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.