Cerebral palsy case solved

Twin pregnancy and cerebral palsy - Twin-to-twin transfusion (or TTTS)

Twin pregnancies can result in cerebral palsy. One condition associated with cerebral palsy is twin-to-twin transfusion (TTTS) syndrome. TTTS is a serious and dangerous complication of a twin pregnancy. It occurs in monochorionic twin pregnancies. Monochorionic means one placenta. When twins share the same placenta in utero the vessels in the placenta can fail to distribute oxygen and nutrients evenly between the twin fetuses. When this happens, it is called twin-to-twin transfusion syndrome, or TTTS.

TTTS is often first suspected when the weights of the babies on ultrasound become discordant – i.e., one baby is growing faster than the other. This happens because one twins (the donor twin) is sending his or her blood, oxygen and nutrients to the other twin (the recipient twin). In this setting, both twins can be harmed from the condition. For example, the donor twin can lose too much blood and become hypovolemic. Likewise, the recipient twin can get receive too much blood and become hypervolemic.

With TTTS, there is a high risk of death and disability. Some babies will have cerebral palsy. As such, when TTTS is timely diagnosed the mother is monitored closely. In some cases, a laser surgery is performed while the babies are still in utero. This type of fetal surgery can be dangerous, but it also can be very successful. Unfortunately, in some severe cases of TTTS, the only way to save one baby is for the other baby to be terminated in utero.

Outcomes are good when TTTS is timely diagnosed and appropriately treated. Most cases of TTTS require care at an academic tertiary center where maternal-fetal medicine specialists who specialize in fetal surgery in the setting of TTTS can closely monitor the pregnancy.

A TTTS baby is diagnosed with cerebral palsy - what caused it?

In late 2012, Meredith Kelley became pregnant with twin girls. Early in the pregnancy, it was determined that the pregnancy was a monochorionic twin pregnancy. Of course, this placed Ms. Kelley at an increased risk of TTTS. In early 2013, at around 28 weeks gestation, Ms. Kelley underwent an ultrasound where it was determined that her twins were significantly discordant. Because of the discordance, her doctors suspected that there may be TTTS. Ms. Kelley was promptly sent for evaluation at an academic tertiary center to undergo additional testing to rule in, or rule out, TTTS. Unfortunately, it was not long before the perinatologists caring for Ms. Kelley diagnosed TTTS.

TTTS is graded in five separate stages. Stage 1 is the most benign, and Stage 5 is the most severe. In Ms. Kelley’s case, when the initial diagnosis was made, her TTTS was believed to be somewhere between Stage 1 and Stage 2. This was good news.

In accordance with the standard of care, her perinatologists began very carefully monitoring the pregnancy. Ms. Kelley had bi-weekly biophysical profile tests, fetal biometry measurements, umbilical doppler studies, blood work, and non-stress tests. For the next six weeks, the TTTS remained stable and the maternal-fetal medicine specialists were optimistic for a good outcome.

However, at approximately 34 weeks, Ms. Kelley’s TTTS rapidly progressed from Stage 2 to Stage 3. An umbilical doppler study was performed that showed that umbilical cord flow in the donor twin was becoming significantly compromised. A condition called absent end-diastolic flow (AEDF) was diagnosed. This diagnosis is made when there is essentially no flow going through the umbilical cord to the baby. AEDF can result in oxygen deprivation, brain damage, cerebral palsy and/or death. Thankfully, at this point in time, the biophysical profile testing was showing that the donor twin was doing well.

The following week, the recipient twin, Veronica, began exhibiting excess amniotic fluid in her amniotic sac. This condition is called polyhydramnios. Polyhydramnios can indicate kidney dysfunction.

Now that the TTTS was obviously affecting both twins, Ms. Kelley’s perinatology providers were faced with a difficult choice. Continue the pregnancy to make sure the babies’ lungs were ready to work outside the womb, or deliver the babies to make sure the TTTS does not injure them. Ultimately, the decision was made to give steroids to aid in developing the babies’ lungs, and then deliver. The steroids were given over a two-day period and then Meredith and Veronica Kelley were born between 35 and 36 weeks.

Given the apparent complications that were arising from the TTTS, both Meredith and Veronica were incredibly stable at birth. They looked great! Their Apgar scores were reassuring and neither baby required aggressive resuscitation or intubation. Although stable, Meredith and Veronica were sent to the NICU.

Meredith did so well that she was discharged home on day of life nine with a clean bill of health.

Veronica did not do so well. She was diagnosed with a heart condition called patent ductus arteriosus (PDA). PDA is common in premature babies. She required PDA repair on day of life four. After the PDA repair, Veronica was noticed to be unstable. She started having breathing difficulties and then started having seizures. A CT scan was taken of her brain, which showed she extensive damage to her brain. Veronica spent over two months in the NICU. After she was discharged, she was diagnosed with spastic quadriplegic cerebral palsy. She required a feeding tube, a wheelchair, and was severely developmentally delayed. This was such a sad story since her twin sister was perfectly healthy.

Six lawyers tell Ms. Kelly she has no case for Veronica's cerebral palsy

Mr. and Ms. Kelley were convinced that there had been some sort of malpractice in the management of her TTTS. Veronica was the recipient twin. The recipient twin often does better than the donor twin. To the Kelley’s, it did not make sense as to why Veronica was so severely injured. So, they started calling lawyers shortly after Veronica’s first birthday.

No case.
No case.
No case.
No case.
No case.
No case.

Ms. Kelley was determined. She went to six (!) different law firm before she contacted WVFO. Every lawyer told her there was no case because the management of the TTTS was “perfect.” Basically, all the lawyers she spoke to before WVFO told her that Veronica’s problems were either just an unfortunate and unavoidable complication of TTTS, or her injuries were being born premature, which everyone agreed had to happen.

Ms. Kelley calls the birth injury team at WVFO

WVFO was essentially the fourteenth set of eyes to look at the case. We met with the Kelley’s and could sense their passion for determining what had gone wrong. We could feel that they were onto something, but they could not put their finger on it. Neither could the twelve set of eyes that looked at the case before WVFO. We were determined to solve this cold case.

WVFO held a meeting with all its partners and began dissecting the case from top-to-bottom. We spent an entire day in our conference pouring over the records. One of the conclusions we made very early on was that the obstetrical and perinatology care was indeed perfect. The perinatologists had handled the TTTS in textbook fashion. They followed every protocol to a T. We quickly ruled out that the TTTS literally had nothing to do with Veronica’s injuries.

But what had happened?

Records are missing

One of the partners at WVFO suggested that we take a closer look at Veronica’s PDA repair. Most of the law firms prior to WVFO had focused exclusively at the TTTS and the delivery process. But, what about the PDA repair. When we started digging into the PDA surgery, we made a startling discovery…the records were incomplete.

The records obtained by WVFO, and by all the law firms before WVFO, were missing important anesthesia and flowsheet records from the PDA repair. They simply were not in the record. WVFO immediately sent a request for the missing records.

PDA repair malpractice causes cerebral palsy

The newly obtained records were the missing piece to the puzzle. What we discovered was that pediatric cardiologist and the pediatric anesthesiologist managing the PDA repair had completely failed to realize that Veronica was crashing during the PDA surgery. This was an obvious and clear breach in the standard of care. Suddenly, everything started to make sense.

Prior to the PDA procedure, Veronica had been stable. Her vital signs were good. Her neurological status was normal. Yet, following the PDA repair there was an abrupt change in both her vital signs and her neurological status. In the hours following the PDA surgery, Veronica was described as drowsy and lethargic. This led to the neonatology team taking a closer look at her blood work. That is when her blood work began showing signs of multi-organ injury, which is something that occurs after there has been as severe hypoxic insult.

We began sending the case to various experts in pediatric cardiology, pediatric anesthesia, neonatology, and pediatric neurology. The opinions were unanimous. The PDA repair had been totally botched and Veronica suffered a hypoxic-ischemic insult as a result. The experts were clear that had the procedure been managed appropriately, Veronica would not have cerebral palsy.

WVFO filed the case in 2016. For a short while the Defendant Hospital contended that Veronica’s injuries were from the TTTS. When WVFO deposed the perinatologists who had cared for Ms. Kelley they of course admitted that this was not true. Shortly after their depositions, the case resolved for a sum of money that would take care of Veronica for the rest of her life.

CASE CLOSED.