Legally Speaking: A botched case of postpartum pulmonary hypertension.

THE FACTS

The patient, a then 33-year-old G4, P2, presented to the co-defendant obstetricians in August 2001, seeking treatment from physicians "expert in high-risk pregnancy." The patient had two episodes of fetal demise in 1999 and 2000, as well as a heart murmur due to congenital heart disease (CHD), requiring prophylactic antibiotics. As a result of the patient's CHD, she was considered high risk and in fact said she was afraid of dying after her delivery, as her own mother had, as a result of her underlying cardiac condition.

OTHER THAN SOME spotting during the first and second trimesters, the patient's pregnancy was uneventful until premature rupture of membranes, on February 27, led her to present to the co-defendant Hospital Center (she had an EDC of April 21). However, the hospital records show that the patient was taking insulin for gestational diabetes, and had taken the "wrong" insulin the morning before her presentation. Her records also indicate that she had a long history of depression, exacerbated by fetal demise in consecutive years.

The patient, however, was discharged on March 2 despite complaints that she was feeling "dizzy and nauseous." When she arrived home, her husband called the co-defendant attending physician complaining that his wife looked "bloated and fat and could not walk because her feet were too swollen," and was told that this was a normal postpartum appearance.

On March 5, 3 days postpartum, the patient spoke to the co-defendant obstetrician and said that she was not feeling well. She went to his office with her husband for an evaluation, at which time a blood test revealed anemia. Although the obstetrician measured the patient's blood pressure and listened to her heart via a stethoscope, no EKG was performed despite her congenital cardiac condition. She was instructed to go home and rest, but while entering her apartment complex she collapsed to the ground. As a result, she was rushed by ambulance to the emergency department (ED) of the defendant hospital center.

In the ED, the patient complained of two syncopal episodes, facial bloating, headache, nausea, vomiting, and not feeling "right" since her delivery on February 28. The physician assistant performed a physical examination that was unremarkable, and the third-year obstetrics resident documented MP and depression. Dr. A, the ob attending, ordered a full workup, including assessment for pulmonary embolism, anemia, and preeclampsia, which included arterial blood gases, chest x-ray, bilateral venous Dopplers, and a lung perfusion/ventilation quantitative scan. The ABG results were pH=7.49, PCO₂=27, PO₂=78, HCO₃=20, with an oxygen saturation of 97%.

Unfortunately, there was a shift change soon after admission and attending Dr. B was misinformed by the third-year resident as to the ABG results. The resident advised the new attending ob that the PO₂ was 97 (the actual value of the oxygen saturation), instead of 78. As a result, and as a result of the patient advising that she was extremely agitated, "having a nervous breakdown," and wanted to see a psychiatrist, the attending Dr. B cancelled the workup based on the ABGs, and instead ordered a psych consult and administered paroxetine. The patient was discharged home with a diagnosis of anxiety, on the same antidepressant, with a discharge order instructing her to follow-up with her primary-care physician the following day.