Andrew I. Kaplan, Esq

Mr. Kaplan is a partner at Aaronson, Rappaport, Feinstein & Deutsch, LLP, specializing in medical malpractice defense and healthcare litigation.

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The 46-year-old plaintiff first presented to her primary care physician (PCP) on April 23, 2013, for a cough that had lasted 3 days. She reported incontinence, dribbling, and an inability to hold her urine after heavy menstruation. She also reported abdominal pain. Her PCP urged her to go to an ob/gyn for a work-up, with the differential possibly being endometriosis versus ruptured cyst. The impression was that the patient had recurrent stress urinary incontinence but the ob/gyn was concerned that it could turn into physical incontinence, given the woman’s gynecologic issues and age. The plan was to send her for an ultrasound (U/S) of the pelvis, which was performed on May 1, 2013. The U/S revealed a very large uterine fibroid (7x7 cm).

On May 5, 2013, the plaintiff presented to nonparty hospital with complaints of lower abdominal pain and vaginal bleeding that had lasted for 2 days. She reported bright red blood with multiple clots that increased throughout the day and her diagnosis with a 7x7-cm uterine fibroid by her PCP but said she did not have an ob/gyn. On exam, she reported that she had a history of heavy menses secondary to the fibroid. Transvaginal  (TVUS) confirmed multiple fibroids, the largest being 8.7 cm, and an enlarged uterus (8.5 x 12.2 cm). The impression was leiomyoma of the uterus. The woman was sent home in stable condition that night because she felt better, with a directive to follow up with an ob/gyn that week.

The plaintiff saw her PCP on July 23, 2013, for the start of preoperative medical clearance for a hysterectomy.She was cleared for surgery. Importantly, she reported incontinence and dribbling and that she could not hold her urine after menstruating. The assessment was vaginal bleeding, with abdominal pain secondary to the abdominal fibroids.

On or about August 26, 2013, the plaintiff presented to Defendant Hospital A for a laparoscopic hysterectomy by Defendant ob/gyn A, secondary to bleeding fibroids. The plaintiff’s history included a cesarean delivery, open cholecystectomy, bilateral breast reduction, and treatment for a miscarriage. During the hysterectomy, she sustained a bladder injury. An intraoperative cystoscopy confirmed a 2-cm tear near the vaginal cuff. Two double-J ureteral stents were placed by Defendant urologist, who recommended that she be transferred to Defendant Hospital B. The woman’s bladder was not repaired intraoperatively; instead she was transferred after Defendant ob/gyn A spoke with Defendant ob/gyn B. 

On August 27 at 11:40 p.m., the plaintiff was transferred from Defendant Hospital A to Defendant Hospital B with an admitting diagnosis of injury to the bladder and urethra and open wound. The admitting physician was Defendant ob/gyn B, who attempted conservative management; for 48 hours, the patient was stable without any issues. On August 29, a decision was made to perform a cystoscopy to further evaluate the bladder injury. Defendant ob/gyn B’s operative report indicated that informed consent was obtained. A cystogram was performed using 200 mL of fluid without obvious contrast extravasation. The plaintiff’s Foley catheter was removed and the two previously placed double-J stents were identified and noted to be in good position. A cystoscopy then was performed, and at the level of the trigone in the posterior portion of the bladder, an area consistent with the intraoperative injury was found. The same was noted to have granulating tissue but no obvious tear or extraperitoneal leak was seen. As a consequence, Defendant ob/gyn B decided “to not proceed with a formal repair” and instead, decided to continue to conservatively manage the plaintiff. The Foley catheter was replaced and the report concluded with a comment that the patient was to follow up in the office within the next 2 weeks for a repeat cystoscopy and removal of the double-J stents that had been placed. In the Postoperative Acute Care Unit, she received 2 units of blood. Discharge was on August 30.

A day later, the plaintiff was readmitted to Defendant Hospital B complaining of no urine output from the Foley catheter for 12 hours, lower abdominal pain, and difficulty breathing. The catheter was changed in the ER without relief of symptoms, so the plaintiff was admitted. On U/S, her bladder was small with fluid around it. A computed tomography (CT) scan showed that the Foley catheter was out of the bladder and in the peritoneum. The catheter was repositioned and conservative management was attempted. However, the patient had desaturations in oxygen to the 80s and was found to have bilateral pulmonary embolisms (PEs). Dopplers came back negative for deep vein thrombosis. Because of the woman’s history of PEs, a removable inferior vena cava filter was placed by vascular surgery. An intravenous (IV) heparin drip also was started. The plan was to stabilize the patient medically and then take her to the operating room (OR) for an open bladder repair. 

On September 3, repair surgery was undertaken by Defendant ob/gyn B. The procedure was described as an open complex cystorrhaphy with a repair of bladder injury and placement of a suprapubic tube. Per the OR report, “due to the location of the injury at the level of the trigone, a decision was made to perform an intravesical repair.” As a result, a cystotomy was performed in the dome of the bladder. The injury was noted to be at the trigone between both ureteral orifices. A suprapubic catheter was placed and the plan was to monitor the patient, transition her back to a heparin drip and eventually warfarin, with the hopes of discharging her a few days thereafter. Postoperatively, the plaintiff had bouts of tachycardia. She remained on a heparin drip. Transthoracic echocardiography showed evidence of some right heart strain. Heparin was changed to enoxaparin sodium. The suprapubic tube eventually drained clear urine and the patient was discharged on September 6 with the suprapubic tube to the Foley catheter and a three-way, 24-French Foley to leg bag. 

On September 13, the plaintiff followed up with Defendant ob/gyn B at his office. On exam, the doctor found her to be doing well with a suprapubic tube and the Foley catheter in place. He planned to keep the catheters in for the next 2 weeks and the note indicated she would be following up with her PCP regarding management of her warfarin level. Defendant ob/gyn B planned to perform a cystogram at the next visit and perhaps remove the Foley catheter but he intended to leave the suprapubic tube in for another few weeks. The plaintiff went to her PCP on September 24 for complaints of a urinary tract infection (UTI) with abrupt onset. Her symptoms concluded voiding scant amounts while urinating and the last occurrence was a few weeks before, and burning pain. Diagnosis was acute cystitis, UTI and she was started on sulfamethoxazole/trimethoprim. 

A note written by Defendant ob/gyn B about the patienht’s return visit on September 27,  repeated the history and said that the patient is “doing well with no complaints other than minimal pain from the Foley.” A cystogram was performed and no evidence of extravasation was noted. The Foley catheter was removed but the suprapubic tube was left in place. When plaintiff returned to Defendant ob/gyn B’s office a week later, a cystogram showed no evidence of extravasation and the suprapubic tube was removed. The bilateral stents were left in place and the patient was directed to return in
	3 weeks for their removal. In addition, she was placed on more antibiotics as a result of a complaint of dysuria. 

On October 8, the plaintiff was seen by her PCP for a complaint of 4-day lumbar radicular syndrome, pain 4/10. She also reported frequent urination, incontinence, dribbling, and painful urination. She reported that the pain started after the catheter was removed. The plan was that she return to the urologist for catheter placement versus further evaluation. On October 10, the plaintiff was transferred to Defendant Hospital B with complaints of nausea, vomiting, and flank pain and a diagnosis of pyelonephritis. A Foley catheter was placed and she was started on IV antibiotics. A CT scan showed bilateral moderate hydronephrosis with left perinephric stranding.

On October 12, Defendant ob/gyn B brought the patient back to the OR for a cystoscopy, during which he removed the bilateral stents. A cystogram was performed and again no contrast extravasation was seen. Thereafter, a cystoscopy was performed. The report noted that the “entire mucosa was extensively observed” and in the area of the previous repair, debris and granulation tissue were noted. Both ureteral orifices were easily identified, and both the right and left ureteral stents were noted to be calcified with debris. It was felt that the stents might be a possible source for the UTI, so they were removed. The plan was to monitor the plaintiff over the next 12 hours to see if there was any improvement. The Foley catheter was removed and she passed a trial of void so she was discharged on October 13. An appointment with Defendant ob/gyn B was made for October 25 but  then rescheduled to November 22. At that visit, the plaintiff was 1 month post-removal of the stents, appeared to be doing well save for the complaint of increasing nocturia every 1 1/2 to 2 hours during the evenings as well as frequency throughout the day. Defendant ob/gyn B performed a physical exam and found nothing out of the ordinary except for some costovertebral angle tenderness. Under “Impression” he called the plaintiff a woman with “significant lower urinary tract symptoms” and indicated that while a urine dipstick showed some white blood cells, there was no obvious UTI. A culture was sent and the patient was placed on solifenacin to see if this would improve her nocturia. She was directed to return in 4 weeks for a repeat uroflow and postvoid residual (PVR) but she did not.

On August 21, 2014, the plaintiff saw her PCP with complaints of frequent urination as well as vaginal bleeding between periods or after sex. She also reported that this began after surgery. She reported being treated with solifenacin with good results. She was given another prescription for the drug, 10 mg daily. The plaintiff returned to Defendant ob/gyn B on September 3 (10 months after her last visit) for the final time. The purpose of the visit was for a new onset of urinary incontinence. In his note, Defendant ob/gyn B recited the woman’s history of the complex bladder injury and repair, the pulmonary embolus. He also mentioned her “bleeding issues” (hypercoagulability), for which she was under the care of a hematologist. The plaintiff reported that she had been feeling well over the preceding 6 months and it was only 2 weeks prior when she started to notice the urinary incontinence. She denied any other urinary issues but did report that she was having some pelvic pain. A urine dipstick done in the office was within normal limits and the patient was scheduled for further evaluation with flexible cystoscopy. She did not return.

On October 30, the woman saw her PCP with complaints of bladder discomfort and UTI symptoms. She did not feel her complaints were socially unacceptable, but had leaking when she laughed, sneezed, and coughed. She also reported urinary frequency but no pain with incontinence. The diagnosis was UTI, acute cystitis. The plan was to start antibiotics. 

The plaintiff went back to her PCP on February 27, 2016. His note reported that she presented for urinary incontinence and indicated that the woman was status-post multiple bladder procedures with new incontinence. The plan was to reorder medication for incontinence and that she should follow up with urology and urological studies. On July 18, the woman was seen by her primary care physician for lesions found on her rib cage via a CT chest. She had no complaints of dysuria, frequency, urgency, nocturia, hematuria or incontinence. Her exam was normal. The PCP referred the plaintiff for a bone scan to rule out metastatic disease, which was performed on July 28. On July 29, The PCP notified the woman that the results were normal.  

The plaintiff argued that the defendants delayed diagnosing a fibroid uterus, menorrhagia, and anemia and delayed treating fibroids and performing a hysterectomy. The plaintiff’s side further alleged that the defendants negligently performed a laparoscopic hysterectomy, delayed timely treatment of complex bladder injury, failed to diagnose said injury intraoperatively, failed to diagnose and treat or prevent bladder damage, delayed surgery, failed to have appropriate surgical specialists available, failed to assess risk factors for a PE, caused a PE, and failed to properly place a Foley catheter. 

They contended that the bladder injury was diagnosed by defendants just after the hysterectomy was completed and during the cystoscopy of August 29, 2013. They argued that good and accepted medical practice required immediate repair of the hole in the plaintiff’s bladder. They contended that the delay placed the plaintiff at risk for further complications including the worsening of her condition, worsening of the hole, reopening of the hole, incomplete closure, additional procedures, infection, increased risk of urinary incontinence and/or frequency and pain.  

Our firm only represented ob/gyn B in this matter. 

Our urology expert was able to defend Defendant ob/gyn B. The plaintiff’s injury, the cystotomy, occurred during the hysterectomy on August 26, 2013. He confirmed that any delay in performing surgery to repair the cystotomy did not cause further injury to the woman. Moreover, incontinence-her alleged injury-pre-existed the surgery. Therefore, any complaint that she was now at an increased risk because she was treated conservatively made no medical sense. In fact, she would be at an increased risk if she had surgery. Furthermore the repair itself was undertaken in a standard fashion and expertly performed.  

The gynecology expert advised that the approximate 2-day delay in repairing the patient’s bladder injury made no difference. On August 29, Defendant ob/gyn B performed a cystogram and a cystoscopy to assess the extent of the plaintiff’s injury. The cystogram showed no evidence of leakage and the cystoscopy confirmed the finding. While some healing tissue was found, no perforation was found and there was no extravasation of dye. Defendant ob/gyn B directly visualized the area, and it appeared to be healing. Given the complexity of the repair that would have been necessary due to the injury’s location, Defendant ob/gyn B decided to treat the plaintiff conservatively. Our expert opined that the prudent course was to let her continue to heal as she appeared to be healing on her own, and not subject her to a further complicated surgery. As a general matter, although there is variation from patient to patient, but if a patient does not have a leak and is healing, treatment is conservative. Waiting for evidence of a leak for 2 days did not cause or contribute to subsequent urinary issues.

At Defendant ob/gyn B’s deposition, it became evident that the plaintiff really had no claims against him and was hoping, by naming him as a defendant and taking his deposition, that he would implicate the co-defendants. To the extent that the plaintiff found it necessary to have him testify that the injury to the bladder occurred at the prior institution, he accomplished his purpose. To the extent he had hoped that ob/gyn B would offer comment that the injury to the bladder was caused by negligence, he was unsuccessful. In fact, he testified that he had no knowledge of how the injury occurred other than learning that it happened during the surgery undertaken at the codefendant Hospital.

The case settled as to co-defendant ob/gyn A prior to trial. Ob/gyn B was given a voluntary discontinuance.

This case was interesting because we essentially knew from the time of our client’s deposition forward that the plaintiff was not focusing on his actions or inactions and that so long as we maintained our defense posture, we were likely to extract him from the case if and when our codefendant settled. We were certainly prepared to defend his care at trial if it came to that. Sometimes things work out that way, but it is imperative to have the case fully worked up and evaluated to ensure you are in your best position to defend whatever allegations–credible or otherwise–are advanced. Ob/gyn B was prepared to not only defend his care but also not to offer opposing counsel any testimony that could implicate his codefendants and further the plaintiff’s somewhat specious claims.

Articles

Allegations in this complex case include negligence in performing laparoscopic hysterectomy and delaying treatment of bladder injury.

Did delay in bladder repair cause urologic issues?


	A pregnant primigravida had her last menstrual period on August 28, 2014, an assigned due date of June 4, 2015. Her key prenatal visit took place on May 6, 2015. With a gestational age of 36 weeks, the fundal height was listed at 35 cm or 38 cm, as it was difficult to read the doctor’s handwriting. The presentation was vertex and fetal heart rate (FHR) and fetal movement were present. There was no indication of preterm labor and the mother’s cervix was intact. She weighed 119 lb, reflecting a 21-lb gain. Urinalysis was noted as negative. A note initialed by the defendant obstetrician indicated that the woman’s next appointment was scheduled in 1 week but there was no entry in the comment section, which reflected a routine visit with no complaints. The patient’s blood pressure was 91/77 mmHg, inconsistent with all blood pressures checked on past visits, which ranged anywhere from 97/64 mmHg to 126/80 mmHg. 

Shortly after midnight on May 7, the patient arrived at the hospital, and according to a note, had been “referred for emergency delivery.” The notes stated that the woman had come in complaining of abdominal pain, diarrhea, and fever since May 5, 2015 with suspected premature contractions. The initial nursing history note at roughly 2:00 a.m. stated that the patient’s chief complaint was “fatigue, feverish, as per family, with abdominal pain, vaginal bleeding.” 

The resident’s assessment noted that the patient came into labor triage at 36 weeks, feeling contractions, and the “team was called” to evaluate bradycardia upon placing the external monitor. The external FHR monitor showed a rate of 75 and the mother was given oxygen by face mask and an intravenous bolus of fluid. The Neonatal Intensive Care Unit and Anesthesia were notified. An obstetrical ultrasound performed shortly after midnight showed that the fetal heart was visible with cardiac activity, but the rate was bradycardic. The patient was taken to the operating room for a STAT cesarean. Verbal consent was obtained because of the emergency situation. 

The attending’s first note suggested that when the patient presented to triage, she had complaints of abdominal pain and diarrhea, “since the morning.” On external monitor, the FHR was 130 bpm and the maternal heart rate was also 130 bpm, prompting a sonogram. Because the FHR could not be “determined” a STAT cesarean was initiated.

A male fetus was delivered via cesarean with a birth weight of 2625 g, and Apgar scores of 0 and 0. The hospital’s obstetrical notes reflected that the emergent delivery was performed for fetal bradycardia, with an estimated blood loss of 1000 mL. during cesarean followed by virtually uncontrolled vaginal bleeding. Ultimately, the patient was diagnosed with disseminated intravascular coagulation (DIC) with suspected sepsis. The patient’s hematocrit dropped from 36.8% on admission to 12.7%. In the surgical ICU following the cesarean, she received 8 units of packed red blood cells, 8 units of fresh frozen plasma, 2 bags of crystalloids, and 1 unit of platelets. She was also receiving triple antibiotics. Nonetheless, the patient continued to actively bleed vaginally. Hypogastric artery embolization was performed with a note that the uterine arteries had been vasoconstricted previously.

The next note was from gynecology and said the reason for the patient’s cesarean was “suspected abruption/possible sepsis,” and that she developed DIC with vaginal bleeding as a result of suspected uterine atony, with suspected intra-abdominal bleeding, based upon abdominal distension and a bedside ultrasound. The note documented that the cesarean was started at 12:29 a.m. with the baby being delivered at 12:30 a.m. Intraoperatively, the patient’s abdomen was persistently contracted and tense, the uterus was pale, and upon entering the uterus there were clots and frank blood, “likely placental abruption” and the baby was delivered with poor Apgars. The next obstetrical attending note stated that “my review of the case at the time of my arrival, patient had an uncomplicated pregnancy, but presented to hospital for two days of diarrhea and abdominal pain, noted to have fetal bradycardia and triaged.” Initial labs were suspicious for abruption, and the patient essentially arrived with DIC.

On May 7 at 1 p.m. the attending was called to the Intensive Care Unit (ICU) by the obstetrical team because the patient “started” to develop severe vaginal bleeding due to uterine atony, requiring vasopressors. Given failure of conservative measures, she was now believed to have a life-threatening hemorrhage. The decision was made to go forward with a lifesaving salvage hysterectomy. The procedure was discussed with the patient’s sister and family and it was explained that, absent surgical intervention, the woman would not survive owing to the bleeding. 

By May 9, the notes reflected that the patient had apparently developed compartment syndrome of her right hand. On that date, the patient underwent a right-hand fasciotomy with a carpal tunnel release. Fasciotomies of the right volar, forearm, and dorsal hand also were performed.

Also on May 9, the patient developed acute compartment syndrome in her right leg. That led to a right thigh compartment fasciotomy and right calf compartment fasciotomy. While in surgical ICU, the woman also developed streptococcal toxic shock syndrome (STSS). On May 13, she went into acute respiratory failure, which resulted in a fiberoptic bronchoscopy and a percutaneous tracheostomy. 

On June 30, as a result of bilateral ischemic gluteal ulcers, a flapping procedure was performed. On July 22, owing to right index finger gangrene, the patient’s right index finger was amputated through the midline phalanx. On July 27, owing to right foot gangrene, the patient underwent a right below-the-knee amputation. On August 10, owing to left foot gangrene, the patient underwent a left below-the-knee amputation.


	Plaintiff alleged that at the last prenatal visit to defendant obstetrician, an appropriate history was not taken. The claim was that the doctor failed to learn the length of time plaintiff was exhibiting complaints of lower abdominal pain with fatigue, which would have required immediate delivery. It was also alleged that the attending failed to appropriately evaluate the mother’s abdomen during the visit and did not appreciate that there was fetal tachycardia. A fetal biophysical profile allegedly should have been performed, given the woman’s complaint of fatigue and lower abdominal pain with fetal tachycardia. The contention was that she should have been sent to the hospital on May 6, in that there was enough clinical suspicion of placental abruption as the cause of fetal distress, as exhibited by tachycardia, that it needed to be ruled out. Failure to appreciate placental abruption allegedly led to placental insufficiency, causing damage to the fetus and ultimately death. Failure to appreciate the abruption, the plaintiff claimed, caused uncontrollable hemorrhage, uterine atony, DIC, and STSS, ultimately leading to ischemic limbs and the need for a hysterectomy and significant amputations. All of this led to the death of the child, multi-organ failure in the mother leading to a hysterectomy, limb ischemia, amputation of the left index finger, and below-the-knee amputations of both her legs. This, in turn, led to the need for prosthetics and use of a wheelchair. The plaintiff claimed a loss of earning capacity and the emotional components of all of these damages.

As to the defendant Hospital, the plaintiff alleged it was improper to close the incision following the cesarean when the patient was still bleeding; a delay in transfusing the patient; and failure to appropriately monitor the patient after the procedure, resulting in DIC. In the face of uterine atony, they alleged there was a failure to timely perform a hysterectomy in an attempt to control the bleeding. 


	Early discussion with defendant OB revealed that he recalled the May 6 visit as a routine scheduled visit not occasioned by any complaints. If the patient had abdominal pain consistent with placental abruption, he did not believe she would have been able to withstand the ultrasound performed by him that day. Pursuant to that ultrasound, however, was a FHR of 194 bpm, which the defendant conceded he should have rechecked prior to sending the patient home. If the FHR did not come down to 160 bpm or below, he would have done a non-stress test to verify the finding and, potentially, would have sent the patient to the hospital for fluids and concern about maternal infection.

Our expert obstetrician wasn’t certain what prompted an ultrasound at 37 weeks but opined that a FHR of 194 bpm is quite abnormal and required immediate attention, i.e., sending the patient to the hospital immediately. A FHR that climbs over 180 bpm, to her mind, should be presumed to be a significant maternal infection, usually chorioamnionitis, and a reading like that is a red flag for maternal sepsis, and defendant OB should have checked the patient’s temperature as well.

She also had critiques for the Hospital co-defendant. She posited they were not having trouble finding the FHR; this was not a case of fetal bradycardia but rather there was fetal demise by the time the patient arrived. In the face of a raging infection, a cesarean would be contraindicated, especially in the face of fetal demise. She believed the proper course of care would have been to start the patient on medications to advance vaginal delivery and deliver the stillborn. Performing a cesarean in the face of a significant ascending infection would allow new entry portals for more organisms and rapidly spread the infection. She posited that ultimately caused the septic shock. 

 infection, and a similar finding was made and confirmed based upon blood cultures. By performing a cesarean rather than controlling the infection with proper antibiotics, the Hospital staff exacerbated the infection. The expert did not believe that there was ever a placental abruption. She believed that the DIC led to internal placental bleeding, which the doctors mistook for an abruption. The fact that the patient progressed to sepsis not only affected the woman’s respiratory ability, but more importantly, affected and caused a drop in platelets, which impaired her clotting ability. This led to DIC, which was the precursor to the salvage hysterectomy that the patient underwent 1 day later. However, she progressed to necrotizing fasciitis, which ultimately led to limb loss.

The patient had been fitted with bilateral lower limb prostheses. Those records reflected a history of undiagnosed group A 

 infection during pregnancy leading to STSS. 

The defendant obstetrician and his practice were responsible for one-third of the settlement and the Hospital the other two-thirds.


	This was a case of significantly high exposure given the injuries, the favorable plaintiff’s venue and the obvious jury appeal. Sometimes, early analysis and resolution of high-exposure claims such as these is the best option, particularly when there is nothing to be gained by proceeding with formal discovery and depositions, and risk of disclosure of additional damaging evidence or testimony is high. We often harp on the necessity of thorough, accurate, contemporaneous documentation in this column. This case is no different, but here there was also a “failure” by the defendant obstetrician to take time in a busy practice to recognize the potential for danger to mother and fetus and investigate pertinent findings before discharging her home. More often than not, it is those seemingly minor oversights that lead to bigger issues later on and, eventually, litigation. 

Failure to recognize the warning signs led to poor outcomes for mother and child.

Author | Andrew I. Kaplan, Esq

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Did delay in bladder repair cause urologic issues?

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