Legal Briefs: In Utero Cerebral Hemorrhage and Alloimmune Thrombocytopenia: Was It Preventable?

Abstract

A 3,425-g, 39-week-gestation male infant was born to a 24-year-old gravida 1 para 0 woman via cesarean section because of a nonreassuring fetal heart rate tracing. Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. He was admitted to the normal newborn nursery, where the nurse noted that he had generalized petechiae. The complete blood cell count was normal, except for a platelet count of 7 × 103/μL (7 × 109/L). He was admitted to the NICU at 27 hours of age for evaluation and care. He was alert and active, with normal blood pressure and vital signs. The neonatologist ruled out autoimmune thromobocytopenia after determining that the mother's platelet count was normal. He asked the obstetrician to order an antiplatelet antibody test on the mother to determine if alloimmune thrombocytopenia was the diagnosis. Intravenous immunoglobulin (IVIG) was given, as well as 2 random donor platelet transfusions, which moderately elevated the platelet count. Because a heart murmur was noted, cardiac ultrasonography was performed, which showed the infant to have a hypoplastic right ventricle, tricuspid atresia, a ventricular septal defect, and a patent foramen ovale. Prostaglandins were started and the infant was sent to a referral center, where a balloon septostomy was performed. The neonatologist at the referral hospital requested a hematology consultation and ordered a platelet antibody test; however, because it was the weekend, the test was deferred until the following Monday. By Monday, the platelet count was normal, and the hematologist wrote a note that alloimmune thrombocytopenia was probably not the cause and the test was never performed. The parents were told that the low platelet count was idiopathic, and because it resolved, nothing further needed to be done. The complex cardiac defect was subsequently repaired, with excellent results. The mother shared …