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Legal Review & Commentary
Alleged: No treatment for ectopic pregnancy
Malpractice action questions causation
Radha V. Bachman, Esq.
Buchanan, Ingersoll & Rooney, PC
Commentary provided by:
Barbara Reding, RN, LHCRM, PLNC
Central Florida Health Alliance
and Leilani Kicklighter, RN, ARM, MBA, CHSP, CPHRM, LHRM
The Kicklighter Group
News: A pregnant woman experienced bleeding and cramps early on in her pregnancy. She visited her doctor, who confirmed that the woman was three weeks pregnant and diagnosed her with a probable spontaneous abortion. Prior to receiving an ultrasound to confirm the abortion, the woman experienced pain and presented to a local hospital. A pelvic ultrasound was ordered, and the reading radiologist noted "ectopic pregnancy is not ruled out. Please correlate clinically." The woman was seen by the hospital's chief obstetric resident, and the woman's symptoms were discussed with the supervising attending physician. Ectopic pregnancy again was listed as a possible diagnosis with a note that it was "clinically unlikely," and the woman was discharged. The woman continued experiencing severe abdominal pain. Eight days after being discharged, the woman again returned to the hospital emergency department. It was determined that her fallopian tube had ruptured as a result of an ectopic pregnancy. Subsequently, the woman instituted a medical malpractice action against the hospital and the supervising attending physician.
Background: A woman, who believed she was pregnant, began experiencing severe abdominal cramping and bleeding soon after completing a home pregnancy test. The woman made an appointment to see her primary care physician who determined that the woman was three weeks pregnant and had probably experienced a spontaneous abortion. The woman then was scheduled for a transvaginal ultrasound about one week later. Prior to receiving the ultrasound, the woman again began suffering from bleeding and went to the emergency department (ED) at a local hospital. A pelvic exam was conducted, blood was drawn, and a pelvic ultrasound was ordered. An OB consult was called, and no signs of active bleeding, blood, clots, or cervical dilation were noted. A pelvic ultrasound, however, indicated a possible ectopic pregnancy. An ectopic pregnancy occurs when a pregnancy implants outside the uterine cavity, typically in the fallopian tube. The radiologist who read the ultrasound determined that there were no signs of an intrauterine pregnancy and that ectopic pregnancy could not be ruled out.
The chief obstetrics resident at the hospital visited the woman and consulted with the supervising physician. The resident noted that the complex fluid in the cul de sac, an area between a female's rectum and back wall of the uterus, raised concerns of ectopic pregnancy. However, the resident said that such a diagnosis was "clinically unlikely." The woman was released with instructions to follow-up three days later. One day after her scheduled appointment, the woman came to the clinic and was seen by the resident. The resident confirmed that the woman was not pregnant and that there was no blood in the vaginal vault. However, he also noted that the woman should be placed on "strict ectopic pregnancy precautions" due to the fact that her beta levels had increased. The resident indicated that if the woman's beta levels continued to increase, she would be considered for an ultrasound and laparoscopy. The woman was released with instructions to return in a few days. That same day, the woman came back to the hospital again with severe cramping and told the nursing staff and the ED physician that she was "pregnant in her tube." Following a basic examination, she was diagnosed with muscle strain and discharged.
Four days after being discharged for the second time, the woman presented at another hospital's ED. The staff discovered that her fallopian tube had ruptured, and the woman underwent surgery to remove the reproductive organs.
The woman filed suit against the hospital and the resident's supervising physician alleging negligent care. The woman's experts testified that had the ectopic pregnancy been treated during the woman's second visit to the hospital, she would not have suffered a ruptured tube. The plaintiff's experts also testified that administration of the drug methotrexate could have been used to treat the ectopic pregnancy. Methotrexate stops the growth of a developing embryo and is commonly used when a woman is suffering from an ectopic pregnancy.
Legal issues: The hospital and the physician defendant joined together to file a motion to dismiss, and they argued that the plaintiff was unable to show that the defendants' failures led to the woman's injuries. The trial court granted the motion and dismissed the case, and the plaintiff appealed.
On appeal, the court looked at whether there was a genuine issue of material fact with respect to the element of causation. A genuine issue of material fact exists when the record leaves open an issue upon which reasonable minds could differ. The appeal court found that, based on the expert testimony of four witnesses, the woman had presented sufficient evidence to create a genuine issue of fact with respect to whether the hospital and physicians' failure to diagnose and timely treat the ectopic pregnancy led to the rupture of her fallopian tube.
The hospital defendant attempted to argue before the appeals court that the woman's failure to return to the hospital for follow-up care as instructed by the resident was the sole cause of the rupture. The court rejected this argument and stated that issues of apportionment of liability and negligence are for a jury. The case was sent back to the trial court and will be continued.
What this means to you: In using as a guideline the definition of causation as "the departure from the standard of care must be the cause of the plaintiff's injury, and the injury must be foreseeable," this case evokes several thoughts from the risk management perspective. Based on the information provided, with no review of the actual records, it seems the care providers "struggled" with making a definitive diagnosis. A pelvic ultrasound (US) indicated a "possible ectopic pregnancy." That possibility alone would warrant additional and timely evaluation and action. According to the Mayo Clinic's online information for a health care consumer, the information provided indicates the "stakes are high" with an ectopic pregnancy where treatment might lead to loss of reproductive organs or infertility. Untreated, the "stakes are even higher" with potential for a ruptured fallopian tube that could result in life-threatening bleeding, according to the Mayo Clinic.
If an ectopic pregnancy was possible (as per pelvic ultrasound), the standard of care (SOC) would indicate the need for further evaluation and diagnosis because the injury, a fallopian tube rupture, was foreseeable. With SOC, injury alone is not proof that the defendant(s) deviated from the SOC.
It would be interesting to read the testimony of expert OB/GYN witnesses. Was the evaluation of the plaintiff timely and appropriate in light of the fact there was suspicion for an ectopic pregnancy? Did the attending/supervising physician come in to exam the patient? It would appear that there were more signs and symptoms to support ectopic pregnancy than support against it. If the evaluation and subsequent diagnostic studies were in line with the SOC, and there was either no departure from the SOC or a departure could be considered "reasonable," then the plaintiff would not be able to demonstrate proximate cause. It would seem the SOC must be thoroughly researched in this case before being able to determine causation. Was there truly a deviation from the SOC?
It appears that what happened in this unfortunate case was a failure to appropriately diagnose the ectopic pregnancy and implement timely clinical intervention. It seems a few of the involved physicians (resident and ED physician) had identified possible ectopic pregnancy and were pursuing potential remedial efforts while others (supervising physician) dismissed such a diagnosis without additional diagnostic studies. There is a wealth of information on the Internet regarding ectopic pregnancy, its signs and symptoms, complications, testing, treatment, etc. Given the severity of delayed treatment, the caregivers should have made ruling out ectopic pregnancy a primary goal. From the risk management perspective, this is one of those cases where, the organization's or facility's leaders should perform a thorough record review, obtain statements from physicians, and hold their breath. This case indeed is a most interesting one. The appellate court must have thought so as well.
Michigan, Genesee Circuit Court; LC No. 08-087809-NH.