Legally Speaking: The case of the missed ectopic pregnancy

October 1, 2007

When diagnostic films, labs, and pathology are unavailable or inconclusive, a physician certainly has the right to rely upon his or her clinical evaluation in rendering a differential diagnosis and recommending treatment. But when physicians make a decision not to use such diagnostic tools-particularly for economic reasons-the clinical evaluation they choose to rely upon had best be eminently reasonable, if not entirely accurate.

THE FACTS

The then 23-year-old patient presented to the co-defendant ob/gyn on September 29, reporting a last menstrual period of August 22. Urinalysis was negative. Blood pressure was 106/59 and her weight was 146.5 lb. The physician made notes about "menstruation late" and "pregnancy test positive." Her abdomen was soft and nontender, and the adnexa were clear. An abdominal sonogram revealed a thick endometrial lining, which was consistent with an early pregnancy. The patient was advised about diet and told to return to the clinic in 2 weeks.

INSTEAD, SHE EXPERIENCED bleeding and abdominal pain during the evening of October 8. She called the co-defendant ob/gyn's office the following morning for an appointment, complaining of worsening pain spreading to her entire abdomen. She proceeded to the co-defendant's office, where she waited for more than 2 hours, as the doctor was involved in a delivery. Ultimately, she was sent by a receptionist to the other defendant ob/gyn's office a few blocks away.*

On exam, the abdomen and breasts were negative. A pelvic exam was essentially within normal limits, including the adnexa and uterus, although vaginal "staining" was noted. An abdominal sonogram showed no free fluid in the pelvis and a normal-sized uterus; however, neither the tubes or ovaries were depicted in the sonogram. Urinalysis revealed 2+ glucose, 3+ albumin, 2+ blood, and 3+ leukocytes. The defendant ob/gyn believed the abnormal urinalysis results were caused by bleeding.

The doctor's assessment was "status post complete abortion." The plan indicated "questionable products of conception, lab declining." As the pathology was not sent to the lab, the physician indicated he counseled her on "bleeding" and "ectopic pregnancy precautions." She was told she would likely bleed lightly for the next 4 to 5 days, and was advised to call the office for any dizziness, abdominal pain, or abnormal bleeding. She was also told to return in 1 week, at which time the defendant would re-evaluate her and order a Pap. The patient never returned.

On October 18, the patient proceeded to the ER of a local hospital, complaining of "severe suprapubic pain" beginning at 12:00 AM and progressively worsening. She also reported nausea and vomiting since the previous night, as well as increasing abdominal pain for 1 to 2 days. An initial ultrasound found "no definitive ectopic." Diagnostic laparoscopy was eventually performed, which lead to therapeutic laparotomy and removal of the right fallopian tube because of a ruptured ectopic pregnancy.

The woman later claimed that an earlier diagnosis would have enabled her to be treated for an ectopic pregnancy with methotrexate and spared her the loss of her right fallopian tube. She further claimed impaired capacity for pregnancy through sexual intercourse. Although the plaintiff was married at the time of the alleged malpractice, she has since divorced for reasons unrelated to the alleged malpractice. We have just received labs from a local hospital, dated 3/14/06, which include an obstetric ultrasound scan. The report reflects that, at the time, the patient was 9 weeks' pregnant.

ALLEGATIONS

The plaintiff alleged that as a result of the failure to consider prior positive pregnancy testing, failure to perform serial bHCG testing, failure to send the pathology to the lab, and failure to perform transvaginal ultrasound to ascertain whether the pregnancy was uterine, fallopian, or whether there was fluid in the cavity, the defendant ob/gyn failed to adequately determine whether or not this was an intrauterine or tubal pregnancy.