Dawn Collins, JD

	A  34-year-old woman was under the care of her long-time family physician for her pregnancy in 2009. The physician had minor privileges to deliver uncomplicated pregnancies at a specific hospital. The patient was in her third trimester when she came for a regular prenatal visit, but she also complained of a headache and a cough. Her blood pressure (B/P) was 130/90. Two days later, she reported acute vaginal bleeding and a headache. The physician admitted her to the hospital with a diagnosis of potential placental abruption. An ultrasound revealed oligohydramnios, intrauterine growth restriction, and grade II placenta. She had repeated high blood pressure readings, headaches, and decreasing platelets. The fetal heart rate (FHR) showed variable and late decelerations. She was subsequently discharged to another hospital to undergo another ultrasound evaluation. Five days after her original admission, the patient’s husband informed the physician that the patient was vomiting, with abdominal pain, and headaches. He brought her to the hospital, where her B/P was 155/100 and she complained of severe headache from front to back, constant throbbing, facial edema, and vomiting. She was admitted and at 3:15 a.m. the following day the nurse found the patient with her head hanging over the bed, having vomited, and unresponsive. The on-call obstetrician diagnosed her with eclampsia and ordered magnesium sulfate, hydralazine, and an immediate cesarean. The infant was delivered, but the patient remained unresponsive and a computed tomography scan revealed a massive intracranial hemorrhage. She was pronounced dead at 5:10 p.m. that same day.

	A lawsuit was filed against the family physician, her group, the hospital and the nurse involved in the patient’s care. The claims included the fact the family physician did not come to the hospital to evaluate her patient. It was alleged that she deviated from the accepted standard of medical care by failing to adequately diagnose and treat her condition or refer her to an obstetrician and, as a result, the patient suffered severe injury which caused her death. Another claim was that the physician materially misrepresented to the patient that she was experienced and trained in the treatment of all her obstetric needs.

	The defense contended that the physician met the standard of care and that she was credentialed to practice obstetrics at the specified hospital. They also claimed the patient’s B/P elevations were never sustained or reached a level that would require a consult with an obstetrician prior to the event at 3:15 a.m.  The physician maintained that she had consulted with a maternal-fetal medicine specialist at an earlier time who recommended antepartum testing and induction at 39 weeks’ gestation. She argued that the patient never met all the criteria for pre-eclampsia.

 The jury awarded the patient’s estate $6,067,830 in compensatory damages. The award was reduced to $900,000 pursuant to a high/low agreement

	While the family practice physician in this case did have privileges at the hospital to deliver uncomplicated pregnancies, she was accused of fraudulently concealing from the patient that her abilities in caring for obstetric patients were limited. The plaintiff’s counsel alleged that the physician was guilty of constructive fraud, was inadequately trained and inexperienced to treat the patient’s complications and actually had abandoned the patient. The physician developed breast cancer prior to the initial trial date, which was postponed, and she eventually died from her disease. The trial proceeded against the physician’s estate and medical practice as to all issues.

NEXT: Unrecognized postpartum cardiomyopathy

	A 41-year-old woman was diagnosed with hypertension during her pregnancy in 2007. She was hospitalized twice prior to delivery by cesarean and was discharged 2 days after delivery with a B/P of 130/90. The patient went to her obstetrician’s office 4 days after delivery with complaints of not feeling well and having extreme swelling. Her B/P was taken twice by a nurse, with readings of 170/80 and 168/90. She was sent home without being examined by the obstetrician, although she passed him in the hallway on her way out of the office. The patient later claimed that she told him she was not feeling well and that her blood pressure was high. She also claimed she was instructed to double her antihypertensive medication. That evening the patient had difficulty breathing and paramedics transported her to a hospital, where she was admitted and immediately intubated. She was without a pulse for 15 minutes, was in a coma for 45 days and suffered permanent brain damage. She is unable to walk without assistance, is legally blind, and her hands are contorted which makes her unable to feed herself. She also suffers from short-term memory loss and difficulty speaking.

	The patient sued the obstetrician and claimed that she had unrecognized classic signs of post-partum cardiomyopathy. She alleged that if the obstetrician had examined her and noted her B/P when she was in the office 4 days after delivery her condition would have been properly treated and prevented her permanent disabilities.

	The obstetrician argued that the patient had not come to the office because she was feeling ill, but to show the staff her baby and have her B/P checked. He claimed that if he had been advised of her B/P readings he would have examined her.

: The jury found in favor of the patient and awarded her $5 million.

	A woman had been diagnosed as a child with a rare gynecological condition that caused her to develop ovarian cysts, and her right ovary was removed at age 10. She later began using a contraceptive NuvaRing and, for a short time, the oral contraceptive Lybrel. In 2011, at age 22, the patient went to the ER with complaints of severe pain in her left lower quadrant and was diagnosed with a cyst on her left ovary and was instructed to follow up with her gynecologist. Two months later she again presented to the ER with complaints of abdominal pain. Examination revealed a mass on her left ovary and she was again instructed to follow up with her gynecologist. A week before her appointment with the gynecologist, she returned to the ER with complaints of severe lower left quadrant pain and she was informed that her left ovary was enlarged. The next week she presented to the gynecologist and he informed her that her pain and the enlargement of her ovary had been caused by back-to-back cysts. One month later, during her annual examination the gynecologist concluded that she was well and told her to return in 1 year. One month later the patient consulted with another physician who instructed her to see a gynecologic-oncologist immediately. She underwent surgery to remove her ovary 2 weeks later, which left her unable to have children of her own, at the age of 22.

	The patient sued the original gynecologist and alleged he failed to perform appropriate tests, diagnose her condition, and treat her promptly. A medical review panel issued the unanimous opinion the gynecologist fell below the standard of care and was a factor in causing the patient’s condition.

	The gynecologist denied any breach of the standard of care and contended the patient’s injury occurred during a 3-week period during which she had stopped taking her hormone-suppressing medications.

:  The jury deliberated for approximately 3 hours before returning a defense verdict.

Articles

Did her family physician meet the standard-of-care? 

Maternal death from  intracranial hemorrhage

In 2004, a Kansas woman presented to the hospital for delivery of her baby. The nurse-midwife managing the labor, sought an obstetrician’s intervention when the head did not descend easily. The obstetrician used forceps to assist the delivery. She applied traction, pulling gently with a contraction 3 times, then removed the forceps, and an 8 pound 8 ounce infant was delivered. The parents sued the obstetrician after the delivery alleging the infant suffered a skull fracture, lacerated ear, bruising around his scalp, and bleeding in the brain as a result of the forceps. They attributed his cognitive impairment and epilepsy to the injuries he received at birth. The lawsuit claimed the obstetrician’s use of forceps was below the standard; the forceps were misplaced; and she should have delivered the infant by cesarean. The obstetrician countered that the fact of the baby’s vaginal delivery negated the claim that he was too large for such a delivery, also there was some question as to whether the baby actually suffered a skull fracture. She maintained that she used proper procedure for application of the forceps and understood the position of the fetal head. She further argued that the normal forces of labor could account for the infant’s injuries at the time of birth, and that the epilepsy is not related to his delivery. The defense also argued the child’s developmental issues were mild – he participates in sports and is in the same grade as others his age.

: The jury found in favor of the defense.

In malpractice cases involving instruments used to assist with delivery of an infant such as vacuum and forceps, the 2 issues that come up are usually the actual use and placement of the instruments and the indication for their use. It is often difficult to prove that the instrument was negligently placed unless the injury is a skull fracture or some other head trauma, and it is then assumed that the instrument caused the injury. So, the case then focuses on the indication for using the device. With an appropriate indication for use of the instrument, it is possible to successfully defend a malpractice case. it is imperative that the indication for using vacuum or forceps for delivery be documented in the medical record along with any or no difficulty in placing the device.

Delay in timely delivery with placenta accreta

A Georgia woman was diagnosed with placenta accreta during her pregnancy. About 10 days prior to the planned delivery date for 39 weeks gestation, she collapsed and died at home. A lawsuit was filed and claimed the obstetricians made the decision to delay delivery to 39 weeks gestation instead of the standard of care, which required delivery no later than 36 weeks, and had she been delivered at that time it would have prevented her death. The case settled for $1.425 million.

Oxytocin overdose anddelivery delay blamed for CP

A Pennsylvania woman was admitted to the hospital in 2012 for delivery of her baby. Oxytocin was ordered to accelerate the uterine contractions. The fetal heart rate (FHR) progressively slowed over the next hour, dropping to 60 bpm. The obstetrician took steps to expedite the delivery and 20 minutes later the head was crowning. Another 10 minutes went by and the obstetrician then cut an episiotomy and delivered the infant. The baby developed spastic quadriparesis cerebral palsy (CP). He experienced impaired cognition, seizures, and global aphasia.

The parents sued those involved with the delivery and claimed the obstetrician mishandled the delivery; failed to properly monitor the labor; started oxytocin when it was not necessary as the patient was progressing and used it at an inappropriately high dose; and failed to discontinue it when the FHR dropped. They also maintained that the obstetrician should have delivered the infant with forceps or vacuum when it was crowning. The obstetrician countered that his treatment of the patient was proper, and he appropriately determined that vaginal delivery was the quickest route. He also testified that it was his practice to stop the oxytocin when the FHR dropped, but he had no independent recollection of stopping the oxytocin in this case. The obstetrician and hospital both argued that the infant’s CP stemmed from insufficiencies in the placenta, seizures, and meconium aspiration syndrome. The jury found in favor of the parents after a 2-week trial and a 4-hour deliberation, and they were awarded $14.48 million.

Bowel perforation during robotic hysterectomy

A New Jersey woman in her late 60s underwent a robotic sling procedure and hysterectomy, performed by her gynecologist. During the operation, she sustained a large perforation of the bowel outside the operative field. She developed sepsis and had multiple attempts at surgical repair. She ultimately required a colostomy. The woman sued the gynecologist claiming there was a failure to properly control the robotic device. She contended that she will require a permanent colostomy. The case settled for $6.25 million.

Alleged failure to respond to FHR results in CP

An Ohio woman filed a lawsuit against those involved in the 2010 delivery of her son. She originally presented to the hospital for delivery of her infant and the FHR tracings were reassuring. She claimed that, during the course of her labor, the FHR deteriorated and required intervention, but neither the obstetrician nor nurses recognized the need to expedite delivery. The infant was born not breathing and was then resuscitated. As a result of the lack of oxygen to his brain, he was diagnosed with CP. In the lawsuit, the parents claimed the child will need lifelong 24/7 care. The obstetrician settled with the parents for $1 million prior to trial. The case then proceeded against the nurse and hospital, and the jury returned a verdict for the child and parents, and $28.8 million that included $24.9 million in future care costs for the child, $2.9 million in lost earning capacity, and $500,000 each for noneconomic damages to the parents.

Neonatal death blamed on hypovolemia from double nuchal cord

In 2006 an Illinois woman was at 40 weeks gestation when she was admitted to a local hospital in labor. A nurse-midwife performed the vaginal delivery that evening. She noted a tight double nuchal cord as the head delivered and she reduced the cord at the perineum and delivered the rest of the infant. The baby was blotchy, limp, and extremely pale when she was placed on the mother’s chest. The nursing staff immediately realized the baby was not moving or crying and moved her to the warmer, initiated resuscitative measures, and called the special care nursery for assistance. The pediatrician immediately took charge of resuscitation and spent 38 minutes attempting to establish an airway and ventilation. Despite his efforts, the infant was pronounced dead at 40 minutes of life. The parents sued all those involved with the delivery and resuscitation on behalf of the infant’s estate. They contended the midwife was negligent for failing to have a neonatal team present at the delivery due to the maternal fever and variable decelerations of the FHR. They claimed the tight double nuchal cord prevented blood flow through the umbilical cord and the pediatrician was negligent for failing to replace the blood volume lost by the fetus due to complete umbilical vein occlusion, which caused hypovolemia, asphyxiation, and ultimately death. The court granted the midwife’s motion for a directed verdict at the close of the plaintiff’s case. The pediatrician asserted that he performed a rigorous textbook resuscitation, that it was improbable that the nuchal cord completely occluded the umbilical vein, that volume administration would have been frivolous without first establishing an airway/ventilation and heartbeat, and, finally, that the baby’s death was due to complications of chorioamnionitis and funisitis, which were present prior to delivery. The jury found in favor of the defense.

A 43-year-old South Carolina woman who suffered from multiple sclerosis (MS) underwent a hysterectomy performed by her gynecologist. During the operation the ureter was injured, requiring additional surgery and leaving her with permanent incontinence. The woman sued the gynecologist and claimed that he failed to notice that during the operation, he stitched around the ureter. She underwent a second surgery to remove the stitches and reimplant the ureter. She alleged it was the second surgery that left her permanently incontinent, and if the first surgery had been performed correctly, the second surgery would not have been necessary. She maintained the incontinence was not a part of her MS. The gynecologist asserted there was no violation of the standard of care and there was no stitching around the ureter. He claimed the ureter was damaged by kinking and the second surgery was performed to address that. He contended the incontinence was a result of her MS. The jury deliberated for 2 hours after a 4-day trial and returned an award of $700,000 for the woman. This included $500,000 economic damages and $200,000 in noneconomic damages.

A 28-year-old Missouri woman had a stillbirth at 38 weeks gestation and underwent a vaginal delivery. The fetus had been diagnosed with a genetic cardiac problem and the pregnancy was managed by a maternal-fetal medicine specialist who performed the delivery. An episiotomy was done and resulted in a fourth-degree laceration during the delivery. A breakdown later occurred, necessitating a repair and an ileostomy. A third operation was done to remove the ileostomy. The woman sued the physician who performed the delivery, claiming the episiotomy was unnecessary and that he failed to inform her of the risks of a fourth-degree laceration. The physician argued that the episiotomy was necessary and there was no need to obtain informed consent. The jury found in favor of the defense.

When the head of a Kansas woman's baby did not descend easily, the nurse-midwife managing the labor sought an obstetrician’s intervention. The obstetrician used forceps to assist the delivery. The parents sued the obstetrician after the delivery alleging the infant suffered a skull fracture, lacerated ear, bruising around his scalp, and bleeding in the brain as a result of the forceps. What's the verdict? Plus more cases.

Brain injury allegedly caused by forceps

A California woman was 35 years old when she delivered an infant in 2014, and the father was 51 years old. She was 10 weeks pregnant when she went to a clinic for care. She elected to participate in the state prenatal screening program, and the results of the screening tests were reported as within normal limits and the risk of birth defects was 1:230. Two weeks later she had her first appointment with an obstetrician and he informed her that the negative prenatal screening indicated that the infant most likely would be born without defects. He ordered an ultrasound to assess fetal structures. The radiologist reported that the ultrasound did not visualize the fetal anatomy well; however, the obstetrician allegedly told the patient at her next visit when she was 23 weeks that the ultrasound was normal. A month later the patient returned to her original physician who noticed that the ultrasound report indicated that the fetal survey was not complete. He ordered another ultrasound with a perinatologist. A significant cardiac defect in the fetal heart was found, and further testing confirmed the fetus had Down syndrome. The patient was scheduled for a late term abortion but she did not keep that appointment, fearing that it was illegal. The infant was born and has severe Down syndrome.

The parents sued all those involved with the prenatal care and alleged that both physicians were told the parents wanted all available testing because of a family history of birth defects, and that they would terminate the pregnancy if fetal abnormalities were found. They contended that the obstetrician was obligated to discuss diagnostic testing such as amniocentesis with the patient despite the negative screening tests and, because he did not, the diagnosis was made too late to terminate the pregnancy. The patient testified she never heard of amniocentesis until she was seen by the perinatologist.The obstetrician denied having any discussions with the parents of their desire to have all tests possible or their wanting to terminate the pregnancy if abnormalities were found. He stated that the difficulty in visualizing the fetus in the second trimester was not uncommon and that he would have routinely ordered a follow-up ultrasound. He also argued that he was not responsible for discussing all prenatal testing with the parents since that discussion should happen in the first trimester when she was seeing her original physician; so he assumed that discussion had already taken place. Further, the defense argued that a prenatal screening pamphlet, which the patient signed at 10 weeks gestation, discussed amniocentesis as a diagnostic test. The jury returned a defense verdict after 4 1/2 hours of deliberations.

In medical malpractice cases that involve delivery of an infant with an abnormality that can be detected by a specific laboratory test, like Down syndrome, the parents must show that the physician was below the standard of care in not offering the test, and they also must show they would have terminated the pregnancy had they known of the abnormality. In this case, even though the patient testified that she had not heard of amniocentesis until too late, there was contradicting testimony. The infant’s grandmother testified that she had a conversation about amniocentesis with the parents early in their pregnancy. In addition, a former employee of the obstetrician’s office testified that after the Down syndrome diagnosis was made she asked the patient why she had not chosen amniocentesis earlier in the pregnancy, and the patient said she decided against it because her prenatal screening test was normal. So not only had she heard of amniocentesis, according to the employee’s recollection she had made the choice not to have it much earlier in the pregnancy.

A 31-year-old woman delivered her child at a New York hospital. During delivery of the head the obstetrician noticed the umbilical cord was wrapped around the neck. He performed an episiotomy and the infant was delivered safely. The next day the patient alleged she told the obstetrician that she noticed an odor from her vagina, and he told her it was a natural occurrence following delivery and would resolve. The woman soon became pregnant again and was examined by a midwife. The patient said she told the midwife about the odor, but there was no mention of it in the midwife’s notes. When she saw the same obstetrician from the previous delivery he determined she could delivery vaginally. After the delivery, the obstetrician then diagnosed a recto-vaginal fistula, which required 13 operations to repair.

The woman sued the physician and hospital and alleged that the fistula was caused by the episiotomy from the first delivery. She claimed the episiotomy should not have been done and that the obstetrician should have diagnosed and treated the fistula earlier, which would have prevented the many procedures needed to repair it. She also alleged that the second delivery should have been a cesarean and that the obstetrician’s decision to allow a vaginal delivery exacerbated the fistula. She claimed the caregivers should have investigated her complaint of the odorous discharge earlier which would have allowed an easier repair prior to the second delivery.

The defense argued the patient’s medical records showed no indication of the complaint of odor until after the delivery of her second child so he could not have provided earlier treatment. He also contended that the patient’s fistula was due to a malformation, not the episiotomy. A $50 million verdict was returned including $10 million personal injury, past pain and suffering, and $40 million personal injury future pain and suffering.

Alleged failure to timely diagnose breast cancer

A 44-year-old Arizona woman sued her gynecologist and claimed the doctor failed to diagnose breast cancer for 2 years, so that she required a mastectomy rather than a lumpectomy as treatment. The patient’s expert opined that the delay resulted in a 70% survival rate as opposed to a 90% rate had there been a timely diagnosis.

The gynecologist denied that the patient’s chance of survival had been reduced. The jury returned a defense verdict after deliberating a little over 5 hours following an 8-day trial.

Ovarian cyst removal results in sigmoid colon injury

A New York woman in her forties underwent surgical removal of a cyst on her ovary, performed by her gynecologist. Over the next few days the patient experienced severe abdominal pain. Tests showed varying amounts of white blood cells in her blood and she underwent exploratory surgery which revealed a tear in her sigmoid colon. She had a colostomy and a follow-up operation after that.

The patient sued the gynecologist and hospital and alleged they failed to properly perform the initial surgery– even though the tear was a known risk of the operation – and that he failed to diagnose and treat the injury in a timely manner. She claimed she had 10 days of symptoms that should have prompted more immediate action from the gynecologist, thereby avoiding the need for the colostomy.

The defense maintained that the operation was not the cause of the injury to the colon, that the surgery did not take place near the sigmoid colon, but that injury to the bowel is an accepted risk to that procedure and days can pass before injuries can be identified. After deliberating for 4 1/2 hours at the conclusion of a 7-day trial, the jury returned a verdict in the amount of $1,520,000, including $20,000 past lost earnings capability; $700,000 past pain and suffering; and $800,000 future pain and suffering.

Delay in fetal monitoring with decreased fetal movement

A 34-year-old Georgia woman was at 35 weeks gestation of her second pregnancy when she presented to her obstetrician for routine prenatal care. She had gestational diabetes and her visit was unremarkable. Two days later, the patient presented back to the office with complaints of decreased fetal movement. She was admitted to the hospital for continuous fetal monitoring, consultation with a perinatologist, and possible delivery. She was not placed on the fetal monitor until 2 hours after arrival, and 1 hour later, the perinatologist was consulted by phone and ordered a biophysical profile (BPP). Six hours after her arrival the BPP was performed and an emergency cesarean was done. The infant was diagnosed with spastic quadriplegic cerebral palsy, profound developmental delays, cortical blindness, and seizures. The infant requires around-the-clock care. She is at home with her mother and will never walk or talk, or care for herself.

The parents sued those involved and claimed the infant’s injuries were due to mismanagement of the mother’s labor and the delivery. They alleged that immediate BPP should have been performed which was the standard of care with decreased fetal movement but was not ordered until almost 4 hours after the patient was admitted to the hospital. They asserted that 3 ultrasonographers were on duty at the time the patient was at the hospital and any one of them could have performed the essential test immediately, as hospital protocol requires. One ultrasound tech was allegedly on break; another was performing other tests; and the third was not notified of the BPP order because of a problem with the hospital’s ordering system.

The defense claimed that the infant’s issues were a result of her mother’s failure to keep her gestational diabetes under control and that any injury occurred prior to her arrival at the hospital when she noted decreased fetal movement. After deliberating 9 hours at the conclusion of a 3-week trial, a $30,545,655 verdict was returned, including $27,045,655 to the child for future medical costs and $3,500,000 to the mother for past and future pain and suffering.

Claim of delay in diagnosis of breast cancer

A New York woman in her fifties learned she had breast cancer and underwent a bilateral mastectomy, chemotherapy and radiation. The cancer was found in the same spots as microcalcifications that were seen on a mammogram 1 year earlier but, at that time the radiologist did not think the microcalcifications necessitated further testing.

The patient sued the radiologist and alleged he failed to timely diagnose her cancer, that his supervisors failed to properly oversee him, and that her mammogram suggested possible cancer and further testing should have been done at that time. She claimed if the cancer had been detected a year earlier she could have undergone a less-invasive treatment. She also claimed she had a family history of cancer which presented another reason for her mammogram to have been taken more seriously.

The radiologist argued that the patient had dense breasts that contained a large amount of fibroglandular tissue which reduced the sensitivity and reliability of mammograms. He claimed he properly interpreted the mammogram and that it had not changed from an earlier mammogram that had revealed 1 or 2 benign calcifications which did not require further screening. The jury returned a defense verdict after deliberating 3 hours at the conclusion of a 10-day trial.

A 41-year-old Pennsylvania woman who had been diagnosed with endometrial cancer underwent a robot-assisted hysterectomy and lymph node dissection performed by her gynecologist. Shortly after her diagnosis, at the consultation with her gynecologist, she had signed a “consent to surgery/anesthesia” form, in which she agreed to the operation or other procedures. After the surgery was performed the patient learned that the pathology department determined that the endometrial samples were “pre-cancerous” and that the gynecologist did not inform her of this fact and went ahead with the operation. The pathology report from the specimens taken during the operation showed that there was no evidence of cancer.

The woman sued the gynecologist alleging he was negligent for failing to inform the patient of her pathology results and for performing unnecessary surgery which caused long-term consequences. She claimed the standard of care was violated because the physician failed to rely on the pathology results of ‘pre-cancerous’ cells and thus recommended she undergo a hysterectomy, which was not required.

The gynecologist asserted that he was aware of the pathology results and so was the patient. They had discussed the results and the surgery was offered to the patient as an option. She had consented to it, which was reasonable in that she previously had a report of “pre-cancerous” cells which could evolve into cancer any time. The jury returned a defense verdict at the conclusion of a 4-day trial.

Complications after anterior/posterior repair with mesh

A Nevada woman underwent a laparoscopic vaginal hysterectomy with removal of both ovaries and fallopian tubes in 2010. The gynecologist then performed anterior and posterior repairs using mesh. The patient complained of vaginal discharge along with pain and bleeding shortly after surgery. She was treated with at least 2 courses of antibiotics and underwent an abdominal-pelvic CT scan for pelvic pain. She was diagnosed with vaginal cuff granulations as a cause of her vaginal discharge and pain. Her pain continued, and 10 months after her original surgery she underwent a vaginal tissue biopsy. The testing noted fecal material present and a small bowel-vaginal fistula was diagnosed. She then underwent a laparoscopic enterectomy, urethral Iysis, anomental pedicle flap, and a cystoscopy. On laparoscopic examination, there was a clear perforation of what appeared to be Gore-Tex mesh or graft material through the loop of the small bowel. One year after the initial operation the patient then experienced increased spinal pain, and a lumbar MRI revealed new fluid/abscess in the disk extending through the tract anterior into the soft tissues of the pelvis. She underwent intensive antibiotic therapy in the hospital and at home for a prolonged period.

The woman sued the gynecologist and alleged he fell below the standard of care in his treatment of her conditions.

The gynecologist denied all allegations and the jury returned a defense verdict.

A California woman was 35-years-old when she delivered an infant with severe Down's syndrome and then sued all those involved with the prenatal care and alleged that both physicians were told the parents wanted all available testing because of a family history of birth defects. What's the verdict? Plus more cases.

Detecting abnormalities, documenting options

Claim of failure to test for cystic fibrosis

A 44-year-old Montana woman gave birth to a child who was subsequently diagnosed with cystic fibrosis (CF). The woman sued those involved with her prenatal care, including the certified nurse practitioner (CNP) and the physician who performed chorionic villus sampling (CVS), claiming that had she known the child had CF, she would have terminated the pregnancy.

The woman alleged that she requested genetic testing, including testing for CF, when she had her prenatal visit with the CNP. The nurse argued that the patient requested testing for concerns related to advanced maternal age and not CF, but that the patient was provided with brochures that included information about testing for CF. The brochure was clear that the initial screening for CF was a blood test of the parents to determine if they were carriers of the CF gene, and that if the results from both were positive, the material gathered from amniocentesis or CVS would be tested. The nurse alleged that the patient did not request the necessary blood tests for CF carrier screening or any CF testing. The patient admitted that she did not read the brochure on CF provided to her.

The patient contended that the physician did not tell her what the material obtained from the CVS procedure would be tested for and that she did not have genetic counseling. The physician argued that he informed the patient that the test was for conditions related to advanced maternal age, such as chromosomal abnormalities including Down syndrome. He further contended that he specifically informed the patient of the availability of blood testing for CF carrier screening of both parents, which is necessary prior to testing for CF in the fetus because of the more than 1000 mutations of CF. He claimed that the patient declined the CF blood tests at that time.

During this case, it was revealed that while the patient admitted that she was referred to the medical genetics department for genetic counseling, she claimed she was confused as to whether she was to contact them or they were to contact her and as a result, she did not call for an appointment until shortly before the scheduled procedure. She then claimed she was told there were no counselors available on such short notice right before a holiday. During trial, witnesses for the genetics department testified that counselors were available when the patient called. They provided documentation in the medical record that the patient declined genetic counseling due to the cost of the service. This illustrates the importance of documenting in the record a patientÃ¢€™s decision to not undergo a recommended service and her reasons for declining.

Next: Bowel preforation during fibroid surgery >>

A 44-year-old Illinois woman presented to a gynecologist in 2010 with a complaint of uterine fibroids. During a hysteroscopic procedure, the uterine wall and colon were inadvertently perforated. The gynecologist converted to a laproscopy and upon finding the perforation in the uterine wall, performed a laparotomy to repair the tear. When the patient became severely ill with peritonitis 3 days later, a surgeon performed a bowel resection with colostomy. A second operation to reverse the colostomy was performed a year later.

The woman sued the gynecologist, alleging negligence in perforating the uterus and bowel and failing to recognize and repair the bowel perforation in a timely manner, which caused her to have abdominal scarring.

The physician argued that he did look at the adjacent organs while repairing the uterus and either there was no hole at that time or it was too small for him to detect any perforation.

The patient was awarded $200,000 in damages.

A Michigan woman with a history of cesarean delivery at 24 weeksÃ¢€™ gestation was offered synthetic progesterone injections at the beginning of her prenatal care in a subsequent pregnancy. She claimed she could not afford the injections. Three weeks after her initial visit, she returned to the high-risk clinic and was again offered the progesterone injections, which she rejected. During her return visit, 4 weeks later, her cervical length on  ultrasound was 3 cm. She again declined the progesterone. At a follow-up visit 2 weeks later, the womanÃ¢€™s cervical measurement was 2.5 cm.  and she once again did not consent to tprogesterone injections. Another ultrasound done 2 weeks later showed a cervical length of 1 cm. The woman was admitted to the hospital but before any orders could be written to for tests to rule out early labor and/or delivery, she left the hospital to care for her other children. She was to return after arranging care for them, but did not come back. Five days later the womanÃ¢€™s cervical length was 1 cm and she received a progesterone injection. Over the next 4 weeks, had 4 more injections but she did not return for the fifth or cervical measurement.

The day after the womanÃ¢€™s missed appointment, she presented to the hospital with cramping. She was admitted and given steroids and medication to stop the contractions. An ultrasound showed that the fetus was breech. The patient consented to a cesarean, but before the procedure was started, the baby was born vaginally. The child suffers from mild brain damage, cerebral palsy, developmental delays, and learning disabilities.

The woman sued those involved with her care during the pregnancy and alleged that the healthcare providers should have offered her vaginal progesterone, which was less expensive than the injections, that steroids should have been given to her earlier to improve neonatal development, and that vaginal delivery should have been prevented.

The defense argued that the infant delivered precipitously on the way to the operating room.

Depression from uterine wall perforation 

A 48-year-old Arizona woman was seen by her primary care physician, who performed a pap test that came back with abnormal results. She was referred to a gynecologist, who recommended a colposcopy, which revealed abnormal cells in the cervix and severe dysplasia. The gynecologist recommended surgery, which was scheduled for a month later. During the procedure the womanÃ¢€™s cervix was removed and her uterus was punctured and repaired. She claimed she suffers depression as a result.

The woman sued the gynecologist and alleged that despite the doctorÃ¢€™s assertion that the operation was needed immediately, no one from her office contacted the patient, and the patient herself contacted the office to schedule the surgery and it was not performed for over a month after the recommendation.

The gynecologist argued that there was no departure from the standard of care, uterine perforation is a known complication and was managed appropriately, and that 9 weeks after the operation the patient returned to work and had no complaints for more than a year afterward.

A Michigan woman alleged that her son suffered pain as a result of a circumcision that was performed the day after his birth. She sued the obstetrician and claimed that the circumcision was improperly performed, necessitating a revision operation 2 1/2 years later that resulted in the development of meatal stenosis at age 7 years. She alleged that once her son was able to talk, he indicated that his penis hurt. She first complained to the physician about the pain when the child was 18 months old. She reported that the baby suffered constant penile pain from the time of circumcision at age 1 day until the revision surgery 2 1/2 years later.

The obstetrician denied any deviations from the standard of care and contended that redundant foreskin is often left following a circumcision.

In 2005, an Illinois woman with elevated blood pressure was admitted to a hospital for induction of labor at 38 weeksÃ¢€™ gestation. She was started on oxytocin and around midnight, the fetal heart rate monitor showed some possible fetal complications. The obstetrician was not in the hospital but was called and ordered preparations for a cesarean delivery. Once he arrived at the hospital and evaluated the patient, he found no fetal concern and decided to proceed with the plan for vaginal delivery. By 3:30 am the patient was fully dilated and pushing when the obstetrician decided to utilize a vacuum extractor to assist with the delivery due to the patientÃ¢€™s elevated blood pressure, headache, shortness of breath, and fatigue. Upon delivery of the head, a shoulder dystocia was encountered and the physician immediately called for assistance. He attempted various maneuvers to deliver the shoulder and successfully delivered the infant. The child was subsequently diagnosed with near-total brachial plexus injury, consisting of tears and avulsions of all 5 brachial plexus nerves with trauma to some of the cervical nerve roots, requiring multiple operations for nerve grafts and other orthopedic procedures.

In the lawsuit that followed the delivery, the patient claimed that use of the vacuum was not indicated. She alleged that she actually had an arrest of descent which required that the obstetrician perform a cesarean, and that he should have suspected fetal macrosomia. She further claimed that, based on the severity of the injury, the obstetrician must have used excessive force to complete the delivery.

The obstetrician denied that the standard of care required a cesarean at the time he applied the vacuum, denied that the vacuum caused the shoulder dystocia, and denied he applied excessive force or traction to accomplish delivery. He contended that the extent of the outcome was partially due to hypotonia, which contributed to the unusual distribution of damage to the infant.

A Maryland couple expressed their decision to not have another child to a gynecologist, who recommended a laparoscopic tubal ligation. Several months later the woman became pregnant and gave birth to a son. The parents are now raising 4 children, the youngest of whom has language delays and learning disabilities.

The parents sued the physician and claimed that this additional child put an increased economic hardship on the family.

The gynecologist contended that a common known complication of the procedure can be the regrowth and reattachment of the Fallopian tubes, resulting in an unintended pregnancy.

The jury found in favor of the parents and awarded $240,000 for the cost of raising a fourth child, and $157,000 to cope with the childÃ¢€™s special needs, for a total of $397,000.

Necrotizing fasciitis after bowel perforation

A 46-year-old woman went to a Florida hospital for removal of an ovarian cyst. The procedure was performed by her gynecologist and afterward, the patient experienced pain and low blood pressure, which was treated with medication. The next day the incision opened and serosanguinous fluid began to drain. The patient was transferred to the intensive care unit with acute respiratory failure with possible sepsis and organ failure. The next day a trauma surgeon ordered emergency abdominal surgery and a bowel transection was discovered. The lower half of the patientÃ¢€™s stomach and abdominal muscles had to be removed due to necrotizing fasciitis. She suffered severe organ, tissue, and muscle damage, and severe hypotension with severely low blood flow to her extremities, resulting in amputation of all 4 extremities. She underwent 11 additional operations, including placement of on ostomy bag, and was in an induced coma for 1 month.

The woman sued the physician and claimed he was negligent in deciding to perform the original surgery laparoscopically despite the risks, transecting her bowel during the procedure, and failing to order emergency surgery in a more timely manner based on her symptoms.

The physician denied any negligence in performing the operation and claimed that the bowel perforation was a known complication of the procedure.

This case emphasizes the importance of keeping detailed records of each patient encounter.

Dawn Collins, JD

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