Was this a case of a missed hematoma?

Factual summary

The 42-year-old patient was initially seen at Health Center on April 26 with a positive urine pregnancy test. As a result, she began her prenatal care on May 9. Her past obstetrical history was significant for having had delivery of a male infant by normal spontaneous vaginal delivery, the delivery of a female infant, and the delivery of another male by normal spontaneous vaginal delivery.

At the time of this initial visit, her blood pressure was 106/70 mm Hg and estimated gestational age was 7 weeks 1 day. Blood was drawn for testing and an abnormally elevated glucose of 151 mmol/L was noted. As a result, the patient was called back to the clinic for a 3-hour fasting glucose test, which was ultimately within normal limits. The patient’s initial ultrasound study was performed on May 17 with a single intrauterine pregnancy, with an estimated age of 10 weeks 1 day and no abnormalities observed.

Throughout her prenatal visits, the patient’s blood pressure was normal, as were both her protein and glucose levels. She had no documented edema. During her pregnancy, she was diagnosed with 1 urinary tract infection, for which medications were prescribed. At her final prenatal visit on November 2, there was some trace protein in her urine, but her glucose and blood pressure were normal, with no evidence of edema.

The patient presented to the emergency department at defendant Hospital at 5:05 am on November 9. She was complaining of right-sided abdominal pain and difficulty breathing. It was reported that she had an argument with her son’s girlfriend at approximately 2:30 am and after the argument, developed right-sided back and upper quadrant pain, with difficulty breathing, secondary to the pain. Her prenatal care had been managed at Health Center, and she had a total of 9 prior pregnancies,
3 resulting in full-term births and
5 elective abortions.

The patient was noted to be extremely uncooperative, and it was difficult to assess her vital signs. The initial assessment was undertaken by the midwife, and the blood pressure recorded at 5:43 am was extremely elevated at 228/135 mm Hg. Her blood pressure was taken again at 5:45 am and remained elevated at 188/107 mm Hg. On exam, the patient’s abdomen was tender to palpation in the right upper quadrant and right flank. At that time, obstetrical examination by the midwife demonstrated cervical dilatation at 0 and the fetus at high station. The assessment was to rule out preeclampsia, an abruption, and a liver hematoma. The plan was to consult with defendant OB A.

Defendant OB A authored an obstetrician-gynecologist (ob-gyn) encounter note, indicating that she was called at 5:50 am and that she was with the patient immediately thereafter. In light of the elevated blood pressures, defendant OB A gave a loading dose of magnesium sulfate and 20 mg of intravenous (IV) labetalol, given at approximately 6:05 am. Upon rechecking the blood pressure at 6:08 am, it remained elevated at 210/105 mm Hg. As a result thereof, defendant OB A pushed an additional 20 mg of labetalol at 6:10 am. At 6:12 am, the blood pressure was recorded at 173/108 mm Hg, and therefore an additional 40 mg of labetalol was given.

Defendant OB A also did a sonogram to look at the patient’s liver and did not see any free fluid in the abdomen or a liver hematoma. A drop in the fetal heart rate in the range of 90 to 100 beats per minute (bpm) was noted. The patient was placed in the left lateral position and oxygen was given. Thereafter, at 6:20 am, the patient was taken to the operating room for an emergency cesarean section. The last recorded blood pressure prior to transfer was 176/114 mm Hg.

Defendant OB A was the primary surgeon for the cesarean delivery, and she was assisted by defendant OB B. An infant boy, weighing 1885 g, was delivered with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively. The operative report for the procedure indicates that a lower midline incision was made, and the vertical fascial incision was extended up and down. Defendant OB A noted in her operative report that “liver and other visceral structures were inspected carefully for any evidence of bleeding and was normal. There was no oozing or bleeding noted from any site. Abdominal sweep was negative….” The report also states that the cul-de-sac and paracolic gutters were cleared of all blood clots and debris. The postoperative diagnosis was: “No liver hematoma, good hemostasis, [and] no oozing or bleeding noted.” Finally, the patient was described as being taken to the recovery room in “stable condition.” The estimated blood loss for the procedure was less than 1000 ccs.

According to defendant OB A’s encounter note, the patient was able to respond appropriately to verbal commands after the cesarean section, and she updated the patient’s family as to the patient’s progress. The patient’s labs indicated severe HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome with abnormal coagulation values, but there was no bleeding or oozing from the operative site.

The patient was received in the obstetric post anesthesia care unit (PACU) at approximately 7:28 am, and the initial blood pressure reading was 167/90 mm Hg.

Thereafter, the nurses’ notes reveal the following blood pressures:

7:41 am

153/85 mm Hg

7:47 am

139/85 mm Hg

7:51 am

138/79 mm Hg

7:56 am

128/71 mm Hg

8:02 am

119/56 mm Hg

8:07 am

118/59 mm Hg

8:12 am

93/60 mm Hg

8:17 am

81/50 mm Hg

8:20 am

72/40 mm Hg

8:22 am

69/40 mm Hg

8:24 am

96/50 mm Hg

8:26 am

103/56 mm Hg

8:31 am

99/65 mm Hg

8:36 am

76/37 mm Hg

8:41 am

81/43 mm Hg

8:45 am

80/42 mm Hg

8:51 am

82/49 mm Hg

8:55 am

80/49 mm Hg

According to a note authored by defendant OB C, she received a report from the prior team at approximately 7:45 am and initially evaluated the patient at 7:50 am. She noted that the patient was groggy but was responding to questions. She described the blood pressures as being in the 100 to 110/60s mm Hg, with a heart rate in the 60s bpm. Urine output in the operating room was noted to be 200 ccs, but since the end of the procedure, the patient had only 10 ccs. Defendant OB C indicated that at approximately 8:15 am, the patient’s blood pressures were noted to be trending down—90s/60s mm Hg to 80s/50s mm Hg—and that the patient was given ephedrine bolus twice. As before, her urine output was minimal (10 cc) and an IV fluid bolus was given. The anesthesia team was at bedside, and they were starting an arterial line for pressors.

At 8:20 am, defendant OB C described that the patient’s abdomen was becoming distended, and she performed a bedside ultrasound, noting that there was a large amount of free fluid and possible collection vs clots near the liver edge. She was concerned for a possible liver hematoma, with rupture and intraperitoneal bleeding. Accordingly, the surgery team was called at 8:30 am, and the main operating room was called for probable need for emergency exploratory laparotomy. She also activated the massive transfusion protocol. At this time, the blood pressures were still in the 80s/40s to 50s mm Hg, with no urinary output.

At 8:55 am, the general surgical team was at the bedside and agreed to proceed with exploratory laparotomy. At that time, pressors, albumin, and fluid resuscitation were ongoing. They were waiting on operating room availability for transfer, and the transfer took place at 9:18 am.

According to nursing history:

7:28 amthe patient was received in the PACU with a diagnosis of severe preeclampsia and HELLP syndrome.

7:40 am, magnesium sulfate was restarted via a Sigma pump at 2 mg/50 ml per hour.

7:45 amdefendant OB A was noted to be present at the bedside.

7:58 ama urine bag was removed and a urinometer was attached to observe strict fluid output. Defendant OB C was noted to be present at bedside and evaluating the patient at that time.

8:12 amblood pressure dropped to 93/60 mm Hg.

8:17 am, the blood pressure was 81/50 mm Hg,

8:18 amthe anesthesiologist was called and came to the patient’s bedside.

8:20 am, the blood pressure dropped to 72/40 mm Hg and ephedrine was given. The blood pressure remained low at 69/40 mm Hg. An IV bolus of lactated ringer was given and defendant OB C performed the ultrasound.

8:45 am, the blood pressure was at 80/42 mm Hg,

8:55 am, the blood pressure was at 80/49 mm Hg.

9:06 am, the rapid response team and massive transfusion protocol was placed in effect.

9:09 am The rapid response team arrived at the bedside at. The next blood pressure recorded was 142/92 mm Hg.

9:18 am Ultimately, the patient was transferred to the operating room.

The initial exploratory laparotomy was performed by defendant surgeon, with the assistance of defendant resident surgeons. The preoperative diagnosis was hemoperitoneum, and the postoperative diagnosis was massive hepatic bleed in the setting of HELLP. Defendant surgeon described observing over 2 L of blood having been suctioned from the abdominal cavity and notwithstanding the packing of all 4 quadrants, the bleeding continued. Massive transfusion protocol was initiated, and the patient required epinephrine boluses in maintaining her mean arterial pressure greater than 60. The liver was carefully mobilized on the right side, and they were unable to observe any single source of bleed. Rather, there was diffuse bleeding that appeared to be coming from the dome of the liver, and the capsule appeared disrupted.

At some point thereafter, the patient was severely acidotic on norepinephrine bitartrate, vasopressin, and epinephrine infusion. The patient was having massive ongoing bleeding from the liver that was not controlled with packing. The patient received transfusions of fluids, multiple blood products, cell saver, and Factor VII but continued bleeding. The estimated blood loss exceeded 20 L. Ultimately, all efforts to control the bleeding and correct coagulopathy failed, and the patient developed pulseless electrical activity that did not respond to resuscitation. She was pronounced dead at 4:37 pm.

Autopsy findings confirmed a liver capsule rupture, involving the anterior and inferior surfaces (segments 2-8). The liver was found to be friable, with extensive necrosis. Microscopic examination of the liver showed a pattern of injury, consistent with preeclampsia and HELLP syndrome. Most of the mucosal and serosal surfaces showed petechial hemorrhage, indicating a severe coagulopathic state because of HELLP syndrome. The immediate cause of death was attributed to exsanguination, leading to high-output heart failure because of liver capsule rupture, which is “common in severe cases of
HELLP syndrome.”

Allegations

Plaintiff alleged a failure to timely diagnose and treat preeclampsia and HELLP syndrome. It was further alleged that the defendants failed to order or perform proper diagnostic tests (including blood tests) and radiological studies to diagnose HELLP syndrome. The plaintiff also alleged that the defendants failed to request or obtain the proper consultations from appropriate specialists and that the surgery was performed in an untimely manner. They also alleged that during the cesarean section, there was a failure to inspect the operative field prior to closing the patient and that the defendants lacerated the vena cava and caused the liver capsule rupture, resulting in hemorrhage and untimely death. It was alleged the defendants failed to perform a hepatic artery ligation and embolization in a timely matter.

Discovery

Our maternal-fetal medicine expert felt the case was defensible from an ob-gyn’s perspective. He explained the plaintiff-decedent was taken to the operating room for an emergent cesarean section rather quickly, and there was no delay in doing so. During the cesarean section, it is documented that there was no indication that the liver had ruptured, and it appears that the physicians examined the liver and looked at the paracolic gutters. He said it was possible the patient could have had a small hematoma of the liver at that time, but if so, it was very hard to see. He explained that even if the plaintiff-decedent had a hematoma at that time, there would have been no intervention to treat the hematoma. There was no reason for the obstetric team to summon a liver consultant/specialist during the cesarean section. He explained that 99% of the time, one is not needed. In fact, he stated that he has encountered liver hematomas and has never called a liver specialist to consult or assist intraoperatively.

Regarding the exploratory laparotomy, he did not find any departures. He did not believe there was any delay in taking the patient back to the operating room. He believed it was done rather quickly and that her condition was being closely monitored. He also emphasized that this was an incredibly complex, rare, and extreme case, resulting from “very aggressive” preeclampsia. He pointed out that although he has seen liver hematomas in severe HELLP syndrome, he has never encountered a patient with a ruptured capsule. He stated that during the procedure, the patient had very experienced physicians involved in the procedure, and therefore they “had all the expertise they needed.” He did not see any evidence of “over manipulation” by any members of the surgical team during the exploratory laparotomy. He also did not see any evidence that the surgeons had caused the bleeding during cesarean section. There could be an issue as to whether the vena cava was damaged by the surgeon during the exploratory laparotomy, but he pointed out that a full code was not required during this very “aggressive” surgery. If the vena cava was damaged by the team, then it happened at the very end of the procedure after the patient’s fate was already sealed. Accordingly, he did not find this to be an issue.

Our liver expert found the patient was timely and appropriately assessed under the circumstances, particularly given that HELLP syndrome is an extremely rare condition. He explained it was appropriate to proceed with a cesarean section, as the recognized treatment for HELLP syndrome is delivery of the infant. He explained that after the infant is delivered, HELLP syndrome normally resolves. However, in this case, he opined that the patient’s HELLP syndrome was so far advanced that delivery was not enough.

However, he was skeptical that a hematoma did not exist since the time decedent presented to the hospital, including at the time of the first ultrasound prior to the cesarean section and at the time of evaluation during the cesarean section, contrary to the notes of the obstetricians indicating there was no hematoma. He explained that the fact that a massive hepatic bleed occurred only a couple hours thereafter, coupled with the fact that the patient presented with right upper quadrant pain, suggested the hematoma existed at that time she presented, as HELLP syndrome does not cause pain on its own but rupture does.

Our liver expert believed the obstetricians likely missed a hematoma(s), simply because it is not their usual practice to interpret liver sonograms or perform evaluations of the liver. Further, the site of the incision for the cesarean section, although optimal for the cesarean section, is below the location of the liver and does not fully expose the liver. However, he did not believe there was any reason for the obstetricians to have made a higher incision to check the liver at the time of the cesarean section. Only in hindsight could the right upper quadrant pain have signaled further evaluation. He also noted that, in hindsight, an angiogram prior to the laparotomy to determine the source of the bleeding could have been helpful.

Result and analysis

The case settled before trial. This was a case we intended to try unless and until opposing counsel became reasonable enough in their demands to make it less than palatable to risk a jury’s consideration. Although the medicine in the case was generally defensible, the vulnerabilities created by the absence of consideration of preeclampsia or HELLP syndrome upon arrival; the possibility that the patient arrived to the hospital with a hematoma existing; and the potential failure to recognize the bleed, or perhaps to respond to it timely in the PACU, resulting in maternal death, posed several hurdles to overcome in what was bound to be an emotionally sympathetic trial. As negotiations ensued during the early deposition process, the decision was made to resolve the case on behalf of the Hospital Center to avoid exposing the various physicians and staff to prolonged depositions, possible finger-pointing as to responsibility and cause of death, and the potential pricing of maternal demise by a jury.