Maternal death from intracranial hemorrhage

November 1, 2016

A 34-year-old Ohio woman was under the care of her longtime family physician, who had minor privileges to deliver uncomplicated pregnancies at a specific hospital, for her pregnancy. The woman is diagnosed with eclampsia in her third trimester and is immediately given a cesarean. After delivery, she is unresponsive having died from a massive intracranial hemorrhage. The physician is sued for fraudulently representing her abilities in obstetric care. What's the verdict?

A 34-year-old Ohio woman was under the care of her longtime family physician for her pregnancy in 2009. The physician had minor privileges to deliver uncomplicated pregnancies at a specific hospital. The patient was in her third trimester when she presented for a prenatal visit complaining of a headache and a cough. Her blood pressure (BP) was 130/90. Two days later, she reported she had acute vaginal bleeding and a headache. The physician admitted her to the hospital with a diagnosis of potential placental abruption. An ultrasound (U/S) revealed oligohydramnios, intrauterine growth restriction (IUGR), and grade II placenta. She had repeated high BP readings, headaches, and decreasing platelets. The fetal heart rate (FHR) monitor showed variable and late decelerations. She was discharged to another hospital to undergo another U/S evaluation.

Five days after her original admission to the hospital, the patient’s husband informed the physician that the woman was vomiting and had abdominal pain and headaches. He brought her to the hospital, where her BP was found to be 155/100. She complained of severe headache from front to back, constant throbbing, facial edema, and vomiting. She was admitted and at 3:15 AM the following day the nurse found her unresponsive. The on-call obstetrician diagnosed her with eclampsia. He ordered magnesium sulfate, hydralazine, and an immediate cesarean. The infant was delivered, but the patient remained unresponsive and a CT scan revealed a massive intracranial hemorrhage. The patient was pronounced dead at 5:10 PM.

Recommended: Patient claims fraud after bladder injury

A lawsuit was filed against the family physician, her group, the hospital, and the nurse involved in the patient’s care. The claims included the fact that the family physician never called for an obstetrician to treat the patient, nor did the physician come to the hospital to evaluate her patient. It was alleged that she deviated from the accepted standard of medical care by failing to adequately diagnose and treat the patient’s condition or refer her to an obstetrician and, as a result, the patient suffered severe injury causing her death. Another claim was that the physician materially misrepresented to the patient that she was experienced and trained in the treatment of obstetric conditions.

The defense contended that the physician met the standard of care and that she was credentialed to practice obstetrics at the specified hospital. They also claimed the patient’s BP elevations were never sustained or reached a level that would require a consult with an obstetrician prior to the event at 3:15 AM. The physician maintained that earlier in the patient’s pregnancy she had consulted with a maternal-fetal medicine specialist who recommended antepartum testing and induction at 39 weeks’ gestation. She argued that the patient never met all the criteria for preeclampsia.

The verdict: The jury awarded the patient’s estate $6.1 million in compensatory damages. The award was reduced to $900,000 pursuant to a high/low agreement.

Analysis: While the family physician in this case did have privileges at the hospital to deliver uncomplicated pregnancies, she was accused of fraudulently concealing from the patient that her abilities in caring for obstetric patients were limited. The plaintiff’s counsel alleged that the physician was guilty of constructive fraud and that she was inadequately trained and inexperienced to treat the patient’s complications and had abandoned the patient. The physician developed breast cancer prior to the initial trial date, which was postponed, and she eventually died from her disease. The trial proceeded against the physician’s estate and medical practice.

NEXT: Failure to monitor IUGR alleged

 

Failure to monitor IUGR alleged

A 39-year-old Missouri woman had her first prenatal appointment when she was at 21 weeks’ gestation. Due to advanced maternal age and a history of previous intrauterine growth restriction (IUGR), her care was transferred to a high-risk pregnancy clinic. At her next prenatal appointment she tested positive for marijuana and it was noted in her record that she was at risk of repeat IUGR. An U/S performed at 25 weeks’ gestation noted the fetal weight was in the 11th–25th percentile and amniotic fluid was normal. The patient missed her next prenatal appointment and was seen at 28 weeks, at which time she had increased BP and headache.

The patient missed her next 5 weeks of appointments and returned at 33 weeks’ pregnant with a blood pressure of 160/97, normal FHR, positive fetal movement, and a fundal height measurement revealing a 3-cm discrepancy in dates and size. She was scheduled for FHR testing the next day and a nonstress test was nonreassuring. She was instructed to go to the hospital for admission and arrived there about 1 hour later. The FHR continued to be nonreassuring and an U/S was done and revealed an IUGR fetus and oligohydramnios. An emergency cesarean was performed and the infant delivered 16 minutes later. The Apgars were 4 and 9. The infant had grade III and grade IV intraventricular hemorrhages, a positive screen for marijuana, and white matter brain damage. The child now suffers developmental delays, cognitive deficits, and breakthrough seizures.

The woman sued the high-risk pregnancy clinic, alleging negligence in the failure to implement a plan at her first prenatal visit to monitor her for IUGR based on her history; failure to advise her of that risk; failure to perform fundal height measurements and U/S at specific intervals; and failure to perform a nonstress test at her 33-week prenatal visit, which she claimed would have led to earlier hospital admission, earlier delivery, and a healthy baby.

Related: Detection and surveillance of IUGR

The physicians argued that the patient was noncompliant and missed many of her prenatal appointments and she also continued to smoke marijuana throughout the pregnancy. They claimed the correct tests were ordered and performed, and that delivery occurred in a timely fashion. They also argued that the problems suffered by the child were a result of prematurity and damage that occurred during the weeks of missed appointments.

The verdict: The case settled for $2.75 million.

Rectovaginal fistula after vaginal delivery

An ob/gyn delivered the child of a 31-year-old New York woman. During delivery the obstetrician found the umbilical cord wrapped around the fetal head, and to safely deliver the infant he performed an episiotomy. In the days following delivery the patient noted gas from the vagina. The obstetrician suggested it would resolve itself without treatment. The patient became pregnant right after this delivery and was evaluated by a midwife. She again mentioned an odorous discharge but it was not addressed. During delivery of the second child the obstetrician determined that the patient had a rectovaginal fistula. She subsequently underwent 13 operations to repair the fistula.

The woman sued the obstetrician and claimed the fistula was a result of the episiotomy he performed at the first delivery. She asserted that the episiotomy should never have been performed and that the obstetrician should have diagnosed and treated the fistula prior to the second delivery or she should have had a cesarean for the second child.

The obstetrician opined that the patient’s record did not show any report of an odorous discharge until after the second delivery.

The verdict: The jury found for the patient and entered a judgment in the amount of $10 million for past pain and suffering and $40 million for future pain and suffering, for a total verdict of $50 million.

NEXT: Alleged miscalculation of due date

 

Alleged miscalculation of due date, injury from premature birth

A New Jersey woman presented to her obstetrician in 2005 for her first prenatal visit. At that time she was unsure of the date of her last menstrual period and she underwent three ultrasounds during her pregnancy, which predicted her due date to be August 15. On August 1, she underwent induction of labor because she was suffering from gastrointestinal reflux. The infant appeared healthy at birth, but shortly thereafter went into respiratory distress. He was slow to meet developmental goals and was initially believed to be autistic. When he was 5 years old a diagnosis of periventricular leukomalacia was made and at 11 years old he suffers from permanent brain injuries.

The woman sued her obstetrician, claiming that he failed to calculate the correct due date, and alleging that according to the ultrasounds the due date should have been August 25. She alleged that the early delivery was the cause of the child’s injuries.

The verdict: The jury awarded $1.2 million.

Prolonged rupture of membranes results in fetal infection

A Virginia woman was 28 weeks pregnant when her membranes ruptured in 2011. She was leaking amniotic fluid and was placed on bed rest. She went to her obstetrician’s office 15 days later with signs of infection and he elected to deliver her that day. Eleven hours later the patient delivered vaginally. The infant was diagnosed with meningitis at birth and suffered infection-related complications including intracranial hemorrhage. She continues to suffer from permanent deficits.

More: Prolonged PROM, labor induction, and cesareans

In the lawsuit that followed, the patient alleged that the obstetrician was negligent in not immediately delivering her by cesarean when she was admitted to the hospital. She alleged that the delay exposed the fetus to infection for an additional 11 hours, leading to her permanent injury.

The obstetrician denied falling below the standard of care in allowing her to labor and deliver vaginally.

The verdict: A defense verdict was entered.

NEXT: Failure to diagnose ovarian cancer

 

Failure to diagnose ovarian cancer

A 71-year-old New Jersey woman presented to her gynecologist, who detected a mass on her right ovary and advised her to come back in 3 months. An U/S was performed on the follow-up visit, and the gynecologist reported that the mass had grown marginally and advised her to come back in 6 months for another examination. Another U/S revealed that the mass had grown significantly, and she was sent to a gynecologic oncologist, who diagnosed ovarian cancer. The woman’s condition is now considered terminal.

The patient sued the gynecologist and alleged that he violated the standard of care by not referring her to an oncologist at the first examination. She claimed her chances of cure decreased from 94% to 0% in the interceding 11 months.

The gynecologist contended that he did not breach the standard of care.

The verdict: The case settled for $1.8 million.

Bowel perforation during hysterectomy

A 44-year-old woman underwent a laparoscopic subtotal hysterectomy performed by her gynecologist at a Pennsylvania hospital. The procedure was done because she had uterine fibroids. During the operation the gynecologist unintentionally sliced into the patient’s bowel. He immediately stopped the hysterectomy due to the increased risk of complications and a general surgeon came and repaired the bowel injury. The patient suffered with a colostomy and prolonged stress.

The woman sued the gynecologist and the resident assistant, alleging that they negligently misidentified her large bowel and cut into it, and contended that she was not informed that this was a known risk of the procedure.

Recommended: Case hinges on timing of bowel perforation

The gynecologist argued that while performing the operation in standard fashion, he noted a fecal odor and immediately suspected the injury and the surgeon was called. He asserted that the patient’s suffering was unfortunate, but that the injury was a known surgical complication that can occur without negligence and it was recognized and appropriately addressed.

The verdict: A defense verdict was returned.

NEXT: Failure to perform cesarea after attempted water birth

 

Failure to perform cesarean after attempted water birth

An Oregon woman presented to the hospital, planning to deliver her infant under water. She claimed she was told she was an ideal candidate for a water birth and that it was just as safe as any other birthing technique. She was placed in the water, therefore the FHR was not continuously monitored. The patient was eventually taken out of the water bath and the baby was delivered vaginally. The infant was subsequently diagnosed with brain damage and is unable to walk or talk.

The woman sued the midwives and hospital and alleged the child’s brain damage was from lack of oxygen and blood flow from the attempted underwater birth. She contended that she was told that the midwives would consult with an obstetrician during the water birth, but did not, and she claimed they were negligent in failing to immediately perform a cesarean when she was removed from the tub.

The verdict: The case settled for $13 million.

Ureter injured during robotic hysterectomy

A 44-year-old Texas woman underwent a robotic hysterectomy to treat her fibroids, polyps, and heavy vaginal bleeding. During the operation one of the ureters sustained a thermal injury, but the patient was discharged home without the injury being diagnosed. She appeared to be fine at follow-up office visits.

Next: Preventing ureteral injury at hysterectomy

Nine days later she presented to the emergency room with symptoms of infection. She underwent a pelvic CT scan, which suggested leakage of fluid into the abdomen and a perforated ureter.

In the lawsuit that was subsequently filed, the gynecologist was accused of negligence for allowing the thermal injury to occur and for not recognizing it at the time of surgery.

The gynecologist denied any negligence and argued that the standard of care was met, that thermal injury to the ureter is a known complication of robotic hysterectomy, that this injury can occur without negligence, and that the perforation most likely occurred 9 days after the operation.

The verdict: The jury returned a defense verdict.