Should IUGR have been found “incidentally”?
SEVEN MONTHS’ PREGNANT, an obese woman was admitted to the hospital with hypertension. Dr. A, a hospital-employed ObGyn, discharged her after 3 days.
The woman returned to the hospital 1 month later, but refused to see Dr. A. Another ObGyn (Dr. B) was unable to find a fetal heartbeat, diagnosed fetal death, and performed a cesarean delivery. Fetal death was blamed on intrauterine growth restriction (IUGR). The parents requested an autopsy.
PATIENT’S CLAIM Dr. A should have diagnosed IUGR with ultrasonography when the woman was first hospitalized. The autopsy was not performed.
DEFENDANTS’ DEFENSE The hospital claimed Dr. A acted properly in not ordering the sonogram, based on the patient’s complaints and symptoms. The hospital also denied there was any duty to perform an autopsy; the cause of death had been determined.
VERDICT A California defense verdict was returned.
Should conservative care trump surgery?
A 38-YEAR-OLD WOMAN WAS REFERRED to a specialty clinic for management of severe urinary stress incontinence and pelvic prolapse. A gynecologic surgeon performed mesh repair of the prolapse, and cystocele repair with bilateral sacrospinous ligament fixation and a prepubic transvaginal sling.
After surgery, the patient suffered increasing pain and fever. Diagnostic laparoscopy failed to find a suspected bowel perforation. An intravenous pyelogram revealed a left ureteral injury; the patient was transferred to another hospital for stent placement. The woman later developed a vesicovaginal fistula, with mesh erosion into the bladder.
PATIENT’S CLAIM Conservative treatment should have been offered first. Too many procedures were performed during one operation, increasing the risk of complications.
PHYSICIAN’S DEFENSE The patient declined conservative treatment. Her severe symptoms required multiple procedures within one operation. The complications that she developed were known risks of the procedures.
VERDICT A California defense verdict was returned.
Mother dies right after birth of twins
BECAUSE OF HER HISTORY of previous obstetrical complications and two cesarean deliveries, a 29-year-old woman, pregnant with twins, was under the care of a high-risk obstetrics clinic at a university hospital.
The patient was hospitalized for 6 days because of preterm contractions, then seen several times in the clinic. Her family testified that she was told to be on bed rest, and that she had complied.
Three weeks after discharge, she delivered twins by cesarean. As delivery was completed, she became unresponsive. Resuscitation attempts failed. An autopsy revealed a massive saddle pulmonary embolus. It had likely broken off from a deep vein thrombosis (DVT) in the legs or pelvis.
ESTATE’S CLAIM When bed rest was recommended, she should have been started on DVT prophylaxis.
DEFENDANTS’ DEFENSE The ObGyn and hospital claimed that no restrictions were placed on the woman’s activity following discharge from the hospital for preterm labor. Standard of care requires DVT prophylaxis for patients with a prior history of clots or thrombophilia; the decedent had neither of those conditions. Heparin was not indicated because it would increase the risk of bleeding and cause anesthesia risks. Mechanical prophylaxes such as TED hose and sequential compression devices have not been proved effective in preventing pulmonary embolism or death.
VERDICT An Illinois defense verdict was returned.