Maternal death from intracranial hemorrhage

January 10, 2018

Did her family physician meet the standard-of-care?

A  34-year-old woman was under the care of her long-time 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 came for a regular prenatal visit, but she also complained of a headache and a cough. Her blood pressure (B/P) was 130/90. Two days later, she reported acute vaginal bleeding and a headache. The physician admitted her to the hospital with a diagnosis of potential placental abruption. An ultrasound revealed oligohydramnios, intrauterine growth restriction, and grade II placenta. She had repeated high blood pressure readings, headaches, and decreasing platelets. The fetal heart rate (FHR) showed variable and late decelerations. She was subsequently discharged to another hospital to undergo another ultrasound evaluation. Five days after her original admission, the patient’s husband informed the physician that the patient was vomiting, with abdominal pain, and headaches. He brought her to the hospital, where her B/P was 155/100 and she complained of severe headache from front to back, constant throbbing, facial edema, and vomiting. She was admitted and at 3:15 a.m. the following day the nurse found the patient with her head hanging over the bed, having vomited, and unresponsive. The on-call obstetrician diagnosed her with eclampsia and ordered magnesium sulfate, hydralazine, and an immediate cesarean. The infant was delivered, but the patient remained unresponsive and a computed tomography scan revealed a massive intracranial hemorrhage. She was pronounced dead at 5:10 p.m. that same day.

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 the family physician did not 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 her condition or refer her to an obstetrician and, as a result, the patient suffered severe injury which caused her death. Another claim was that the physician materially misrepresented to the patient that she was experienced and trained in the treatment of all her obstetric needs.

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 B/P elevations were never sustained or reached a level that would require a consult with an obstetrician prior to the event at 3:15 a.m.  The physician maintained that she had consulted with a maternal-fetal medicine specialist at an earlier time who recommended antepartum testing and induction at 39 weeks’ gestation. She argued that the patient never met all the criteria for pre-eclampsia.

The verdict: The jury awarded the patient’s estate $6,067,830 in compensatory damages. The award was reduced to $900,000 pursuant to a high/low agreement

Analysis

While the family practice 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, was inadequately trained and inexperienced to treat the patient’s complications and actually 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 as to all issues.

NEXT: Unrecognized postpartum cardiomyopathy

 

Unrecognized postpartum cardiomyopathy

A 41-year-old woman was diagnosed with hypertension during her pregnancy in 2007. She was hospitalized twice prior to delivery by cesarean and was discharged 2 days after delivery with a B/P of 130/90. The patient went to her obstetrician’s office 4 days after delivery with complaints of not feeling well and having extreme swelling. Her B/P was taken twice by a nurse, with readings of 170/80 and 168/90. She was sent home without being examined by the obstetrician, although she passed him in the hallway on her way out of the office. The patient later claimed that she told him she was not feeling well and that her blood pressure was high. She also claimed she was instructed to double her antihypertensive medication. That evening the patient had difficulty breathing and paramedics transported her to a hospital, where she was admitted and immediately intubated. She was without a pulse for 15 minutes, was in a coma for 45 days and suffered permanent brain damage. She is unable to walk without assistance, is legally blind, and her hands are contorted which makes her unable to feed herself. She also suffers from short-term memory loss and difficulty speaking.

The patient sued the obstetrician and claimed that she had unrecognized classic signs of post-partum cardiomyopathy. She alleged that if the obstetrician had examined her and noted her B/P when she was in the office 4 days after delivery her condition would have been properly treated and prevented her permanent disabilities.

The obstetrician argued that the patient had not come to the office because she was feeling ill, but to show the staff her baby and have her B/P checked. He claimed that if he had been advised of her B/P readings he would have examined her.

The verdict: The jury found in favor of the patient and awarded her $5 million.

NEXT: Failure to diagnose ovarian mass

 

Failure to diagnose ovarian mass

A woman had been diagnosed as a child with a rare gynecological condition that caused her to develop ovarian cysts, and her right ovary was removed at age 10. She later began using a contraceptive NuvaRing and, for a short time, the oral contraceptive Lybrel. In 2011, at age 22, the patient went to the ER with complaints of severe pain in her left lower quadrant and was diagnosed with a cyst on her left ovary and was instructed to follow up with her gynecologist. Two months later she again presented to the ER with complaints of abdominal pain. Examination revealed a mass on her left ovary and she was again instructed to follow up with her gynecologist. A week before her appointment with the gynecologist, she returned to the ER with complaints of severe lower left quadrant pain and she was informed that her left ovary was enlarged. The next week she presented to the gynecologist and he informed her that her pain and the enlargement of her ovary had been caused by back-to-back cysts. One month later, during her annual examination the gynecologist concluded that she was well and told her to return in 1 year. One month later the patient consulted with another physician who instructed her to see a gynecologic-oncologist immediately. She underwent surgery to remove her ovary 2 weeks later, which left her unable to have children of her own, at the age of 22.

The patient sued the original gynecologist and alleged he failed to perform appropriate tests, diagnose her condition, and treat her promptly. A medical review panel issued the unanimous opinion the gynecologist fell below the standard of care and was a factor in causing the patient’s condition.

The gynecologist denied any breach of the standard of care and contended the patient’s injury occurred during a 3-week period during which she had stopped taking her hormone-suppressing medications.

The verdict:  The jury deliberated for approximately 3 hours before returning a defense verdict.