Disrupted delivery plan leaves OB in difficult situation

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Facts

A 32-year-old G5P4004 with four prior cesarean deliveries underwent an ultrasound at 12 weeks’ gestation, which revealed a pregnancy in the lower uterine segment with a probable placenta previa. An ultrasound at 20 weeks’ gestation revealed a definite placenta previa, with lacunae and hypervascularity suggestive of a morbidly adherent placenta (MAP, now called placenta accreta spectrum). Magnetic resonance imaging (MRI) confirmed the ultrasound findings. 

Although the mother was a long-term patient of the obstetrician, she was transferred from a community setting to a regional perinatal center 40 miles away. Her care continued at the perinatal center with a plan for cesarean hysterectomy at 34 to 35 weeks’ gestation. The patient was instructed to call the perinatal center immediately if she experienced any bleeding or significant contractions prior to the planned delivery date.

At 32 weeks’ gestation, the patient awoke in the night with severe pain and bleeding. She called 911 and was brought by ambulance to the local community hospital at 11:00 pm, where, fortuitously, the original referring physician was on call. Although the physician had not cared for the patient for several months, regular communication had been from the perinatal center. The physician was aware of the plan for cesarean hysterectomy. Although the patient’s vital signs and fetal heart monitor readings were stable, the degree of pain and bleeding necessitated urgent delivery at the community hospital. Anesthesia was consulted, multiple sites of intravenous (IV) access were established, and the blood bank was prepared for possible massive hemorrhage. The patient underwent a low transverse cesarean under general anesthesia and delivered a viable male infant who weighed 1845 g and had Apgar scores of 5 and 7 at 1 and 5 minutes, respectively. The baby did well. The placenta separated “normally,” but significant bleeding was noted at delivery and the estimated blood loss was not documented. Although bleeding initially was brisk, the uterus was deemed “dry” following primary closure. 

Over the next 6 hours, the patient had multiple episodes of hypotension and bleeding. She did not leave the operating room (OR), nor could she be extubated. She received multiple uterotonics, 12 units of packed red blood cells and 10 units of fresh frozen plasma. The community obstetrician consulted with the regional perinatal center, as well as intensivists and hematologists at the community hospital. Subsequently, the patient developed disseminated intravascular coagulation (DIC). She was ultimately transported by helicopter to the regional perinatal center, where she was moribund on arrival and died upon admission to the hospital. Autopsy concluded that death was due to the obstetrical hemorrhage and DIC from a placenta accreta. 

Allegations

The patient’s family sued for wrongful death of the woman. They sued the community physician for: 

• Not offering pregnancy termination at 12 weeks’ gestation, when the placenta accreta first was suspected; 

• Not referring the patient to the perinatal center until after 20 weeks, after the time when termination would have been available;

• Not transferring the patient to the regional perinatal center after initial stabilization on the night of delivery; 

• Not executing the delivery plan, specifically performing a cesarean hysterectomy at the time of delivery; and 

• Not reopening the patient while in the OR to perform a life-saving hysterectomy. 

The family also sued the perinatal center for not admitting the patient at 30 to 32 weeks for in-patient observation. They also sued the perinatal center for not recommending a hysterectomy during consultation shortly after delivery, while the patient was in the OR. 

Discovery

The community physician stated that the patient was happy with the pregnancy and termination was never an issue. Upon admission she was not stable enough for transfer. The cesarean was performed in a timely manner, with delivery of a healthy infant who required only a short stay in the Level II nursery. Further, despite the diagnosis of MAP, the placenta delivered easily, and thus, a cesarean hysterectomy, with its increased morbidity, was not necessary. None of the consultants recommended further surgery. The anesthesiologists opined that the patient was not stable enough for further surgery, throughout the 6 hours that she remained in the OR. Everything possible was done and, despite that, the patient succumbed.

The perinatal center physicians stated it was not the standard of care to admit patients with MAP prophylactically at 30 to 32 weeks’ gestation. Further, although they recommended earlier transfer and hysterectomy, the community physician felt the patient was too unstable for either further surgery or transfer. 

Outcome

Prior to trial, a large settlement was made on behalf of the community obstetrician. The perinatal center was dismissed from the claim. 

Discussion

Risk factors for MAP (placenta accreta spectrum) include previous cesarean delivery, with likelihood increasing from 0.3% for one previous cesarean delivery to 6.74% for five or more cesarean deliveries. Placenta previa further increases risk for MAP. Ultrasound remains the mainstay of diagnosis, although there exists significant interobserver variation. In this case, the diagnosis was made by the community physician, confirmed with MRI, with appropriate referral to a higher level of maternal care-the regional perinatal center-although not early enough for pregnancy termination to be considered. For previa pregnancies, counseling for pregnancy termination for material indications should be documented. In this case, the planned timing and location of delivery comported with recommended management.

Regional perinatal centers have multidisciplinary teams, which may include MFM specialists, gynecologic oncology, urology, vascular surgery, trauma surgery, interventional radiology, hematology, intensivists, and a fully functional blood bank with extensive resources. Further, these centers have substantial support services and staff, including more extensively trained nursing staff and OR personnel. This environment enhances favorable outcomes.

This community obstetrician was clearly placed in a difficult situation, which occurs when delivery plans are disrupted by clinical circumstances. The obstetrician could have considered asking for surgical assistance from a general surgeon, trauma surgeon, urologist, or even surgical oncologist. Because the patient was not stable enough for transfer, proceeding with the cesarean delivery was appropriate. Several management options were available following the delivery, including leaving the placenta attached, with subsequent methotrexate, or removing the placenta and using prophylactic or therapeutic tranexamic acid, insertion of a Bakri balloon, or uterine artery embolization. The obstetrician also could have left the placenta attached, closed the uterus, and proceeded with hysterectomy. Alternatively, assuming the patient was stable after leaving the placenta attached, transfer to the regional perinatal center for further care could have been considered. 

In cases refractory to uterotonics, massage, and tamponade, hysterectomy is recommended. Unfortunately, the delay in responding to the ongoing bleeding, e.g. not proceeding with hysterectomy in a prompt fashion, contributed to the patient’s demise. Although the ultimate result may have been unchanged, proceeding with the hysterectomy in a timely manner would have enhanced defensibility in this case.

Dr. Shwayder is extremely grateful to Steven Warsof, MD, who shared this case from his files. The case also appears in a book they coauthored,Legal Concepts and Best Practices in Obstetrics: The Nuts and Bolts Guide to Mitigating Risk.