When a newborn struggles to breath after birth many things must be considered and persistent fetal circulation / persistent pulmonary hypertension in the newborn (PPHN) is one of them. PPHN means that the pressure in the blood vessels supplying the lungs remains high and this leads to problems.
In babies with PPHN, certain blood vessels that remain closed during gestation do not open up properly after birth to allow blood flow to the lungs. This can result in a very dangerous situation where the baby is not able to start breathing independently often requiring emergency neonatal resuscitation. Medical malpractice involving PPHN usually involves a failure to properly respond to and manage babies in need of respiratory support.About PPHN
PPHN is a lung and cardiopulmonary process. During pregnancy the fetal lungs are still developing and are not used to exchange oxygen and carbon dioxide as is normally the case. To allow for development during gestation blood vessels to the lungs remain closed sending most of the blood away from the baby's lungs through special connections in the heart and large vessels. When a baby is first born this fetal circulation changes dramatically. A change in air pressure normally prompts the blood vessels to open and allow blood circulation into the lungs so that the baby can start using their new lungs to breather independently and take in oxygen.
In babies with persistent pulmonary hypertension of the newborn, this natural change in the vasculature does not occur at birth. The baby's pulmonary blood vessels fail to open up and circulation reverts back to the fetal system with blood directed away from the lungs. The lung pressure stays very high, which is why the condition is called persistent pulmonary hypertension.
This is a problem because when blood is shunted away from the lungs they cannot perform the oxygen and carbon dioxide exchange required. Babies with PPHN struggle to breath and may be unable to get the oxygen they need to survive. Oxygen deprivation presents an immediate danger to all organs in the baby's body including the brain.PPHN Occurrence & Risk Factors
PPHN is a very uncommon condition, occurring in about 1 out of every 500 babies. PPHN can be a very serious and very dangerous condition for a newborn. Approximately 8% of children with PPHN die and many more suffer brain injuries, hearing deficits and permanent lung injuries.
PPHN is associated with term or post term infants usually after a difficult birth. Risk factors associated with PPHN include meconium aspiration, birth depression, maternal infection and congenital abnormalities of the heart or lungs. There is also an association with mothers who took certain medications such as nonsteroidal anti-inflammatories and certain antidepressants.PPHN Symptoms & Treatment
The signs of PPHN are rapid breathing, moaning sounds, poor color, low oxygen level and low blood pressure. These symptoms are usually identified immediately after birth with an APGAR test. If clinical symptoms of PPHN are present diagnostic confirmation is usually done with an ultrasound (echocardiography) which is considered the most reliable noninvasive test to establish the diagnosis. Prompt diagnosis of PPHN is extremely important because babies with this condition usually need immediate medical assistance and care.
Initial response and treatment of PPHN involves keeping the baby warm, administering antibiotics if infection is suspected, and delivery of supplemental oxygen. Oxygen may be delivered through a mask, hood or tubes inserted through the mouth or nostrils. Occasionally the baby is intubated and put on a ventilator which administers higher amounts of oxygen and assists the baby in breathing. The whole idea of treatment is aimed at increasing the oxygen to the rest of the body. In severe cases the use of nitrous oxide to help dilate blood vessels or a procedure called ECMO (extra corporeal membrane oxygenation) may be used.PPHN Malpractice
When PPHN comes up in obstetric medical malpractice cases, it usually involves some sort of failure on the part of doctors or hospital staff to administer immediate and proper respiratory assistance after birth. Doctors must promptly diagnose PPHN and be fully prepared to engage in emergency neonatal resuscitation procedures.Verdicts & Settlements
The verdicts and reported settlements summarized below are from medical malpractice cases involving PPHN. The amount of the awards are less important than the stories of what makes for a viable PPN birth injury or wrongful death claim.
- Baby Doe v. AAA Hospital (Michigan 2019) $8 million: A newborn sustained an hypoxic injury after an emergency C-section. This occurred after the labor failed to progress for several hours, even with Pitocin. Following her birth, the NICU staff treated her for PPHN, meconium aspiration syndrome, multi-organ failure, and metabolic acidosis. The girl developed spastic cerebral palsy, cognitive delays, and seizures. She required lifelong assistive care. Her mother alleged that the delaying of a C-section caused her permanent injuries. This case settled for $8 million.
- Sodjago v. Pediatrix Medical Group of Georgia (Georgia 2014) $3 million: A post-term baby was born unresponsive, not breathing, and with no heart rate. The hospital staff resuscitated her and raised her blood oxygen levels. The baby suffered from PPHN, which was treated with nitric oxide. Despite undergoing this treatment, she already sustained permanent neurological damage including cortical blindness, cognitive impairments, and behavioral problems. Her mother alleged that the delaying of the nitrous oxide treatment prolonged her PPHN, causing permanent injuries. A jury awarded a $3 million verdict.
- Baby K v Hospital (Florida 2014) $2.9 million: A baby is born with gastroschisis. This is a congenital anomaly where parts of the baby's organs, including intestines and internal organs, are on the outside rather than inside the baby's body. Closure surgery is performed to correct condition but after the procedure the baby has trouble breathing. Her oxygen levels slowly deteriorate and she is diagnosed with PPHN. The hospital does not have an extracorporeal membrane oxygenation (ECMO) machine. The baby tragically dies. The parents hire a wrongful death birth injury lawyer and file a lawsuit, alleging the doctors and nursed failed to manage baby's PPHN. The family also argued that the child should have transferred her to another hospital for an ECMO procedure that would have saved her life. Case settles prior to trial for $2,959,000.
- Sodjago v Pediatrix Medical (Georgia 2013) $3 million: fetal monitoring strips indicate major distress but a miscommunication between nurses and doctors results in long delay before emergency C-section is performed. Baby is not breathing when delivered but neonatal resuscitation team restores breathing and heart-beat but she has PPHN and is not getting enough oxygen. She is eventually given nitric oxide to help open blood vessels to her lungs but prolonged oxygen deprivation leaves her with brain damage, cognitive impairment and partial blindness. Jury awards $3,000,000.
- Plaintiff v Defendant (California 2013) $9.9 million: mother in her late-30s is towards the end of a high risk pregnancy further complicated by gestational diabetes when she goes for prenatal visit and doctors find very concerning signs of fetal distress. She is immediately sent to hospital for delivery but a series of logistical errors and miscommunications result in an extended delay before a doctor arrives to finally perform emergency C-section. Baby suffers hypoxic-ischemic encephalopathy (HIE) injury and persistent pulmonary hypertension of the newborn (PPHN). Baby remains in NICU for 5 weeks and eventually diagnosed with cerebral palsy with permanent cognitive impairment and developmental delays. Mother sues doctor and hospital for negligent mishandling of labor and delivery and jury awards $9.9 million.
- Ketterman v Capital Women's Care (Maryland 2009) $1.8 million: This is the most recent PPHN verdict our lawyers could find in Maryland. In this case, the mother in labor attempts pushing for 3 hours but baby's head does not descend into birth canal and becomes wedged in the mother's pelvis. Defendant OB/GYN elects to use vacuum extractor to facilitate delivery. Vacuum pump injures the baby's head and causes a massive brain bleed which causes persistent pulmonary hypertension (PPHN). Baby's PPHN triggers cardiac failure and he dies. Parents sue doctor alleging that his use of the vacuum extractor was negligent and not appropriate given the baby's position in the pelvis. Defendant claims that baby's PPHN developed in utero and was not cause by the vacuum injuries. Jury in Montgomery County finds in favor of plaintiffs and awards $1.8 million in damages.
- Elizarde v Laredo Regional (California 2009) $250,000: 30-year-old mother delivers female baby at only 27-weeks' gestation. Baby has persistent pulmonary hypertension which causes her death after 20 hours from cardiopulmonary collapse. Mother sues hospital and doctors alleging that they were negligent in failing to take a more aggressive approach in treatment and care of the baby after birth. Specifically they allege that baby should have been immediately intubated. Defendants insist that more aggressive intervention was not mandated under the circumstances. Case settles for $250,000.
Persistent pulmonary hypertension is when the child is unable to make the transition from fetal circulation to normal circulation.
The placenta does all of the oxygenating and ventilating in utero. When the baby delivers, she has to make the transition to adult circulation. The baby must open up her lungs and breathe and evacuate fluid. When a child has PPHN, it is not making this transition.
When the baby breathes, oxygen goes into the lungs and clears carbon dioxide. The oxygenated blood goes from the lungs to the pulmonary veins.
The left side of the heart pumps this good blood out the aorta, and it goes to the body, and the body uses the oxygenated blood which becomes blue blood. The blue blood comes back to the right side of the heart and is moved through the pulmonary artery back to the lungs to become good blood. For whatever reason, with PPHN, it is like someone stepped on the hose bringing the blue blood back to the lungs.
The cause of PPHN is not always known. But we know several things that can cause pulmonary hypertension:
- meconium aspiration syndrome
- amniotic fluid aspiration
- pulmonary hyperplasia
To react quickly to PPHN, it helps to suspect PPHN sooner rather than later. Doctors should realize that the probability of PPHN goes up when these factors are present.
- Pregnancy Longer Than 40 Weeks
- Asphyxia at delivery
- Prolonged Rupture of Membranes
- Material Fever
- Mother Is Group B Strep Positive
- Mother Took SSRIs or Aspirin
The clinical signs and symptoms are a bluish discoloration of the skin, severe respiratory distress, poor perfusion.
Hypoxemia can cause PPHN by causing a pulmonary vascostriction.
Meconium aspiration can trigger PPHN by causing pneumonia in the lungs causing vasoconstriction.
In PPHN birth injury malpractice cases, the most common medical errors are not in stopping PPHN but treating it when it does arise. The child will almost invariably need oxygen quickly to prevent rain damage. The child also might need blood pressure support, nitric oxide, or a temporary heart-lung bypass (ECMO). The failure to provide any of these treatment modalities to a child that desperately needs it could be medical malpractice.
In a birth injury lawsuit involving PPHN, experts and attorneys on both sides will use medical literature to make their case to the jury. These are some of the articles you can expect to see used in litigation.
- Rosenzweig EB, et. al: Paediatric pulmonary arterial hypertension: updates on definition, classification, diagnostics, and management. Eur Respir J. (2019) 53:1801916. doi: 10.1183/13993003.01916-2018. The authors are not discussing medical malpractice directly but underscore that too many mistakes are being made because children in PPHN are improperly managed because they use adult treatment guidelines.
- Simonneau G, et. al: Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur Respir J 2019; 53: 1801913.
- Sharma V, et. al: Berkelhamer S, Lakshminrusimha S. Persistent pulmonary hypertension of the newborn. Maternal Health, Neonatology Perinatol. 2015;1(1):14. Often cited article discussing the improvements in treating pediatric pulmonary hypertension and the outstanding challenges that have not yet been researched.
- Teng RJ, et. al: Persistent pulmonary hypertension of the newborn. J Formos Med Assoc 2013;112:177-84. doi:10.1016/j.jfma.2012.11.007. Overview of PPHN diagnosis and treatment that reiterates many of the statistics offered in above.
The birth injury attorneys at Miller & Zois can help you investigate your PPHN case and pursue any potential claims for medical malpractice. Calls us for a free consultation at 800-553-8082 or submit an online contact form.