have swelling of the head and evidence of shock, which is severely low blood volume and blood pressure. Almost half of a baby’s blood volume can end up in the subgaleal space, which is why this type of bleed must be treated very quickly.
Preventing Brain Bleeds in a Baby
Brain bleeds and hemorrhages can be prevented by minimal use of forceps, vacuum extractors, Pitocin and Cytotec. Conditions associated with birth trauma, such as macrosomia, cephalopelvic disproportion (CPD) and abnormal presentations should be promptly diagnosed and properly managed. Conditions that deprive a baby of oxygen must be quickly recognized so that delivery can occur immediately. A C-section delivery is usually the safest and fastest way to deliver a baby who is in distress or at risk of experiencing birth trauma. Indeed, delivery can be traumatic for a baby, and standards of care must be followed at all times, which includes prevention of premature birth whenever possible.
Neonatal sepsis is an infection in the baby’s bloodstream that can damage the brain either by direct infection of the central nervous system or by causing inflammation of the brain. Sepsis is often caused by an improperly treated maternal infection that travels to the baby at birth. If sepsis is not diagnosed right away in a newborn, it can cause septic shock and / or meningitis. When a baby has septic shock, there is organ dysfunction as well as dysfunction with the heart and blood flow. Blood pressure in the baby usually becomes extremely low, which causes a lack of oxygen in the baby’s brain that can result in hypoxic ischemic encephalopathy.
Meningitis is inflammation of the membranes that surround the brain and spinal cord, and it can cause fluid build-up in the brain, increased intracranial pressure, pus-filled pockets, hydrocephalus, restriction of brain blood flow and stroke.
Sepsis can cause hypoxic ischemic encephalopathy even if the condition doesn’t progress to septic shock. Sepsis, septic shock and meningitis can cause the baby to have lifelong problems, such as cerebral palsy, developmental delays and intellectual disabilities.
Prevention of Sepsis
The most common causes of neonatal sepsis are Group B strep and Escherichia coli (E. coli), both of which can cause a urinary tract infection (UTI). Other causes include chorioamnionitis and herpes simplex virus (HSV). When a mother has chorioamnionitis and / or any of these infections, the conditions must be promptly diagnosed and treated. If there is even a suspicion of maternal infection when the mother is admitted to the labor and delivery unit, antibiotics should be given by IV, in most cases. The antibiotics will transfer to the baby and help prevent the baby from getting infected. Certain instances require a C-section delivery; these include active HSV infection or suspicion of the onset of HSV active infection and advanced cases of chorioamnionitis when the baby fails to progress through the birth canal.
HELP FOR CHILDREN WHO HAVE HYPOXIC ISCHEMIC ENCEPHALOPATHY, BRAIN DAMAGE & CEREBRAL PALSY
If you are seeking the help of a lawyer, it is very important to choose a lawyer and firm that focus solely on birth injury cases. Reiter & Walsh ABC Law Centers is a national birth injury law firm that has been helping children with birth injuries for almost 3 decades
Birth Injury lawyer Jesse Reiter, president of ABC Law Centers, has been focusing solely on birth injury cases for over 28 years, and most of his cases involve hypoxic ischemic encephalopathy (HIE) and cerebral palsy. Partners Jesse Reiter and Rebecca Walsh are currently recognized as being two of the best medical malpractice lawyers in America by U.S. News and World Report 2015, which also recognized ABC Law Centers as being one of the best medical malpractice law firms in the nation. The lawyers at ABC Law Centers have won numerous awards for their advocacy of children and are members of the Birth Trauma Litigation Group (BTLG) and the Michigan Association for Justice (MAJ).
If your child was diagnosed with a birth injury, such as cerebral palsy, a seizure disorder or hypoxic ischemic encephalopathy (HIE), the award winning birth injury lawyers at ABC Law Centers can help. We have helped children throughout the country obtain compensation for lifelong treatment, therapy and a secure future, and we give personal attention to each child and family we represent. Our nationally recognized birth injury firm has numerous multi-million dollar verdicts and settlements that attest to our success and no fees are ever paid to our firm until we win your case. Email or call Reiter & Walsh ABC Law Centers at 888-419-2229 for a free case evaluation. Our firm’s award winning lawyers are available 24 / 7 to speak with you.
Jacob, Jack, et al. “Etiologies of NICU Deaths.” Pediatrics 135.1 (2015): e59-e65.