On December 18, 2009, at 7:19 am, a 28-year-old woman at 37 weeks’ gestation presented to a hospital by ambulance with ruptured membranes and right-upper-quadrant pain. The patient/plaintiff had received her prenatal care at another hospital and had a medical history of neurofibromatosis, a genetic disorder characterized by nerve tissue tumors that can grow rapidly during pregnancy and can cause complications such as hypertension.
On initial exam, no fetal heart rate (FHR) was detected. At 7:32 am, FHR monitoring was begun and revealed a FHR of 50 bpm. Co-defendant ob/gyn Dr. A was alerted and a STAT cesarean delivery was called at 7:44 am. The operative record reveals that the patient was in the OR at 7:45 am, anesthesia started at 7:47 am, skin incision was made at 7:50 am, and delivery was accomplished at 7:52 am. The infant had Apgars of 1 and 2. Cord blood PCO2 was 100 with a base excess of -32.
In his operative report for the cesarean delivery, Dr. A noted that the cul-de-sac was cleared of all clots and debris. After he confirmed hemostasis, the peritoneal membrane was closed. On presentation to the delivery room, the plaintiff’s blood pressure was low (82/59), with a heart rate of 127. At 8:45 am, when the defendant resident anesthesiologist Dr. B discharged the plaintiff to the recovery room and signed off to defendant attending anesthesiologist Dr. C, the patient’s blood pressure was documented at 100/50, with a heart rate of 130.
During the next 3 ½ hours, the plaintiff was monitored in the recovery room. Her blood pressure and pulse were labile, ranging from a low of 70/37 to a high of 146/103. Her heart rate was consistently tachycardic, ranging between 133 and 162. She was placed in the Trendelenburg position at 8:51 am. Approximately 3 L of IV fluid were administered. Bolusing began at 9:21 and fluid was given again at 10:44. However, the patient remained tachycardic and the exact amount of the boluses is not recorded.
At approximately 10:30 am the patient complained of cramping in her left leg; she had a history of left leg fracture as a child and had undergone reparative surgery. She was able to move all her extremities, pedal pulses were present, and capillary refill was felt to be adequate. Venodyne boots remained in place.
The chief ob/gyn resident, Dr. D, evaluated the patient and ordered Toradol for her discomfort. An hour later the plaintiff was noted to be drowsy, lethargic, and to have minimal verbal response. Internal hemorrhage was considered, and an abdominal ultrasound confirmed what looked like a pelvic collection. The medical emergency team was called and pressors, fluids, and 2 units of packed red blood cells were administered. A femoral line was placed and the patient was intubated and taken to the OR at 12:25 pm.
Dr. A performed an exploratory laparotomy because he suspected uterine artery bleeding. A supracervical hysterectomy was performed and no bleeding from the uterine vessels was found. Dr. A called for an intraoperative vascular consult, which was answered by nonparty vascular surgeon Dr. E, who noted a large hematoma in the retroperitoneum. Upon opening the retroperitoneum, he discovered a rupture in the iliac artery, which he described as friable and attempted to repair.
Despite administration of multiple blood products, fluids, and pressors, the plaintiff coded 5 times and expired at 3:58 pm. On autopsy, the cause of death was noted as retroperitoneal hemorrhage due to spontaneous rupture of the left iliac artery as a consequence of neurofibromatosis and pregnancy.