An ob/gyn diagnosed a 26-year-old’s pregnancy on December 8, 2004. The patient had had 3 spontaneous abortions; 2 of which occurred during the first trimester, and 1 during the second trimester, at 4 months’ gestation. The placental pathology for the second-trimester miscarriage was consistent with chorioamnionitis. At the conclusion of the December 8 visit, the patient was advised to follow up in 2 weeks, and in the interim, to have an ultrasound (U/S).
An U/S performed on December 17 was consistent with a 12-week pregnancy. The cervical length was 3.5 cm. The patient was seen on December 22, and referred to the high-risk clinic at the defendant hospital. On December 29 the patient presented to the defendant hospital’s emergency department (ED) with complaints of abdominal pressure and vaginal bleeding. She was examined and underwent a U/S which was noted to be normal, and she was discharged in good condition.
The patient was seen by another attending ob/gyn on January 4, 2005, and her cervix was noted to be closed. An abnormal Pap smear necessitated a colposcopy on January 6 during which a benign cervical polyp was found. An U/S the next day revealed a cervical length of 3 to 3.4 cm. Routine prenatal blood testing revealed abnormal Protein S and antithrombin III antigen. The patient was sent to defendant Dr A, the chief of ob/gyn at the defendant hospital, who was certified in obstetrics as well as maternal-fetal medicine.
Dr A saw the patient on January 11 at the high-risk clinic. He took a detailed obstetrical history, including her chronic hypertension, prior pregnancy outcomes, and the possibility that the woman had an incompetent cervix. Dr A documented a long counseling session (more than a half hour) discussing the risk and benefits of a cerclage. The patient refused the cerclage, stating that she wanted to continue to monitor her cervical length. Dr A also discussed the risk of losing the pregnancy at 23–25 weeks. A discussion about the patient’s abnormal clotting factors was also held, and she refused Lovenox.
An U/S performed on January 21 at 17 weeks’ gestation revealed a normal cervical length of 4.1 cm. The patient was counseled to reconsider her refusal of Lovenox and once again declined the medication. The patient returned on February 1 at 18 5/7 weeks’ gestation. A February 10 U/S that revealed a cervical length of 1.3 cm was read by Dr A, who recommended that the patient be admitted to the hospital and consider a cerclage.
The patient was admitted to the defendant hospital on February 10 for observation, bed rest, and consideration of a cerclage. On February 14 U/S revealed a cervical length of 1.7 cm, and Dr A and defendant ob/gyn attending Dr B decided to perform a rescue cerclage. Dr B and the patient had an extensive informed consent discussion regarding the risks of preterm labor, premature rupture of membranes, and infection. The cerclage was placed and the patient was discharged on February 16 with a prescription for antibiotics and an appointment to follow up with Dr A at the high-risk clinic on February 23.