Legally Speaking: CP diagnosed after preterm delivery in Spain

Ms. Collins is an attorney specializing in medical malpractice in Long Beach, California. She welcomes feedback on this column via e-mail to dawncfree@gmail.com.

CP diagnosed after preterm delivery in Spain

A California woman with a history of 2 premature deliveries and a single miscarriage became pregnant in 2004. A few days after the pregnancy was confirmed, she was seen by a physician at a military base in connection with an application to accompany her husband overseas. The application was approved and the patient went to Spain, where she delivered at 31 weeks’ gestation in 2005. The infant was hospitalized for 17 days and subsequently diagnosed with cerebral palsy. She suffers from tetraplegia, cannot walk without assistance, and has significant cognitive impairment and vision loss.

The woman sued the United States for negligence by the physician at the military base in California. She claimed the personnel there failed to tell her she was at high risk of preterm delivery and failed to caution her against traveling overseas to a facility that was not equipped to handle a high-risk pregnancy or to care for a premature infant. In order to prosecute this case against the United States, the patient had to show that the negligence had occurred there. Her claim maintained that the malpractice occurred when the physician at the California military base approved her application for overseas screening.

The court initially ruled that the plaintiff’s claim should be brought in South Carolina, where the infant was treated after her return to the United States. It then reversed that ruling and allowed the case to be brought in California.

The verdict

The court found that the physician failed to further fully investigate the patient’s obstetrical history and determined that this failure led directly to the risk of preterm delivery and to the patient being in Spain without an appropriate facility to manage her high-risk pregnancy or treat her premature infant. It ultimately awarded $10,409,700, which included $250,000 for the parents’ pain and suffering.

Infection after endometrial ablation leads to death

A 36-year-old Texas woman underwent endometrial ablation to treat heavy vaginal bleeding in 2007. The procedure was performed by her gynecologist in his office. The patient had been treated by this doctor since 2002. The next day the patient called the office and complained of abdominal pain. She was told to stop the medication she was on and to go to an emergency room (ER) the next day if she still had pain. The next day she went to an ER and was found to be in septic shock. An exploratory laparotomy was performed and 500 ccs of pus drained. An emergency hysterectomy was also performed. Three days later the patient died from pulmonary arrest caused by toxic shock syndrome. It was later discovered that her sepsis was caused by a highly unusual group A Streptococcus infection.

The lawsuit filed by her estate claimed that the patient was not a proper candidate for endometrial ablation because of her history of chronic cervical infections. It also claimed that the physician perforated the cervix during the procedure and tried to conceal it, and that he had inadvertently introduced group A strep into the patient’s system. It was also claimed that the office staff had failed to ask the proper questions when the patient called the day after the procedure and that they should have told the patient to go to the ER then.

At trial, the physician and his medical group disputed whether the patient had a chronic cervical infection prior to the ablation procedure, denied perforating the cervix or uterus during the procedure, and also claimed that a strep A infection is so rare that it would have been difficult to foresee or diagnose.

The verdict

A defense verdict was returned.

Failure to perform timely cesarean allegedly caused IVH

In 2003 a 36-year-old Ohio woman in preterm labor at 23 weeks’ gestation was admitted to the hospital. She was discharged 3 days later, but readmitted 2 more times over the next 2 weeks. Each time the labor was stopped with medication and bed rest. The patient had a cesarean delivery at 32 weeks’ gestation 14 years earlier and she had discussed having a cesarean for this pregnancy. The patient’s membranes ruptured at 25 weeks’ gestation and she was admitted to the hospital. When her physician arrived about 5 hours later, the patient mentioned a cesarean, but he wanted to wait to see if labor progressed. Three hours later the fetal heart rate (FHR) showed signs of distress and an emergency cesarean delivery was performed. The infant suffered a massive brain hemorrhage and was diagnosed with cerebral palsy, cognitive delays, and visual impairment, and will require life-long care.

The woman sued those involved with her care and alleged negligence in discharging her from the hospital on all her previous admissions for preterm labor. She claimed that a cesarean delivery should have been performed soon after rupture of the membranes, and that it was not done in a timely fashion once the FHR deteriorated. She argued that the severe variable decelerations of the FHR caused cerebral blood flow fluctuations that led to the intraventricular hemorrhage (IVH).

The physicians claimed that severe chorioamnionitis led to the preterm labor and premature rupture of the membranes and that caused the infant to be delivered at such a critically premature age. They argued that IVH is a complication seen in such premature infants and nothing would have changed the outcome.

The verdict

A $14.5 million verdict was returned, which included $1.5 million for the mother and $13 million for the child.

Postpartum hemorrhage results in death 

A 19-year-old Virginia patient with a full-term pregnancy presented to a community hospital in labor. After several hours of labor and a diagnosis of arrested descent, she was taken to the operating room for a cesarean delivery. About 15 minutes after the delivery she had “scant” then “moderate” vaginal bleeding, then decreasing blood pressure and tachycardia. The post-anesthesia care unit nurse assessed her uterus as “boggy” and alerted the obstetrician, who immediately assessed the patient. Some clots were expressed from the uterus and the fundus was noted to be firm. Oxytocin infusion was continued but the patient continued to bleed. After 15 minutes, the patient’s vital signs worsened. The physician ordered blood products and uterotonics, an additional intravenous, and uterine massage. The patient had transient improvement but did not stabilize. She was returned to the operating room (OR), where a hysterectomy was performed after the physician attempted to stop the bleeding with O’Leary stitches. About 6 hours after the hysterectomy and after more than 12 units of blood had been infused, the patient coded multiple times over a 2-hour period and was pronounced dead about 14 hours after her delivery. The cause of death was disseminated intravascular coagulopathy (DIC) due to uterine hemorrhage.

The lawsuit that followed claimed that the physician failed to recognize the extent of the postpartum hemorrhage and should have acted more aggressively to resuscitate the patient and return her to the OR. It was also alleged that the obstetrician was negligent in ordering cross-matched blood rather than O negative, which took 45 minutes to arrive, and that he did not recognize and appropriately treat the DIC.

The physician denied any negligence and maintained that he had acted properly in returning the patient to the OR within 90 minutes of first learning of the hemorrhage.

The verdict

A $1 million settlement was reached.

Vesicovaginal fistula follows abdominal hysterectomy

A gynecologist performed a total abdominal hysterectomy on a Virginia woman. At the patient’s first postoperative visit, a vesicovaginal fistula was diagnosed and the physician attempted a repair the following day. The repair failed and the fistula continued for 6 more months and the patient underwent 2 additional repairs before it was corrected. During the 6 months she suffered leaking urine constantly, was nearly house bound, and had to bathe and change her bed sheets nightly.

In the lawsuit filed against the gynecologist, the patient claimed that the doctor improperly utilized blunt dissection to isolate the bladder instead of sharp dissection, which should have been used because of her history of a cesarean delivery and endometriosis, as well as the dense adhesions encountered during the hysterectomy. She argued that use of blunt dissection weakened the bladder wall and caused the vesicovaginal fistula. She further claimed that the gynecologist attempted the repair without the assistance of or referral to a urologist or urogynecologist, and that his inexperience led him to neglect to place a flap of tissue between the bladder and vaginal defect.

The verdict

The jury found in the patient’s favor and awarded her $387,000.

Misreporting of GBS status results in neonatal death

A pregnant 16-year-old patient went to an Arizona obstetrician in 2009. The usual practice at the obstetrician’s office was to send patients’ records to the hospital at about 25 weeks’ gestation. In 2010 when the patient was at 33 weeks’ gestation, a vaginal culture to test for group B Streptococcus (GBS) was performed by the physician. The positive results were sent electronically to the obstetrician’s office. The result was not entered into the patient’s chart. At 35 weeks, the patient went to the hospital with contractions but was evaluated and discharged home. A week later she again went to the hospital and again was discharged home. She returned the next day, now at 36 weeks’ gestation, and was admitted by an obstetrician covering for her doctor. A labor and delivery nurse called the physician’s office for the GBS result and was told it was negative. This was documented in the prenatal records from the office, which were in the chart. When the original obstetrician arrived later that day, he reviewed the prenatal record and noted the negative GBS sign. The infant was delivered later that day and had Apgar scores of 7 and 7 and was limp and grunting. A pediatrician felt the infant had some transient respiratory problems related to prematurity. The infant’s condition continued to deteriorate and antibiotics were ordered about 7 hours after birth. The infant was transferred by helicopter to another facility a few hours later and died soon thereafter. An autopsy found the cause of death to be GBS sepsis and pneumonia.

The patient filed suit, claiming that the obstetrician was negligent in failing to properly record and communicate the positive GBS result.

The obstetrician argued that it was his practice to note laboratory results at the time of the next prenatal visit, but the patient delivered before her next appointment. He also argued that the on-call physician was comparatively at fault for failing to give antibiotics when the patient presented in preterm labor with unknown GBS status, and further that the hospital was negligent for not suggesting that prophylactic antibiotics be given. He also accused the hospital of being negligent in failing to verify the results with a copy of the written laboratory report faxed to them. Alternatively the physician argued the infection occurred in utero, not during passage through the birth canal, and so, antibiotics would not have changed the outcome at that point.

The verdict

The hospital settled for a confidential amount prior to trial. The jury found the obstetrician not at fault, the hospital 40% at fault, and the on-call physician 60% at fault. They awarded $200,000 each for the parents of the infant, but because the parents had already reached a settlement agreement with the hospital, they received nothing further.

Bowel perforation after hysterectomy

In 2009, a gynecologic oncologist performed a hysterectomy for treatment of uterine cancer on a 65-year-old Michigan woman. After surgery the patient developed an infection and required surgery by a general surgeon, who detected and repaired a bowel perforation. The patient was hospitalized for 4 months due to continuing infection.

The patient sued the first surgeon and claimed he perforated her small bowel and failed to identify and repair it during the first operation.

The physician denied any negligence in the performance of the hysterectomy, claiming that the patient had significant adhesions from prior surgeries and minor serosal tears of the bowel, several of which were repaired during the operation. He maintained that he checked the length of the bowel for perforations several times and found none, and that one of the weak areas must have broken down after the operation. He also argued that perforation is a known complication and it was recognized and repaired in a timely manner.

The verdict

A defense verdict was returned, and the physician was awarded $14,535.30 in costs.