Legally Speaking: HELLP is on the way

December 1, 2007

It goes without saying that expedient recognition of a rare condition, in and of itself, does not necessarily guarantee a favorable outcome. In situations where a physician exercises questionable judgment and the outcome is less than favorable, however, the door is open for second-guessers and an increased potential for litigation.

• THE FACTS

The patient was a 31-year-old G3 P1011 when she presented to the defendant Hospital Center on July 1 complaining of severe, painful contrac tions, nausea, and vomiting for 8 to 10 hours. Her EDC was July 16. Her first child was delivered 4 years earlier by cesarean section, for failure to progress. She was the private patient of the attending co-defendant Dr. A, who was notified by the Hospital Center of her presentation while on vacation. He was covered by co-defendant attending Dr. B.

THE PATIENT WAS ADMITTED at 5:50 AM with a blood pressure of 167/96 mm Hg. By 6:20 AM it had shot up to 180/107 and at 7:15 AM it was 186/105. The chief resident, Dr. C, per formed a vaginal exam and found the patient's cervix to be 6 to 7 cm dilated, 90% effaced at –1 station. The possibility of vaginal delivery was discussed, but according to a nurse's note, Dr. B's subsequent examination indicated that the patient's cervix was only 1 to 2 cm dilated and 60% effaced, with the fetus at +1 station. The patient had edema of her legs and proteinuria (urinary protein 300 mg/dL/day), and so the plan was for a repeat C/S. The woman was mildly anemic on admission (hemoglobin 10.4 mg/dL; hematocrit 31.9%), but her platelets were within normal limits at 188,000 mL. Further evidence of preeclampsia was manifested by her liver function tests, which were elevated (AST 188 and ALT 78). A loading dose of IV magnesium sulfate was given at 7:55 AM, and the patient was taken to the operating room for her C/S. According to the Operative Report, the C/S was performed by Dr. B, with the assistance of Dr. C and was without complication.

At 10:00 PM the patient said she was feeling better, but still had diminished urine output (25–75 mL/hr) and despite the diminished hemoglobin and hematocrit, had no evidence of bleeding. At 11:00 PM, her chart noted that the resident discussed the case with Dr. B, and the maternal-fetal specialist, Dr. D, who recommended monitoring the patient closely without transfusing her. The MFM specialist also recommended not restarting the magnesium sulfate until the signs of magnesium toxicity diminished and her reflexes recovered. He formally diagnosed hemolysis, elevated liver enzyme levels, and low platelet count (HELLP) syndrome, without signs of bleeding externally or internally. Dr. B then wrote his own note at 11:40 PM, indicating that he discussed the case with the MFM specialist, who suggested close observation because the patient was stable, the urine output was picking up, and there was no evidence of disseminated intravascular coagulation (DIC). The decision was made not to check the labs until the following day and the MFM specialist planned to see the patient in the morning.