Infection, misdiagnosis lead to hysterectomy

A 21-year-old seeking prenatal care had a history that included anemia with palpitations and a left ovarian cyst. She was also morbidly obese. The woman’s prenatal course was benign until she presented to L&D at the defendant hospital on November 18, 2009, with complaints of irregular contractions at 39 1/7 weeks’ gestation. She was admitted by Dr A. She had a previous delivery by cesarean for a non-reassuring fetal heart rate (FHR) and requested a repeat cesarean. Risks included in the informed consent obtained by attending Dr B included bleeding, infection, and damage to the abdominal or pelvic organs, and possible need for a blood transfusion and/or emergency hysterectomy.

Recommended: Hysterectomy without consent? 

The patient’s baby boy was delivered by elective cesarean under spinal anesthesia at 11:24 pm with Apgars of 8 and 10. Her uterus was cleared of all clots and debris and the uterine incision was closed in 1 layer with Vicryl. Her estimated blood loss was 900 cc. Significantly, the operative report, which was authored by the resident and signed by Dr B, documents a textbook cesarean delivery. However, the “Delivery Comments Attending” notes mention dense adhesions from the anterior uterus to the anterior abdominal wall, and an omental adhesion to the anterior abdominal wall was noted. Also significant is that, counter to the hospital’s protocol, no preoperative or intraoperative antibiotics were given.

On November 19, the patient was found have a blood pressure of 92/58. She complained of chest tightness, tachycardia, and shortness of breath. Her heart rate was up to 120 beats per minute and she spiked a fever
of 100.5 F.

An ultrasound done that day and interpreted by a PGY-1 resident showed some abdominal free clear fluid. Attending Dr C noted that she would consider a computed tomography (CT) scan of the abdomen and pelvis if the patient’s hemoglobin and hematocrit continued to drop, but there were no orders written for the test. The next day, when the patient’s hemoglobin dropped to 6.7 and her hematocrit was noted to be 20%, she was transfused with 2 units of packed red blood cells (PRBCs).

NEXT: Further course of illness

An OB resident documented that if the patient spiked another fever, the plan was to begin antibiotics and obtain blood cultures. At 6:00 pm, the patient’s fever spiked to 100.6 F. Later that evening, the patient’s white blood cell (WBC) count was noted to be 17.3, she had no abdominal pain, sluggish bowel sounds, and adequate urine output. The resident also documented that the ultrasound done the day before had “no collection” and that in the event of another temperature spike she would order a blood culture, start antibiotics, and transfuse another 2 units of PRBCs when the patient was afebrile.

Blood cultures were negative and a urine analysis revealed a possible urinary tract infection (UTI). A urine culture was ordered but the sample was never tested. The patient remained afebrile. No ultrasound or CT scan was ordered.

On November 21, because the patient’s hemoglobin was 8.3 and her hematocrit was 24.2%, she received 2 more units of PRBCs. A medical consult was obtained to evaluate her complaints of tachycardia and shortness of breath. The consulting physician recommended a sepsis work-up and intravenous cephtriaxone 1 g stat, to be continued for 5 days. The attending internal medicine physician recommended consideration of antibiotics for a possible UTI but the OB team did not order them.

More: Claim of unnecessary hysterectomy

On November 22, the patient’s hemoglobin was 10.4 and hematocrit 29.9%. Her abdomen was soft with some distension and positive bowel sounds. Cesarean incision staples were in place and her wound was healing well with no signs of infection. The patient was discharged by Dr A with standard instructions. The discharge summary co-signed by Dr A documented a repeat cesarean with bilateral tubal ligation, but the patient never had or requested sterilization.

On November 24 the patient presented to the Women’s Health Center (WHC) for staple removal. A physician assistant found that her wound was healing well with no drainage and she had no fever. The staples were removed without incident.

On November 26 the patient presented to the hospital’s emergency department (ED) with complaints of abdominal pain, slight vaginal bleeding, chills, night sweats, diarrhea, anorexia, dizziness, nausea, and cramps. Her temperature was 99.8 F. ED physician Dr D evaluated the patient and found her abdomen soft and non-tender. Her stool guaiac test was negative and her WBC count was 8.9. Dr D did not order a CT scan or an infectious disease consult. He took a stool culture, believing that the patient was suffering from hospital-acquired C difficile. He discussed the case with the ob/gyn resident, who recommended that the woman follow up at the WHC on November 30. She was given prescriptions for Flagyl and Percocet if her symptoms persisted and instructed to return if she had worsening pain, high fevers, blood in the stool, or persistent vomiting.

The patient did not return to the WHC on November 30 but did on December 1, complaining of abdominal pain, chills, fever, and diarrhea, and asking for the results of her C difficile stool culture. She was examined by Dr E and noted to have a temperature of 103.6 F. An abdominal examination revealed a well-healed, non-tender incision, above which was a 15- to 20-cm poorly delineated area of tenderness. Dr E sent the patient to the ED to be evaluated for endometritis or a pelvic collection. The impression was a subfascial collection, hematoma rather than abscess. Labs and a CT of the abdomen/pelvis were ordered.

NEXT: The allegations

The WBC was slightly elevated to 13.4. Ultrasound was notable for a heterogeneous cystic structure anterior to the uterus. The patient was admitted. The CT scan revealed an intra-abdominal abscess with 3 separate collections. An interventional radiologist performed CT-guided percutaneous drainage and placed a pigtail catheter. When the fluid grew Enterococcus faecalis, an infectious disease specialist suggested Unasyn and Flagyl.

By December 3, the patient was ambulating, voiding, and tolerating a regular diet. She was afebrile for 48 hours on antibiotics. She was to follow up for a repeat CT scan and appropriate antibiotics. On December 4, blood and urine cultures were negative. Body culture fluid showed light growth of enterococcus. Infectious disease recommended continuing the IV antibiotics. The patient did well over the next 48 hours, remaining afebrile with occasional bouts of diarrhea; only minimal drainage was noted from the in situ catheter. A CT scan performed on December 7 revealed a 7- x 2-cm residual collection in the cul de sac and a 6- x 4-cm collection around the right adnexa, a significant decrease. Infectious Disease changed the patient’s antibiotics to vancomycin and Zosyn and recommended a peripherally inserted central catheter (PICC) line be placed and IV antibiotics administered on an outpatient basis until the abdominal fluid collection was completely resolved. The catheter was removed on December 8. A PICC line was placed on December 9. The patient was advised to stay in the hospital to receive IV antibiotics until home nursing could be arranged. Despite Dr B’s discussion regarding the risks of sepsis, death, and infection, the woman signed herself out against medical advice but did return the next day to receive her IV ertapenem.

Recommended: Diagnosis and management of accreta

On December 15, the patient presented to a different ED with complaints of lower abdominal pain and fever. A CT scan showed multiple collections  “consistent with abscess formation.” She was taken to the OR. Extensive adhesions of the bowel to the anterior abdominal wall were identified, the uterine incision was dehisced, and the anterior wall of the uterus was found to be necrotic and friable. The posterior cul-de-sac also was obliterated by adhesions and hematoma.

Two areas of small bowel were deserosalized and repaired. A hysterectomy and salpingectomy were performed. The ovaries were spared. The patient remained in the hospital until December 23.

Allegations

The plaintiff alleged that the defendants failed to timely diagnose and treat an intra-abdominal abscess; caused bowel injury during the cesarean; improperly closed the surgical incision in 1 layer instead of 2, resulting in wound dehiscence; and misdiagnosed her condition as gastroenteritis. She alleged that as a result of the delay in diagnosis and treatment, she suffered an unnecessary hysterectomy and salpingectomy; persistent abdominal pain; and post-traumatic stress disorder (PTSD) and major depression.

NEXT: Discovery and resolution

Discovery

Our emergency medicine expert was critical of the care provided by Dr D, who misdiagnosed the plaintiff with a C difficile infection. The misdiagnosis meant that the patient did not come back within 36 hours, the standard for abdominal pain. Dr D failed to order an ultrasound, CT scan, and/or a gynecological consult. While timely intervention might not have altered the result, a CT scan would have discovered the abdominal collections.

Our infectious disease expert believed the OB attending should have prescribed antibiotics postoperatively. He felt that the source of the bacteria was fluid that transudated from the deserosalization injury to the bowel, caused by the lysis of adhesions required during the cesarean.

Next: How one hosptial manages delivery in women with a history of should dystocia

The interventional radiologist should have known that the remaining collection was dense hematoma requiring surgical removal because it was inpenetrable by antibiotics. E faecalis is not sensitive to ertapenem, making the outpatient regimen prescribed by the hospital staff ineffective.

Our OB expert was critical of Dr B’s failure to provide antibiotics pre- or postoperatively. She believed that in the face of dense adhesions, Dr B should have given antibiotics appropriate for bowel bacteria, and should have closed the uterus with 2 layers to prevent dehiscence. She believed that the uterine suture broke down, causing or contributing to the hematoma. The bacteria in the genitourinary tract would have spilled into the abdomen, causing the fluid collections to join the hematoma. She also conceded that the uterine incision could have broken down and become necrotic because of infection caused by the bowel injury. She also felt that the ED doctor should have realized that the patient’s symptoms were consistent with endometritis and not C difficile.

Resolution

The plaintiff demanded $4 million prior to trial. The care was seemingly indefensible. Several departures could have been leveled against the hospital and the attending physicians, Drs A and B, who both still worked at the facility. Their only potential salvation would have been to lay blame on ancillary hospital staff and the ED doctors. After months of negotiation, the case settled for $2 million, with the hospital paying 60% and Dr B paying 40%.