Case: Molar pregnancy develops into choriocarcinoma

A 21-year-old Maryland woman went to an ob/gyn in 2008 for an examination and was diagnosed with a molar pregnancy. She was instructed to obtain 3 consecutive beta human chorionic gonadotropin (hCG) tests and a chest x-ray before a follow-up appointment in 2 weeks. The chest x-ray was normal, and the beta hCG tests revealed elevated levels that decreased with each test. When the patient returned to the physician’s office, she was told that she needed 1 more beta hCG test to complete her treatment. She had the test 3 days later but was not notified of the results.

Three months later the woman suddenly had massive vaginal bleeding. She went to an emergency room, where a beta hCG test was performed. The level was more than 200,000 mIU/mL. A dilation and curettage (D&C) was performed, but the patient continued to have uterine hemorrhaging and low blood counts. She was emergently transferred to another hospital and was seen by a gynecologic oncologist. She was taken to the operating room, but her bleeding could not be stopped and a hysterectomy was performed. The molar pregnancy had developed into cancer, which had spread to the lungs. The patient underwent several months of chemotherapy, She required multiple hospitalizations, and experienced nausea, vomiting, fatigue, and hair loss. She also had depression related to her inability to bear children.

Legal perspective

In this case the patient was not notified of the results of the final beta hCG test, which showed an increasing level, indicating the ongoing presence of a molar pregnancy, which if untreated can become malignant and metastasize.

The patient filed a lawsuit against the original ob/gyn and claimed that the doctor should have notified her of the test results and sent her to a gynecologic oncologist for immediate treatment. At that time, the patient alleged, the treatment would have consisted of only a short course of chemotherapy. The claim of not following the molar pregnancy to its conclusion, of course, would be difficult to defend. The claim of injury from prolonged treatment and hysterectomy would be subject to expert medical opinions. The jury in this case returned a verdict for the patient in the amount of $1.07 million.

Premature delivery results in cerebral palsy

In 2001 a Maryland woman was admitted to a hospital for hypertension at 31 2/7 weeks’ gestation. She was placed on a fetal heart rate (FHR) monitor and evaluated by a maternal-fetal medicine specialist, who determined that delivery was necessary and that a vaginal route was reasonable as long as the patient and fetus were stable, otherwise cesarean delivery would be required. The patient was managed by an ob/gyn and a nurse midwife. She was given Cervidil and was started on oxytocin the next morning. In the after noon, some late and variable decelerations of the FHR were noted. A nuchal cord was found when the woman delivered vaginally a few hours later. Apgar scores were 4 and 7, and the infant initially required positive pressure ventilation due to bradycardia and poor respiratory effort. He was subsequently diagnosed with cerebral palsy and is not cognitively impaired, but is severely physically handicapped. He underwent multiple operations to correct uneven leg lengths, and has only 65% use of his arms, making him unable to comb his hair, brush his teeth, or dress himself.

The patient sued those involved with her care, claiming that a cesarean delivery should have been performed 3 hours earlier than the vaginal delivery. She claimed that the late and variable decelerations were severe and prolonged, that the fetus required delivery just after noon, and that allowing the labor to continue caused the brain injury.

The defense maintained that the FHR tracing was normal up to the delivery, the Apgar score of 7 at 5 minutes was normal, cord blood gases showed a pH of 7.3, and the ultrasound (U/S) of the infant’s head did not show any abnormality. The first abnormal U/S of the head was performed when the infant was 2 weeks old, and the defense pointed to prematurity as the cause of the child’s handicaps. A $21 million verdict was returned, including $1 million in non-economic damages, which was to be reduced to $650,000 under the state cap. An appeal is pending.

Obstruction of ureter after cystoscopy

A 59-year-old New York woman underwent gynecological surgery, which included a cystoscopy, in 2006. The ob/gyn who performed the surgery found normally functioning ureters. During the following month, the patient was seen for several follow-up examinations. A year later the patient was diagnosed with a complete obstruction of the right ureter. The problem was repaired but the patient lost all function in her right kidney. She will require medication to improve the function of her left kidney for the rest of her life.

The woman sued the ob/gyn and claimed that the obstruction was due to the original operation, alleging that the ureter was ligated and should have been diagnosed in the weeks following surgery.

The physician claimed the cystoscopy was properly performed and that the patient did not report any symptoms after the procedure that would have suggested the presence of a ureteral obstruction. He claimed the obstruction was a gradual development that could not be diagnosed any sooner than it was. A defense verdict was returned.

Uterine artery laceration during cesarean delivery

A 29-year-old Texas woman underwent a scheduled cesarean delivery in 2008, performed by her ob/gyn. After the delivery the patient had low pressures and an altered state of consciousness. She was returned to the operating room and her abdomen was reopened. A uterine artery hematoma and lacerations were found and repaired, but uterine atony continued and an emergency hysterectomy was performed.

The patient sued those involved with the cesarean, alleging negligence in lacerating the uterine artery, failure to recognize it during the surgery, and failure to properly monitor her after surgery and repair the artery in a more timely manner. She also claimed the hospital nurses failed to properly check her vital signs postoperatively and failed to report abnormalities in her blood pressure and alertness to the physician earlier.

The hospital and physician claimed that a uterine laceration can occur in the absence of negligence and is a known risk of cesarean delivery. A defense verdict was returned.

Perforation following drain placement results in sepsis

A 50-year-old Rhode Island woman underwent a total abdominal hysterectomy performed by her ob/gyn. After the surgery the patient developed an abdominal cyst. A Jackson-Pratt drain was placed. The patient was subsequently diagnosed with a perforated colon. She developed overwhelming sepsis and died. An autopsy was inconclusive for the cause of death.

A lawsuit was filed on the patient’s behalf and alleged that the colon was perforated when the drain was placed and the physician failed to recognized and treat the injury, leading to the patient’s death.

The physician denied perforating the colon during placement of the drain. He claimed that the patient suffered from diverticulosis, which was revealed by radiologic tests 3 months prior to the surgery and that complications from the diverticulosis caused the perforation. A defense verdict was returned.

Misplaced forceps delay delivery of twin

In 2007, a woman gave birth to twins in a North Carolina hospital. The first twin, a boy, was delivered without complications. The patient labored over the next hour with the second twin, a girl, monitored by a second-year resident and an attending physician. When the FHR tracing became concerning, a third physician was called to review the FHR strip. He recommended immediate delivery. The attending physician decided to perform a forceps delivery rather than a cesarean delivery. It took 15 minutes to locate forceps and the infant was born with severe brain damage and was subsequently diagnosed with cerebral palsy. She has a tracheostomy and is at home but requires 24-hour nursing care for life. A lawsuit was filed against those involved with the delivery and a $10 million settlement was reached for past and future care.

Uterus and colon perforations during D&C and hysteroscopy

A 70-year-old New York woman underwent an operation in 2009 that included a D&C and a hysteroscopy. The procedure was performed by an ob/gyn she had been referred to 2 months earlier for vaginal bleeding. On the same day she was discharged following surgery, the patient returned to the hospital with abdominal pain. A general surgeon performed a laparotomy and discovered perforations of the uterus and colon. A colostomy was performed at that same time. Three months later the colostomy was reversed. The patient had 2 incisional hernias and has ongoing abdominal complaints.

The woman sued the ob/gyn, alleging negligence in perforating the colon and in failure to timely diagnose and treat the perforations.

The physician claimed that perforations are a known complication of the procedure and that they can occur in the absence of negligence. He also claimed that a primary repair could not have been performed and the treatment would have been the same even if the perforations had been diagnosed sooner. A defense verdict was returned.