Did cervical incompetence cause preterm labor case?

THE FACTS

The plaintiff presented to the defendant obstetrician's group for prenatal care on November 18, 2004. She was seen by a physician assistant who noted that the patient had no vaginal bleeding, had morning sickness, and had a positive pregnancy test. The physician assistant also noted that a colposcopy had been performed in October 2002, but did not specifically note that the patient had had concurrent cryosurgery. On examination, the patient's cervix was "closed and clear"; the uterus was 8 weeks' size; her prenatal laboratory studies and Pap smear were normal. The physician assistant's assessment was "early pregnancy" and she ordered a sonogram.

On November 30, a formal prenatal workup was started. The records reflect that this was the patient's second pregnancy; she had had a prior elective first trimester abortion. Her estimated date of confinement was July 12, 2005, by dates, and July 6, 2005, by subsequent ultrasound. A December 1 sonogram described no abnormalities and did not mention cervical length. The defendant obstetrician testified that the absence of commentary on the cervix simply meant that it was normal. It is unclear whether this was a transvaginal or transabdominal ultrasound.

When the patient next saw him at 15 weeks, she reported no obstetrical complaints, but spoke of headaches, including migraines, and was given a referral to a neurologist. She was referred for a maternal serum alpha-fetoprotein (MSAFP). At her next visit on February 14, she again had no complaints, and the MSAFP result was normal. The obstetrician wrote an order for a sonogram to be performed within 7 to 14 days (ie, at 20 to 22 weeks).

He saw the patient, now at 21 weeks, for the final time on March 2. She again had no complaints. She was referred for blood work, prematurity precautions were discussed again, and the plan was to see her in 3 weeks. The obstetrician did not make note of the level II sonogram on this visit. He later testified that his progress note mentioned precautions twice: The first reference meant that the patient had been alerted to clinical symptomatology, but reported none. The second related to tests to be performed. He said that when he saw the patient on March 2, he expected that she would have had the level II sonogram he had ordered, and he said that she told him that she had an appointment for one within a few days. He explained that an earlier, rather than later, level II sonogram is important because if congenital abnormalities are found, the patient has time to have the appropriate workup including amniocentesis (if indicated), and could reach an emotional decision about continuing the pregnancy. He said that he explained this to the patient on February 14 and again on March 2.

The plaintiff presented to the hospital for a level II transvaginal sonogram on March 16, at 22 weeks' gestation. Her sonogram showed the fetus in the breech/footling position, the placenta was posterior, and amniotic fluid levels were normal. The cervix was 5 mm in length with 83% funneling and the anatomy of the fetus was described as within normal limits. The final diagnostic report states that this was an intrauterine pregnancy at 22 weeks with shortened cervical length. That evening she was admitted to the hospital's obstetrical emergency unit with cramping and a thick, yellowish discharge. She reported having had unprotected sexual intercourse 4 days previously. Positive fetal movement was noted on examination. The patient was 2 cm dilated with clear, bulging membranes and no contractions. Sonogram estimated the fetal weight of 444 g, and magnesium sulfate therapy was initiated. The patient was started on penicillin, kept in the Trendelenberg position, and the risk of prematurity was explained. The plan was to attempt tocolysis. Prophylactic antibiotics with deep vein thrombosis precautions and perinatal consult were undertaken.

At 5:15 AM on March 20, the chief obstetrical resident was called to evaluate the patient for bright red blood coming from her vagina. She denied having contractions or discomfort. A bedside sonogram showed that her amniotic fluid index was less than 1, and that there was placenta previa. She was told that if the bleeding continued, she would require cesarean delivery. A neonatologist explained to her that given the gestational age and estimated weight, the "prognosis for the fetus is very poor and long-term sequelae includes, but is not limited to, cerebral palsy, blindness, respiratory problems (sic)" and that a very small percentage of fetuses at this gestational age survive and do well. The patient requested aggressive management for the fetus.

Approximately 1 hour later, she underwent a low transverse cesarean delivery. She had difficulty maintaining her blood pressure postpartum and her pulse increased as a result of anemia. She was discharged 3 days later after a blood transfusion resolved her anemia.

The infant's hospital course was stormy. His Apgar scores were 1, 1, 1, and 1, at 1, 5, 10, and 20 minutes. He immediately was suctioned, received cardiac compressions, was intubated, started on ampicillin and cefotaxime, and admitted to the NICU. He was transferred to another hospital for patent ductus arteriosus (PDA) ligation, then returned to the first hospital for the remainder of his admission. He was discharged on July 21 with oxygen, an apnea monitor, and a pulse oximeter. He weighed 2,507 g and his head circumference was 34 cm at discharge. Since discharge his medical history has included PDA, elevated direct bilirubin, respiratory distress syndrome and chronic lung disease, hypotension, and posthemorrhagic hydrocephalus.