Legally Speaking: The case of the bungled Bartholin's infection?

May 1, 2006

Faced with a challenging, unusual presentation, accuratedocumentation that spells out the clinician's rationale forcare-or absence of care-takes on even greatersignificance.

THE FACTS

In July 1999, the patient, a 37-year-old single female, presented to the defendant ob/gyn-whom she had been seeing for more than 15 years-with complaints of pain and swelling of the vulva. The woman's history was significant for absence of the left fallopian tube and left kidney, an hypoplastic uterus, and a prior left oophorectomy and ovarian cystectomy.

Pap smear and cultures for chlamydia and gonorrhea were negative. The ob/gyn examined the patient, diagnosed a right-sided Bartholin's duct infection, prescribed a broad-spectrum cephalosporin, and advised the woman to return in 1 week. The patient did not keep her appointment but rather called the physician 12 days later, and reported that the lump was smaller and less painful. She was advised to continue the antibiotic for another week. She was seen on July 17 and the ob/gyn noted some left-sided erythema (opposite to the side where the mass had been) and documented that the mass was much smaller and nontender, with no evidence of fluctuance. The woman reported using "multiple agents," including alcohol, on her vulva and was instructed to return in 1 to 2 weeks.

Three months later-on November 9-the patient called to report a fluid collection under the skin, which she had expressed herself. She reported that the region had healed well, and that she had only "a tiny spot left." The ob/gyn urged her not to manipulate the area and advised her to be seen as necessary. The patient called again on November 30 to report bleeding from the vulva, and was advised to present to the office for evaluation.

When the woman next came to the ob/gyn's office, on January 18, 2000, blood was observed emanating from a 2-mm defect in her right labia majora. On evaluation, the ob/gyn found no surrounding erythema or other evidence of infection nor abscess in the Bartholin's duct. He surmised, however, that the condition was "bleeding from an infectious cellulitis space of the skin over the labia," and placed a single suture, under local anesthesia, after a failed attempt to stop the bleeding with a solution. He planned to recheck the patient in the office 1 week later.

On January 24, when the patient returned, she reported some bleeding. No induration or redness was seen. Removal of the suture showed evidence of a 1-mm area of granulation tissue, and the ob/gyn noted the healing was "better than anticipated."

The patient's last contact with the ob/gyn was January 31, when she called to report another small collection of blood that had emptied. He recommended she come to the office for evaluation and possible excisional biopsy to prevent recurrence.

On February 7, the patient presented to a new gynecologist (not a party to the lawsuit) who noted swelling of the right labia since August. Examination revealed a 2.5-cm left Bartholin's cyst and a 1-cm draining area in the hairy portion of the labia. The patient was prescribed silver nitrate and a Pap smear and external vulvar culture were ordered, both of which were negative. Conservative healing was recommended, and the possibility of marsupialization was discussed.