Toward rational boundaries of tort liability for injury to the unborn: prenatal injuries, preconception injuries and wrongful life.
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Abortion, Legal↗
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[Pathomorphology and clinical aspects of brain injuries-prenatal, natal and postnatal injuries-in early childhood].
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Abnormalities, Drug-Induced↗
Wrongful births. When is there liability for prenatal injury?
Every jurisdiction recognizes the right of a child to recover damages for prenatal injury caused by the negligence of a third party. This concept of liability for prenatal injury has been extended to include the right of parents (and sometimes the child) to recover damages from a physician who negligently deprives them of the opportunity to prevent the "wrongful birth" of an affected child. The most troubling question to arise, however, is whether a pregnant woman has a legal duty to avoid negligent behavior that may injure her future child. The unique and compelling conflicts that surround the recognition of such a prematernal duty encompass the child's right to be born free of any negligently induced injury and the pregnant woman's rights to personal privacy and bodily autonomy.
Abortion, Legal↗
Isolated congenital hemianopia caused by prenatal injury to the optic radiation.
Isolated congenital hemianopias are typically caused by developmental abnormalities of the occipital lobe cortex. We describe two patients with an incidental partial hemianopia associated with unilateral periventricular leukomalacia that was acquired prenatally. Magnetic resonance imaging scans suggest a late second or early third trimester unilateral cerebral ischemic event.
Adult↗
Criminal prosecution for prenatal injury.
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Abdominal Injuries↗
Morphological consequences of prenatal injury to the primate brain.
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Afferent Pathways↗
The incidence of prenatal brain injury.
Recent epidemiological studies have shown that cerebral palsy is only rarely associated with birth asphyxia and that there may be more important causative factors in the prenatal period. For this reason a series of 165 brains of infants who were stillborn or died in the early neonatal period was examined in order to identify the incidence and nature of prenatal brain damage. Seventeen (44%) of the stillborn infants showed evidence of brain damage thought to be related to circulatory disorders. The most frequent abnormality, widespread ischaemic damage to the white matter of the cerebral hemispheres, occurred in 10 (26%). Criteria for white matter ischaemia were reactive astrocytosis, macrophage infiltration, karyorrhexis and endothelial swelling or reduplication. This abnormality was only seen after 27 weeks gestation. In five (13%) of the stillborn infants, haemorrhage was seen in association with ischaemic damage and in only two (5%) did brain haemorrhage occur in utero without evidence of co-existing ischaemic damage. Of the 90 live-born infants, 12 (16%) of those surviving less than 3 days and three (20%) of 15 infants who lived between 3 and 7 days after birth showed ischaemic damage which was of prenatal origin. The most frequent pathological change in the infants studied was white matter gliosis occurring in infants who survived into or beyond the last trimester. This may interfere with normal myelination by diverting glial stem cells into reactive astrocytes and thus reduce the population of oligodendrocytes available to synthesize myelin and so cause permanent neurological damage.
Abortion, Spontaneous↗
Role of the clinical toxicologist in court.
The clinical toxicologist may play a role in court when issues arise concerning therapeutic drug monitoring, drug abuse, environmental chemicals, or toxic torts, where the traditional forensic toxicologist may not have expertise. Beyond being credible in court, the toxicologist's testimony must be based on good scientific evidence. The ruler for measuring good scientific evidence had previously been the Frye Test, or the general acceptance test. In 1993, however, the US Supreme Court established four balancing tests that should be used for the admissibility of scientific evidence. Although the ruling is binding only in federal courts, state courts are expected to follow. When testifying, the clinical toxicologist should be aware of other court rules and expectations. As with all testimony, objections from opposing counsel can be raised to disallow the presentation of evidence by a toxicologist. The toxicologist is usually used to establish causation of injury, whether from negligence, prenatal injury, or environmental chemicals. Several examples are presented.
Chemistry, Clinical↗
Effects of prenatal exposure to methylazoxymethanol (MAM) on brain weight, hypothalamic cell number, pituitary structure, and postnatal growth in the rat.
Congenital brain damage syndromes typically are described in terms of behavioral symptoms. Many brain functions are not reflected in behavior, however, and prenatal injury to the developing nervous system could alter these functions, as well. To test the hypothesis that prenatal brain injury can result in postnatal endocrine malfunction, rats were exposed in utero to 20 mg/kg of methylazoxymethanol acetate, a potent neuroteratogen, at two stages of gestation when different sets of growth-controlling neurons of the hypothalamus are forming. The growth hormone releasing factor (GRF) neurons stimulate release of growth hormone from the somatotropes of the anterior pituitary, contributing to rapid growth in the period between weaning and puberty. The somatotropin release inhibiting factor (SRIF) neurons have the opposite effect on the pituitary and can inhibit the GRF cells directly. Growth of treated animals was monitored daily from birth to 40 days and compared to that of controls. Treatment on the 14th day of gestation produced a small number of dwarf animals characterized by normal weight at birth and a sudden decrease in growth rate at the beginning of the fourth postnatal week that led to a body weight about 50% of normal. Treatment on day 16 yielded an acceleration of postnatal growth (significant in males). In each group, most treated animals were like controls in adult size and pattern of growth. As adults, both treatment groups demonstrated massive reductions in brain weight which characterized all the subjects, whether or not they exhibited growth anomalies. The animals treated on day 14 were confirmed to have a significant, selective reduction in growth hormone releasing factor neurons. Reductions were greatest in the middle and posterior levels of the GRF cell distribution, the regions forming most actively at the time of exposure. Unexpectedly, the same group also had increased numbers of periventricular SRIF neurons. Neither type of neurons was significantly altered in the later treatment group. Examination of pituitary structure indicated that dwarfs had very small pituitaries, with an immature pattern of somatotrope distribution, and giants had very large pituitaries, with some hypertrophy of somatotropes. The results suggest that endocrine anomalies which manifest themselves long after birth may originate as birth defects of the nervous system.
Animals↗
Neuropathologic documentation of prenatal brain damage.
Neuropathologic evidence of prenatal brain damage, chiefly in cerebral white matter, was found in 25% of infants who died at 7 days of age or less, with a total of ten preterm (16%) and 12 term (48%) infants among the 89 subjects studied. Few clinical features distinguished infants with prenatal injury from those without such injuries. Apgar scores were low, seizures were rare, and acute intracranial hemorrhage occurred equally often in both groups. Few pregnancies were entirely normal, but hydramnios was the only factor that occurred more often in prenatally injured infants, a statistically significant difference only among term infants. Oligohydramnios was not associated with prenatal brain injury. Unless fetal/maternal abnormalities in late gestation are identified and corrected, improved neonatal care will increase survival for prenatally damaged infants and the incidence of cerebral palsy may rise.
Brain↗
Glucose metabolism in the human cerebellum: an analysis of crossed cerebellar diaschisis in children with unilateral cerebral injury.
Using high-resolution positron emission tomography (PET), we have recently described the normal pattern of glucose utilization in 11 anatomical regions of the human cerebellum. In the present study, we evaluated the phenomenon of crossed cerebellar diaschisis in 40 patients (mostly children) with unilateral cerebral injury sustained at various periods of brain development. Diaschisis refers to a functional impairment at a remote site following injury to an anatomically connected area of brain and, presumably due to a loss of afferent input to the remote site. Of the 40 patients, 11 had sustained their cerebral injury prenatally, 7 in the perinatal period (+/- 24 hours of birth), and 22 postnatally (1 day to 15 years). Crossed cerebellar hypometabolism was seen in 22 patients; symmetric cerebellar metabolism was found in 16 subjects. The presence of crossed cerebellar hypometabolism was typically associated (75% of cases) with a postnatal injury, while symmetric cerebellar metabolism was seen only in patients with injury occurring prior to 4 weeks of age (13 of the 16 had prenatal or perinatal insults). A third pattern of cerebellar metabolism, consisting of paradoxical crossed cerebellar hypermetabolism, was seen in two patients; both had sustained their cerebral injury at 4 months of age. These findings suggest the presence of considerable plasticity, which is dependent on age at injury, in the cerebrocerebellar pathway of developing brain.
Adolescent↗
Uniform abnormalities in the hippocampus of five chronic schizophrenic men compared with age-matched controls.
In a post-mortem study five chronic schizophrenic men were matched with respect to age and sex to five control subjects without a known history of psychiatric illness, and were compared in pairs with regard to neurone number and pyramidal cell orientation in the left hippocampus. All five schizophrenics had significantly more disoriented pyramidal cells in the Cornu Ammonis subregions CA1-CA3 than their matched controls. They also had significantly fewer pyramidal cells in the observed areas of CA1 and CA3, but not in CA2 and CA4. There was no difference in the number of granular cells of the dentate gyrus. In pairwise comparisons the pattern was never reversed with respect to these two parameters, except in a single case where one schizophrenic proband had more cells in subregion CA2. In the absence of gliosis the findings were interpreted as sequelae of an early, presumably prenatal, injury.
Aged↗
Congenital trigeminal anaesthesia. A review and classification.
Forty-three patients with the syndrome of congenital trigeminal anaesthesia (CTA) have been reported to date. The cases have been divided into three groups based on the presence and nature of any associated clinical problems. Three additional cases are presented as characteristic of each of the groups. A different aetiology is proposed for each group. Group I consists of patients with CTA as an isolated finding. It is almost always bilateral, and typically involves the distribution of only the first division of the fifth nerve. There is no evidence of other neurological abnormalities or associated mesoectodermal congenital anomalies. The aetiology is suspected to be a primary neural hypoplasia. Patients with associated congenital mesenchymal anomalies were placed in the second group. CTA was often a minor part of another well defined, more extensive clinical syndrome, such as Möbius or oculoauriculovertebral dysplasia (OAVD). The sensory abnormality was either unilateral or bilateral. The skin of the face was almost always involved, as well as the cornea and conjunctiva. This may be a heterogenous group with multiple aetiologies having in common an injury early in embryogenesis. The third group is defined as patients with CTA without evidence of mesenchymal dysplasia. These cases differ from the first group primarily because of the presence of associated focal brainstem signs. The aetiology is thought to be due to focal neural dysgenesis secondary to a prenatal injury, possibly vascular in nature.
Child, Preschool↗
Skeletal growth lines seen on radiographs of newborn infants: prevalence and possible association with obstetric abnormalities.
OBJECTIVE: Skeletal transverse metaphyseal and vertebral lines, seen frequently on radiographs of infants and children, are usually believed to result from interrupted bone growth. Such lines have not been systematically studied in neonates. Accordingly, I determined the prevalence of growth lines on chest radiographs of newborn infants and assayed the gestational and obstetric abnormalities that occurred with these infants. MATERIALS AND METHODS: Chest radiographs were obtained (over a 4-year period) in 3687 neonates within the first 48 hr after birth for clinical indications. A single observer prospectively examined the radiographs for the presence of skeletal lines. When skeletal lines were seen on chest radiographs, lines in the pelvis were also sought when this region was imaged during the first 48 hr after birth. The medical records of affected neonates were reviewed to determine the presence and nature of potential in utero injuries. RESULTS: Skeletal lines were noted on chest radiographs of 200 neonates (5%) and appeared most commonly as "bone-within-bone" vertebral bodies and as transverse metaphyseal lines in the proximal humeri. Of affected neonates, 176 (88%) were born prematurely (< 38 weeks' gestation) and 59 (30%) had significant intrauterine growth retardation. Obstetric risk factors, which were varied and often multiple, were noted in 177 neonates (89%). The most common of these factors were pregnancy-induced hypertension (58 patients), multiple gestations (48 patients), drug abuse (30 patients), magnesium therapy (30 patients), prescribed maternal medications (27 patients), preterm labor before final labor (23 patients), and oligohydramnios (20 patients). In 23 neonates, no gestational complications were identified. CONCLUSION: Skeletal lines in the population of neonates who require chest radiography are relatively common, and often but not invariably appear to occur in the setting of potentially significant prenatal injury. It is speculated that these lines represent a tool for identifying and exploring causes of intrauterine growth disturbance.
Bone and Bones↗
Subtle signs of prenatal maldevelopment of the hand ectoderm in schizophrenia: a preliminary monozygotic twin study.
Genes that predispose to psychosis may act by making individuals more vulnerable to the disruptive effects of various prenatal insults. Fetal organogenesis is mostly completed in the first prenatal trimester. The second trimester is a critical period of massive neuronal migration from the periventricular germinal matrix to the cortex. A peripheral appendage developing simultaneously with this neural migration to the cortex is the distal upper limb. The ectodermal cells of the fetal upper limb migrate to form the hand skin during the fourth and fifth months of gestation (first two-thirds of the second prenatal trimester). Discrepancies in hand morphology between two identical (monozygotic [MZ]) co-twins may be temporal markers, that is, the "fossilized" evidence of various ischemic and other nongenetic insults that may have affected one fetus more than his MZ co-twin during that early part of the second trimester. In twins, prenatal insults (e.g., ischemia) frequently do not affect both co-twins to the same extent, so we examined seven putative markers of prenatal injury to the hand in 24 MZ twin pairs discordant for schizophrenia or delusional disorder. Compared with well co-twins, the affected co-twins had significantly higher total scores of fourth- and fifth-month dysmorphological hand anomalies.
Delusions↗
Multicystic encephalomalacia of infancy: clinico-pathological report of 7 cases.
Clinical follow up and complete neuropathological examination was made on seven cases of multicystic encephalomalacia of infancy. Etiological factors were carefully studied in all the cases. They consisted of prenatal injuries presenting as a cord prolapse, in 3 cases; prolonged labour with marked cyanosis; abdominal trauma during gestation, and various maternal infections at different stages of pregnancy. Pathological interest is centred on the variable involvement of different areas of the brain, generally sparing the cerebellum and brain stem, and being minimal or absent in the occipito-temporal areas. This distribution may be explained by a different effect of the "causal agency" on these different areas, or by a different capacity of these regions to react against injury. Among the etiological factors reviewed in the literature, the anoxic theory appears the most probable, as there was a close parallelism between lesions and vascular areas, mainly the carotid and vertebro-basilar systems.
Asphyxia Neonatorum↗
Minor physical anomalies in schizophrenia.
This study was conducted to investigate the value of using physical anomalies (PAs) to evaluate early prenatal injury in schizophrenia. PAs are minor abnormalities in development of the head, hands, and feet that are presumably associated with insult during the first trimester. Sixty-seven schizophrenic inpatients and 88 normal controls were evaluated for PAs. The schizophrenic patients showed significantly more anomalies than the controls. The difference remained significant even when patients were compared to controls of low socioeconomic status. Both male and female patients showed a high incidence of mouth abnormalities, and female patients showed a high incidence of abnormalities in head circumference. Patients with early age of onset (less than or equal to 18 years) had more physical anomalies than did later onset patients. This relationship was most noticeable for males. Physical anomalies were not associated with deficits on measures of vigilance, selective attention, or orientation.
Adult↗