Legally Speaking: The case of the secreted cerclage

March 1, 2010

Emotions alone are not enough to prove an allegation of improper care.

The facts

In January 2002, the private ob/gyn recommended that a cerclage be placed because of the prior second trimester losses, which was done at 14 weeks' gestation. The patient was placed on bed and pelvic rest until January 23, at 16 weeks' gestation, when she noted blood-tinged vaginal fluid and mild cramping, at which time she called the nonparty ob/gyn, who instructed her to go immediately to the hospital.

The ultrasound showed oligohydramnios and a 16-week, 2-day, live fetus. The patient was admitted and maintained in the Trendelenberg position, genital cultures were done, and she was started on intravenous (IV) antibiotics. She had a normal white blood cell count and mild anemia. There was no reported cramping or further fluid leakage overnight. Fetal heart rate was within normal range, and the mother reported fetal movement.

On January 24, the cerclage suture was removed by the on-call defendant ob/gyn "A" (not the patient's private ob/gyn). Over the next 24 hours, the patient was induced with vaginal prostaglandin preparations. By the afternoon of January 25, the patient began to have moderate contractions, and that evening, she passed the fetus. The infant, a male, was considered to be stillborn. Oxytocin infusion was begun, but the placenta did not pass.

The patient was taken to the operating room, where another nonparty ob/gyn removed placental tissue using sponge forceps. He described finding uterine atony, with "quite profuse" vaginal bleeding. Intramuscular methylergonovine maleate and uterine massage were administered, but the patient continued to bleed heavily. Carboprost was given, and "gentle" curettage was carried out. The uterus firmed up, and bleeding became minimal.

By later that morning, the plan was to discharge the patient; however, she reported dizziness while out of bed and so was given IV fluids. That afternoon, defendant ob/gyn "B" ordered the transfusion of 2 units of packed red blood cells. This resulted in a temperature spike, and the transfusion was discontinued. The patient developed increasing tachycardia, which was reduced with increased IV fluids.

The following day, the patient was still weak and had scant vaginal bleeding. She received a transfusion and underwent a computed tomography scan and a chest x-ray. The studies were unremarkable, and after transfusion, her systolic blood pressure stabilized and her pulse rate decreased. A transvaginal ultrasound revealed no evidence of retained tissue, but the patient was assessed as being infected as a result of prolonged ruptured membranes and was septic on that basis.

The patient was discharged home on February 9 without complaints or complications.