Heterotopic or ectopic pregnancy?


An ectopic pregnancy is terminated, but traces of a uterine pregnancy are found. Was it heterotopic?



Ms. Collins is an attorney specializing in medical malpractice in Long Beach, California. She welcomes feedback on this column via e-mail to dawncfree@gmail.com.

Heterotopic or ectopic pregnancy? 

A Louisiana woman was treated at a hospital for a suspected ectopic pregnancy in 2010. She was transferred to another hospital for a more definitive diagnosis and a consult with an obstetrician for the use of methotrexate. The on-call obstetrician was in surgery when the patient arrived and a nurse informed the patient that the physician had ordered the administration of methotrexate, which was given and terminated the pregnancy. Several weeks later the patient complained of abdominal pain. After evaluation it was determined that she had had a uterine pregnancy, not an ectopic.

Also read: Extrauterine pregnancy detection and management

The patient sued the obstetrician and the second hospital, arguing that the physician ordered methotrexate to terminate a normal uterine pregnancy without seeing the patient first, and that he should have repeated the testing performed at the first hospital. She claimed that testing would have identified an intrauterine pregnancy and avoided the termination.

The nurse claimed the physician ordered the methotrexate when the patient arrived, but the physician argued he did not give the order for the drug. They also claimed that the patient had a rare heterotopic pregnancy.

The verdict

A defense verdict was returned.


In this case, the defendants pointed the finger of blame for the methotrexate order at each other. This “dueling defendants” scenario usually does not play well with juries, as they assume there must have been substandard care. Here the jury found for the defense, however, even with dueling defendants. The plaintiff made a motion asking the judge to enter judgment in favor of the plaintiff notwithstanding the jury’s verdict, and the judge granted the motion, deciding there must have been credible evidence of negligence. An appeal of this decision is expected.



Delay in delivery blamed for brain injury

A Georgia woman went to her obstetrician with a term pregnancy in 2007. She had had no complications during the pregnancy and showed no signs of labor at this visit. Her physician was hesitant to allow the pregnancy to continue past 41 weeks’ gestation and scheduled her for induction of labor a few days later. The induction was started but discontinued after the patient made no progress. A fetal ultrasound was reassuring, so the patient was discharged with instructions to return in 4 days unless she went into labor. When she returned the next day with strong contractions, fetal heart rate (FHR) monitoring was begun. A nurse found that the FHR showed severe distress and immediately called the nurse midwife, who evaluated the patient and called the obstetrician. An emergency cesarean was started almost 40 minutes later. The infant was delivered in acute distress and non-responsive and was resuscitated but suffers from neurologic and cognitive damage.

The patient sued those involved with the delivery, claiming that earlier delivery was indicated and could have avoided the brain injuries. She also alleged that more timely use of nitric oxide by the neonatologists following the delivery would have mitigated some of the damage.

The defense denied any negligence. The nurse indicated that she believed an emergency cesarean was needed. The midwife claimed that the nurse indicated neither that the fetus was in acute distress nor that an emergent cesarean was indicated when she called her. And all the defendants maintained that the damage to the fetus had occurred prior to the patient’s arrival at the hospital that day.

The verdict

A jury found negligence by the midwife, the doctors group, the hospital, and the nurse, and awarded $3 million. The midwife and medical group were responsible for $1.8 million and the hospital and nurse for $1.2 million. The neonatologists received a defense verdict.


Next: Alleged failure to timely perform cesarean >>



Alleged failure to timely perform cesarean

A Florida woman was 39 ½ weeks pregnant when her membranes ruptured and she went to the hospital in 2009. When she arrived she had contractions every 4 minutes and was 3 cm dilated and 50% effaced. She was admitted and oxytocin was started about 4 hours later. After 1 hour on the oxytocin the FHR showed variable decelerations down to 70 bpm with a slow return to baseline. Tachycardia developed. An amnioinfusion was started but the FHR indicated deterioration and an emergency cesarean delivery was performed. The infant required immediate resuscitation at birth and had no heart rate and was not breathing. The infant was transferred to another hospital and diagnosed with hypoxic-ischemic encephalopathy and seizures. The child has permanent brain damage and requires speech therapy, physical therapy, and occupational therapy.

The patient and her husband sued those involved with the delivery, alleging negligence in delay to delivery, arguing that the emergency cesarean should have occurred at least 2 hours earlier. They also claimed negligence in the resuscitation of the newborn.

The verdict

A $2.4 million settlement was reached with $1 million paid to the parents, $1 million to a reversionary trust, and the remainder paid for an annuity to provide monthly payments for the child’s care.



Failure to read and report pathology report delayed diagnosis of cancer

In 2007, a surgeon treated a 49-year-old Kentucky woman for diverticulitis. The patient underwent a resection of the colon. The pathologist reported that the tissue had a strong stromal component, which can be linked to cancer growth. The pathologist sent the tissue samples to a major university for a final interpretation. The report, which confirmed the concern for cancer, was sent to the first hospital, where another pathologist forwarded it to the surgeon. The final report showed evidence of low-grade endometrial stromal sarcoma. In an effort to not alarm the patient, the surgeon told the patient that she had a sarcoma, which was less worrisome than cancer. He then referred the patient to a gynecologist.

The gynecologist did not read the pathology report, and simply treated the patient for endometriosis. Two years later the patient complained of pelvic pain while riding an all-terrain vehicle. When she sought evaluation of the pain, she learned of the cancer diagnosis. The gynecologist also learned of the diagnosis at that time. The patient had a complex course over the next 3 years, with multiple procedures and treatments.

The woman sued the original surgeon and the gynecologist for not informing her for 2 years of the diagnosis of cancer reported by the pathologists. She had no evidence of cancer at the time of the trial.

The surgeon settled with the patient for an undisclosed amount, and the case went to trial against the gynecologist. The patient claimed that the gynecologist was negligent in failing to read the pathology report when she was referred to him for treatment. The physician argued there was no reason for him to review the pathology report of the bowel resection and that he had properly treated her for endometriosis, which was the reason she was referred to him.

The verdict

A defense verdict was returned.


Next: Uterine septum repair results in Asherman's syndrome


Uterine septum repair results in Asherman’s syndrome

A 34-year-old Virginia woman and her husband had been trying to conceive a child. She had been pregnant 5 times but suffered first-trimester miscarriages. Magnetic resonance imaging was performed and showed a uterine septum. In 2009, the patient went to a fertility specialist, who told her he could perform open surgery (ie, Jones metroplasty) to remove the septum, which would allow her to conceive and carry a pregnancy. The patient underwent the procedure in 2010 and was hospitalized for several days afterward. She had postoperative bleeding and after a few months began having severe pelvic pain.

The patient went to a different fertility group. Testing revealed severe scar tissue, and the patient was diagnosed with Asherman’s syndrome and adenomyosis. The second specialist attempted to clean out the uterus with a hysteroscopic procedure, but was unsuccessful. The patient was told in 2011 that she would be unable to carry a pregnancy. She continued to have pelvic pain and vaginal bleeding that required the use of Depo-Provera shots every 3 months. Her physician also recommended a hysterectomy.

The patient sued the first fertility specialist, claiming that the Jones metroplasty procedure was outdated. She also alleged lack of informed consent, in that the physician did not discuss the option of a hysteroscopic procedure.

The verdict

A $425,000 settlement was reached.

Death from pulmonary embolus following hysterectomy

An Illinois gynecologist performed a total abdominal hysterectomy on a 43-year-old woman in 2004. The patient was seen in the gynecologist’s office for a postoperative visit and died the following day from bilateral pulmonary emboli. A lawsuit was filed on behalf of her estate, claiming that the physician failed to use proper prophylactic measures to prevent deep vein thrombosis (DVT) and pulmonary embolism (PE), and then failed to recognize and treat the signs and symptoms of a PE during the patient’s postoperative visit.

The gynecologist argued that there was no negligence because he did provide intraoperative and postoperative DVT prophylaxis and the patient did not have classic signs of either a DVT or a PE during the office visit.

The verdict

A $2.7 million verdict was returned for the patient’s estate.



Cerebral palsy after cesarean

An Illinois woman underwent a cesarean delivery in 2006. At the time of delivery a 9-cm umbilical cord hematoma was discovered that had occurred as a result of a ruptured umbilical vein. The infant’s Apgar scores were 0 at 1, 5, and 10 minutes. The child survived with severe cerebral palsy. At the age of 8 years the child was non-verbal, had no true functional mobility, and had the cognitive level of a 6- to 9-month-old infant.

In the lawsuit that followed the delivery, the plaintiff claimed that the physicians and nurses failed to properly interpret and act on nonreassuring FHR recordings throughout the evening prior to delivery. The plaintiff also argued that an emergency cesarean should have been ordered earlier.

The physicians argued that there was no reason or order a cesarean delivery earlier and that the umbilical hematoma was caused by umbilical vein compression.

The verdict

A defense verdict was returned.



Monoamniotic twins suffer stillbirth, brain injury

A 37-year-old Kentucky woman was referred to a maternal-fetal specialist early in her pregnancy due to her high-risk condition of monoamniotic twins in 2007. A plan was made for the patient to be on bedrest and be hospitalized at 24 or 25 weeks’ gestation. On the ninth day after admission the nurses briefly had trouble finding the twins’ heartbeats, but they were ultimately recorded and were reassuring. The next morning the heartbeats were not found and an emergency cesarean was performed. One twin was stillborn and the other was born with severe and permanent brain injury.

The importance of determining chorionicity in twin gestations

A lawsuit was filed claiming that the infants suffered an umbilical cord complication and that delivery should have been performed earlier, and that an ultrasound should have been done, or continuous FHR monitoring applied.

The physician argued that proper monitoring was done and denied that continuous monitoring was required. The physician also maintained that the patient was at high risk of stillbirth and the brain injury was due to the high-risk delivery of a very premature infant.

The verdict

A defense verdict was returned. An appeal is pending.



Bowel injury during LAVH

A gynecologist performed a laparoscopically assisted vaginal hysterectomy on a 41-year-old Kentucky woman in 2009. The physician noted bleeding as she entered the abdomen, so she irrigated the area and looked for evidence of a bowel injury, but none was found and the operation was completed. The patient had significant abdominal pain the following day and the gynecologist called a general surgeon, who performed an emergency laparotomy. A bowel perforation was found and repaired. The patient required multiple operations and suffered other complications, including diarrhea and pain.

The woman sued her gynecologist and claimed that she was negligent in both the choice of the laparoscopic procedure and the patient’s position on the table, which increased the risk of a bowel injury. The patient maintained that the gynecologist should have converted to an open procedure when bleeding was encountered in order to discover the bowel perforation.

The gynecologist argued that the surgical technique and positioning were proper and that the bowel injury was a known complication that was recognized the next day and immediately repaired.

The verdict

A defense verdict was returned.

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