Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Department of Obstetrics and Gynecology, Geffen School of Medicine at UCLA, Los Angeles, CA.
Am J Obstet Gynecol. 2019 Apr;220(4):348-353. doi: 10.1016/j.ajog.2018.11.1107. Epub 2018 Dec 6.
Obstetricians and gynecologists belong to 1 of the medical specialties with the highest rate of litigation claims. Among birth injury cases, those cases with cerebral palsy outcomes account for litigation settlements or judgments often in the millions of dollars. In cases of potential perinatal asphyxia, a threshold level of metabolic acidosis (base deficit ≥12 mmol/L) is necessary to attribute neonatal encephalopathy to an intrapartum hypoxic event. With increasing duration or severity of a hypoxic stress resulting in metabolic acidosis, newborn infant umbilical artery base deficit increases. It may be alleged that, as base deficit levels increase beyond 12 mmol/L, there is an increased likelihood and severity of cerebral palsy. As a corollary, it may be claimed that an earlier delivery (by minutes) would reduce the base deficit and prevent or reduce the severity of cerebral palsy. This issue is of relevance to obstetricians as defendants, because retrospective "expert" analysis of cases may suggest that optimal management decisions would have resulted in an earlier delivery. In addressing the association of metabolic acidosis and cerebral palsy, base deficit should be measured as the extracellular component (base deficit) rather than the commonly used base deficit. Studies suggest that, beyond the base deficit threshold of 12 mmol/L, the incidence and severity of cerebral palsy does not significantly increase (until ≥20 mmol/L), although the risk of neonatal death rises markedly. Thus, among most infants with hypoxia-associated neonatal encephalopathy, the occurrence of cerebral palsy is unlikely to be impacted by delivery time variation of few minutes, and this argument should not serve as the basis for medical legal claims.
妇产科医生属于医疗专业中诉讼索赔率最高的专业之一。在出生伤害案件中，脑瘫后果的案件往往以数百万美元的诉讼和解或判决告终。在潜在围产期窒息的情况下，代谢性酸中毒（碱缺失≥12mmol/L）的阈值水平是将新生儿脑病归因于分娩期间缺氧事件所必需的。随着导致代谢性酸中毒的缺氧应激持续时间或严重程度的增加，新生儿脐动脉碱缺失增加。可能会声称，随着碱缺失水平超过 12mmol/L，脑瘫的可能性和严重程度增加。相应地，可能会声称更早分娩（几分钟）会降低碱缺失并预防或减轻脑瘫的严重程度。这个问题与作为被告的妇产科医生有关，因为对病例的回顾性“专家”分析可能表明，最佳的管理决策将导致更早的分娩。在解决代谢性酸中毒与脑瘫之间的关联时，应该测量细胞外成分（碱缺失）而不是常用的碱缺失。研究表明，超过 12mmol/L 的碱缺失阈值后，脑瘫的发生率和严重程度不会显著增加（直到≥20mmol/L），尽管新生儿死亡的风险显著增加。因此，在大多数与缺氧相关的新生儿脑病的婴儿中，脑瘫的发生不太可能受到几分钟分娩时间变化的影响，并且这个论点不应成为医学法律索赔的基础。
