Análisis de las Secuelas Neurobiológicas y Legales tras eventos de Encefalopatía Hipóxico-Isquémica Neonatal, Evaluando la Responsabilidad Médica y el Impacto Psiquiátrico a Largo Plazo en la Madre (tept).

Magaly Stefania Inga Ordoñez; Lucía Daniela Serrano Barahona; Evelyn Odalis Checa Paspuezán; David Fernando Moretta Cardenas; Roxana Esther  Mayorga Nuñez

doi:10.70577/asce.v5i3.1066

Authors

Magaly Stefania Inga Ordoñez Investigador Independiente https://orcid.org/0009-0003-8296-198X
Lucía Daniela Serrano Barahona Adhinflex s.a https://orcid.org/0009-0007-1612-2036
Evelyn Odalis Checa Paspuezán Universidad Técnica del Norte https://orcid.org/0009-0003-0047-0408
David Fernando Moretta Cardenas Investigador Independiente https://orcid.org/0009-0001-9824-6521
Roxana Esther Mayorga Nuñez Universidad de Guayaquil https://orcid.org/0009-0007-2967-6361

DOI:

https://doi.org/10.70577/asce.v5i3.1066

Keywords:

Hypoxia-Ischemia, Brain; Liability, Legal; Stress Disorders, Post-Traumatic; Brain Damage, Chronic; Malpractice; Forensic Psychiatry; Maternal Mental Health.

Abstract

Neonatal hypoxic-ischemic encephalopathy (HIE) is a major cause of neurological morbidity and raises complex medical liability scenarios. Additionally, the psychiatric impact on mothers, specifically post-traumatic stress disorder (PTSD), has been insufficiently addressed in its long-term dimension. To systematically analyze the available evidence on the neurobiological sequelae of HIE in neonates, long-term maternal psychiatric impact (PTSD), and its consideration in medical liability processes. Systematic review conducted following PRISMA 2020 guidelines. PubMed/MEDLINE, Scopus, Web of Science, PsycINFO, and LILACS were searched (January 2000-October 2025). Original studies, systematic reviews, meta-analyses, and clinical guidelines were included. Methodological quality was assessed using JBI and AMSTAR-2 tools. A total of 1,245 records were identified, of which 48 studies met the inclusion criteria. Evidence confirms that HIE generates neurological sequelae in 25-45% of survivors (cerebral palsy, epilepsy, neurodevelopmental disorders). PTSD prevalence in mothers ranges from 15-35%, associated with HPA axis dysregulation and functional neuroimaging alterations, with symptom persistence beyond 24 months in 35% of cases. Medical liability litigation focuses on intrapartum monitoring (58% of cases), cesarean delay (42%), and inadequate resuscitation (28%). Only 15% of analyzed judgments consider maternal psychological damage autonomously. The findings support the implementation of systematic PTSD screening in mothers of neonates with HIE, the development of standardized expert protocols for assessing maternal psychological damage, and the need for longitudinal studies evaluating integrated preventive interventions. Infant neurological damage and maternal PTSD are interconnected sequelae of the same event. Its approach requires a biopsychosocial and legal perspective, including maternal mental health in expert assessment of compensable damage.

Downloads

Download data is not yet available.

References

1. Kurinczuk JJ, White-Koning M, Badawi N. Epidemiology of neonatal encephalopathy and hypoxic-ischaemic encephalopathy. Early Hum Dev. 2010;86(6):329-38. DOI: https://doi.org/10.1016/j.earlhumdev.2010.05.010

2. Lee AC, Kozuki N, Blencowe H, Vos T, Bahalim A, Darmstadt GL, et al. Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990. Pediatr Res. 2013;74(Suppl 1):50-72. DOI: https://doi.org/10.1038/pr.2013.206

3. Douglas-Escobar M, Weiss MD. Hypoxic-ischemic encephalopathy: a review for the clinician. JAMA Pediatr. 2015;169(4):397-403. DOI: https://doi.org/10.1001/jamapediatrics.2014.3269

4. Ferriero DM. Neonatal brain injury. N Engl J Med. 2004;351(19):1985-95. DOI: https://doi.org/10.1056/NEJMra041996

5. Volpe JJ. Brain injury in premature infants: a complex amalgam of destructive and developmental disturbances. Lancet Neurol. 2009;8(1):110-24. DOI: https://doi.org/10.1016/S1474-4422(08)70294-1

6. Barkovich AJ, Miller SP, Bartha A, Newton N, Hamrick SE, Mukherjee P, et al. MR imaging, MR spectroscopy, and diffusion tensor imaging of sequential studies in neonates with encephalopathy. AJNR Am J Neuroradiol. 2006;27(3):533-47.

7. Martinez-Biarge M, Diez-Sebastian J, Kapellou O, Gindner D, Allsop JM, Rutherford MA, et al. Predicting motor outcome and death in term hypoxic-ischemic encephalopathy. Neurology. 2011;76(24):2055-61. DOI: https://doi.org/10.1212/WNL.0b013e31821f442d

8. de Vries LS, Jongmans MJ. Long-term outcome after neonatal hypoxic-ischaemic encephalopathy. Arch Dis Child Fetal Neonatal Ed. 2010;95(3):F220-4. DOI: https://doi.org/10.1136/adc.2008.148205

9. Glass HC, Glidden D, Jeremy RJ, Barkovich AJ, Ferriero DM, Miller SP. Clinical neonatal seizures are independently associated with outcome in infants at risk for hypoxic-ischemic brain injury. J Pediatr. 2009;155(3):318-23. DOI: https://doi.org/10.1016/j.jpeds.2009.03.040

10. Uria-Avellanal C, Marlow N, Rennie JM. Outcome following neonatal seizures. Semin Fetal Neonatal Med. 2013;18(4):224-32. DOI: https://doi.org/10.1016/j.siny.2013.01.002

11. Badawi N, Dixon G, Felix JF, Keogh JM, Petterson B, Stanley FJ, et al. Autism following a history of newborn encephalopathy: more than a coincidence? Dev Med Child Neurol. 2006;48(2):85-9. DOI: https://doi.org/10.1017/S001216220600020X

12. van Handel M, Swaab H, de Vries LS, Jongmans MJ. Long-term cognitive and behavioral consequences of neonatal encephalopathy following perinatal asphyxia: a review. Eur J Pediatr. 2007;166(7):645-54. DOI: https://doi.org/10.1007/s00431-007-0437-8

13. Shankaran S, Laptook AR, Pappas A, McDonald SA, Das A, Tyson JE, et al. Effect of depth and duration of cooling on deaths in the NICU among neonates with hypoxic ischemic encephalopathy: a randomized clinical trial. JAMA. 2014;312(24):2629-39. DOI: https://doi.org/10.1001/jama.2014.16058

14. Azzopardi D, Strohm B, Marlow N, Brocklehurst P, Deierl A, Eddama O, et al. Effects of hypothermia for perinatal asphyxia on childhood outcomes. N Engl J Med. 2014;371(2):140-9. DOI: https://doi.org/10.1056/NEJMoa1315788

15. Pappas A, Shankaran S, McDonald SA, Vohr BR, Hintz SR, Ehrenkranz RA, et al. Cognitive outcomes after neonatal encephalopathy. Pediatrics. 2015;135(3):e624-34. DOI: https://doi.org/10.1542/peds.2014-1566

16. Shaw RJ, Bernard RS, Deblois T, Ikuta LM, Ginzburg K, Koopman C. The relationship between acute stress disorder and posttraumatic stress disorder in the neonatal intensive care unit. Psychosomatics. 2009;50(2):131-7. DOI: https://doi.org/10.1176/appi.psy.50.2.131

17. Lefkowitz DS, Baxt C, Evans JR. Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the Neonatal Intensive Care Unit (NICU). J Clin Psychol Med Settings. 2010;17(3):230-7. DOI: https://doi.org/10.1007/s10880-010-9202-7

18. Yildiz PD, Ayers S, Phillips L. The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis. J Affect Disord. 2017;208:634-45. DOI: https://doi.org/10.1016/j.jad.2016.10.009

19. Ayers S, Bond R, Bertullies S, Wijma K. The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychol Med. 2016;46(6):1121-34. DOI: https://doi.org/10.1017/S0033291715002706

20. Horsch A, Jacobs I, Gilbert L, Favrod C, Schneider J, Morisod Harari M, et al. Impact of perinatal asphyxia on parental mental health and bonding with the infant: a prospective longitudinal study. J Psychosom Obstet Gynaecol. 2021;42(2):108-16.

21. Cook N, Ayers S, Horsch A. Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review. J Affect Disord. 2018;225:18-31. DOI: https://doi.org/10.1016/j.jad.2017.07.045

22. Garthus-Niegel S, Horsch A, Handtke E, von Soest T, Ayers S, Weidner K, et al. The impact of postpartum posttraumatic stress disorder on mother-child bonding: A longitudinal study. Arch Womens Ment Health. 2021;24(3):435-43.

23. Ionio C, Colombo C, Brazzoduro V, Mascheroni E, Confalonieri E, Castoldi F, et al. Mothers and fathers in NICU: The impact of post-traumatic stress symptoms on parent-infant bonding. Early Hum Dev. 2019;133:52-7.

24. Forcada-Guex M, Pierrehumbert B, Borghini A, Moessinger A, Muller-Nix C. Early dyadic patterns of mother-infant interactions and outcomes of prematurity at 18 months. Pediatrics. 2006;118(1):e107-14. DOI: https://doi.org/10.1542/peds.2005-1145

25. Greene MM, Rossman B, Patra K, Kratovil A, Khan S, Meier PP. Depressive, anxious, and perinatal post-traumatic distress in mothers of very low birth weight infants in the NICU. J Dev Behav Pediatr. 2015;36(5):362-70. DOI: https://doi.org/10.1097/DBP.0000000000000174

26. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008;112(6):1279-83. DOI: https://doi.org/10.1097/AOG.0b013e31818da2c7

27. Berglund S, Grunewald C, Pettersson H, Cnattingius S. Risk factors for asphyxia associated with substandard care during labor. Acta Obstet Gynecol Scand. 2010;89(1):39-48. DOI: https://doi.org/10.3109/00016340903418751

28. Holcroft CJ, Graham EM, Aina-Mumuney A, Rai KK, Henderson JL, Penning DH. Cord gas analysis, decision-to-delivery interval, and the 30-minute rule for emergency cesareans. J Reprod Med. 2008;53(9):657-62.

29. Thomas J, Paranjothy S, James D. National cross sectional survey to determine whether the decision to delivery interval is critical in emergency caesarean section. BMJ. 2004;328(7441):665-8. DOI: https://doi.org/10.1136/bmj.38031.775845.7C

30. Vázquez Ferreyra RA. Daños a la persona. Buenos Aires: Hammurabi; 2019. 432 p.

31. Simón Castellano P. La valoración del daño psíquico en la responsabilidad civil médica. In: Medicina y derecho: perspectivas actuales. Madrid: Dykinson; 2022. p. 145-68.

32. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. DOI: https://doi.org/10.1136/bmj.n71

33. Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ. 2020;368:l6890. DOI: https://doi.org/10.1136/bmj.l6890

34. Natarajan G, Pappas A, Shankaran S. Outcomes in childhood following therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy. Semin Perinatol. 2016;40(8):549-55. DOI: https://doi.org/10.1053/j.semperi.2016.09.007

35. Rutherford MA, Pennock JM, Counsell SJ, Mercuri E, Cowan FM, Dubowitz LM, et al. Abnormal magnetic resonance signal in the internal capsule predicts poor neurodevelopmental outcome in infants with hypoxic-ischemic encephalopathy. Pediatrics. 1998;102(2 Pt 1):323-8. DOI: https://doi.org/10.1542/peds.102.2.323

36. Martinez-Biarge M, Bregant T, Wusthoff CJ, Chew AT, Diez-Sebastian J, Rutherford MA, et al. White matter and cortical injury in hypoxic-ischemic encephalopathy: antecedent factors and 2-year outcome. J Pediatr. 2012;161(5):799-807. DOI: https://doi.org/10.1016/j.jpeds.2012.04.054

37. Sabir H, Scull-Brown E, Liu X, Thoresen M. Immediate hypothermia is not associated with improved neurodevelopmental outcome after hypoxic-ischemic encephalopathy. Pediatr Res. 2024;95(2):456-63.

38. Glass HC, Wusthoff CJ, Shellhaas RA, Tsuchida TN, Bonifacio SL, Cordeiro M, et al. Risk factors for epilepsy in children with neonatal encephalopathy. Pediatr Res. 2014;76(5):475-80.

39. Shellhaas RA, Wusthoff CJ, Tsuchida TN, Glass HC, Chu CJ, Massey SL, et al. Profile of neonatal epilepsies: Characteristics of a prospective US cohort. Neurology. 2017;89(9):893-9. DOI: https://doi.org/10.1212/WNL.0000000000004284

40. Weeke LC, van Ooijen IM, Groenendaal F, van Huffelen AC, Toet MC, van der Aa NE, et al. Rhythmic EEG patterns in extremely preterm infants: a longitudinal study. Clin Neurophysiol. 2018;129(1):56-62.

41. van Kooij BJ, van Handel M, Nievelstein RA, Groenendaal F, Jongmans MJ, de Vries LS. Serial MRI and neurodevelopmental outcome in 9- to 10-year-old children with neonatal encephalopathy. J Pediatr. 2010;157(2):221-7. DOI: https://doi.org/10.1016/j.jpeds.2010.02.016

42. Løhaugen GC, Østgård HF, Andreassen S, Jacobsen GW, Vik T, Brubakk AM, et al. Small for gestational age and cognitive function: A population-based study of preschool children. Early Hum Dev. 2014;90(9):527-32.

43. Pappas A, Shankaran S, Laptook AR, McDonald SA, Ehrenkranz RA, Tyson JE, et al. Hypocapnia and adverse outcome in neonatal hypoxic-ischemic encephalopathy. J Pediatr. 2011;158(2 Suppl):S52-8. DOI: https://doi.org/10.1016/j.jpeds.2010.10.019

44. Massaro AN, Murthy K, Zaniletti I, Cook N, DiGeronimo R, Dizon ML, et al. Short-term outcomes after perinatal hypoxic ischemic encephalopathy: a report from the Children's Hospitals Neonatal Consortium. J Pediatr. 2015;166(2):268-74. DOI: https://doi.org/10.1038/jp.2014.190

45. Chalak LF, Sánchez PJ, Adams-Huet B, Laptook AR, Heyne RJ, Rosenfeld CR. Biomarkers for severity of neonatal hypoxic-ischemic encephalopathy and outcomes in newborns receiving hypothermia therapy. J Pediatr. 2014;164(3):468-74. DOI: https://doi.org/10.1016/j.jpeds.2013.10.067

46. Shaw RJ, St John N, Lilo E, Jo B, Benitz W, Stevenson DK, et al. Prevention of traumatic stress in mothers with preterm infants: a randomized controlled trial. Pediatrics. 2013;132(4):e886-94. DOI: https://doi.org/10.1542/peds.2013-1331

47. Hynan MT, Steinberg Z, Baker L, Cioffi J, Geller PA, Lassen S, et al. Recommendations for mental health professionals in the NICU. J Perinatol. 2015;35(Suppl 1):S14-8. DOI: https://doi.org/10.1038/jp.2015.144

48. Williams KG, Patel KT, Stausmire JM, Bridges C, Mathis MW, Barkin JL. Postpartum depression and posttraumatic stress disorder in mothers of infants with hypoxic-ischemic encephalopathy. J Perinatol. 2022;42(6):748-54.

49. Gangi S, Darlow BA, Trower N, Horwood LJ, Woodward LJ. Posttraumatic stress disorder in mothers of very preterm infants: 2-year outcomes. J Dev Behav Pediatr. 2021;42(3):183-90.

50. Pace CC, Spittle AJ, Molesworth CM, Lee KJ, Northam EA, Cheong JL, et al. Evolution of depression and anxiety symptoms in mothers of preterm infants during the first year postpartum. J Pediatr. 2016;170:60-7. DOI: https://doi.org/10.1001/jamapediatrics.2016.0810

51. Holditch-Davis D, Bartlett TR, Blickman AL, Miles MS. Posttraumatic stress symptoms in mothers of premature infants. J Obstet Gynecol Neonatal Nurs. 2003;32(2):161-71. DOI: https://doi.org/10.1177/0884217503252035

52. Ayers S, Eagle A, Waring H. The effects of postnatal posttraumatic stress disorder on mother-infant bonding. J Psychosom Obstet Gynaecol. 2006;27(3):157-63.

53. Schechter DS, Moser DA, Paoloni-Giacobino A, Stenz L, Gex-Fabry M, Aue T, et al. Methylation of NR3C1 is related to maternal PTSD, parenting stress and maternal medial prefrontal cortical activity in response to child separation among mothers with histories of violence exposure. Front Psychol. 2015;6:690. DOI: https://doi.org/10.3389/fpsyg.2015.00690

54. Schechter DS, Moser DA, Wang Z, Marsh R, Hao X, Duan Y, et al. An fMRI study of the brain responses of traumatized mothers to viewing their toddlers during separation and play. Soc Cogn Affect Neurosci. 2012;7(8):969-79. DOI: https://doi.org/10.1093/scan/nsr069

55. Bernard K, Nissim G, Vaccaro S, Harris JL, Lindhiem O. Association between maternal posttraumatic stress disorder and mother-infant bonding: A meta-analysis. J Affect Disord. 2021;289:89-97.

56. Treyvaud K, Doyle LW, Lee KJ, Ure A, Inder TE, Hunt RW, et al. Parenting behavior at 2 years predicts school-age performance at 7 years in very preterm children. J Child Psychol Psychiatry. 2016;57(7):814-21. DOI: https://doi.org/10.1111/jcpp.12489

57. Forcada-Guex M, Borghini A, Pierrehumbert B, Ansermet F, Muller-Nix C. Prematurity, maternal stress and mother-child interactions. Early Hum Dev. 2011;87(2):123-9. DOI: https://doi.org/10.1016/j.earlhumdev.2010.09.006

58. Horsch A, Tolsa JF, Gilbert L, Borradori Tolsa C, Faouzi M, Bickle Graz M. Improving maternal mental health following preterm birth using an expressive writing intervention: a randomized controlled trial. Child Psychiatry Hum Dev. 2022;53(2):234-46.

59. Mendelson T, Cluxton-Keller F, Vullo GC, Tandon SD, Noazin S. NICU-based interventions to reduce maternal depressive and anxiety symptoms: A meta-analysis. Pediatrics. 2017;139(3):e20161870. DOI: https://doi.org/10.1542/peds.2016-1870

60. Jonsdottir SS, Thome M, Steingrimsdottir T, Lydsdottir LB, Sigurdsson JF, Olafsdottir H, et al. A randomized controlled trial of a preventive intervention for parents of infants born extremely preterm. J Pediatr. 2024;265:113814.

61. Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol. 2008;199(1):36.e1-5. DOI: https://doi.org/10.1016/j.ajog.2008.03.007

62. Berglund S, Grunewald C, Pettersson H, Cnattingius S. Severe asphyxia due to substandard care during labour. Acta Obstet Gynecol Scand. 2005;84(5):442-7.

63. Menezes MV, Siqueira ML, Schoen TH, Katz L, Amorim MM. Analysis of lawsuits related to neonatal asphyxia in a teaching hospital in Brazil. Rev Assoc Med Bras. 2018;64(5):426-31.

64. Tolcher MC, Johnson RL, El-Nashar SA, West CP. Decision-to-incision time and neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol. 2014;123(3):536-48. DOI: https://doi.org/10.1097/AOG.0000000000000132

65. Ayres-de-Campos D, Spong CY, Chandraharan E; FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. Int J Gynaecol Obstet. 2015;131(1):13-24. DOI: https://doi.org/10.1016/j.ijgo.2015.06.020

66. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol. 2008;112(3):661-6. DOI: https://doi.org/10.1097/AOG.0b013e3181841395

67. Cohen J, Blatter S, Leuthold S, Amsler F, Mouton W, Nelle M, et al. Compensating for birth-related neurological damage: a Swiss nationwide analysis of legal claims. J Perinat Med. 2021;49(5):623-30.

68. Sánchez Ruiz ME. La reparación del daño psíquico en la responsabilidad médica perinatal. Rev Derecho Salud. 2024;8(2):45-62.

69. Torres Gómez LF, Martínez Vera JC. Valoración pericial del trastorno por estrés postraumático en madres de neonatos con encefalopatía hipóxico-isquémica. Cuad Med Forense. 2024;30(1):23-35.

70. Castro Mendoza AG, Sánchez Ruiz ME. Daño psíquico materno en litigios por asfixia perinatal: análisis jurisprudencial comparado. Rev Iberoam Derecho Med. 2024;12(1):78-94.

71. Weathers FW, Bovin MJ, Lee DJ, Sloan DM, Schnurr PP, Kaloupek DG, et al. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans. Psychol Assess. 2018;30(3):383-95. DOI: https://doi.org/10.1037/pas0000486

72. First MB, Williams JB, Karg RS, Spitzer RL. Structured Clinical Interview for DSM-5 Disorders (SCID-5). Arlington: American Psychiatric Association; 2015.

73. Ustün TB, Kostanjsek N, Chatterji S, Rehm J. Measuring health and disability: manual for WHO Disability Assessment Schedule (WHODAS 2.0). Geneva: World Health Organization; 2010.

74. Weiss DS, Marmar CR. The Impact of Event Scale-Revised. In: Wilson JP, Keane TM, editors. Assessing psychological trauma and PTSD. New York: Guilford Press; 1997. p. 399-411.

75. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. J Trauma Stress. 2015;28(6):489-98. DOI: https://doi.org/10.1002/jts.22059

76. Perrin S, Smith P, Yule W. The assessment and treatment of post-traumatic stress disorder in children and adolescents. J Child Psychol Psychiatry. 2000;41(3):277-89.

77. Shapiro F. The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: addressing the psychological and physical symptoms stemming from adverse life experiences. Perm J. 2014;18(1):71-7.

77. Perrin S, Smith P, Yule W. The assessment and treatment of post-traumatic stress disorder in children and adolescents. J Child Psychol Psychiatry. 2000;41(3):277-289. DOI: https://doi.org/10.1017/S0021963099005454

78. Shapiro F. The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: addressing the psychological and physical symptoms stemming from adverse life experiences. Perm J. 2014;18(1):71-77. DOI: https://doi.org/10.7812/TPP/13-098