Was this uterine perforation properly managed?

Facts

In October 2007, the patient presented to a women’s health center, at which time an intrauterine device (IUD) was placed. In July 2009, the patient returned, requesting that the IUD be removed. On exam, the IUD thread was not seen and, as such, the removal could not be accomplished. Later that month, transvaginal ultrasonography (TVUS) showed that the device was in the uterine cavity, but part of the device appeared to have penetrated the myometrium posteriorly.  

The plaintiff presented to Defendant Hospital emergency department (ED) in August 2009, with complaints of abdominal pain with foul-smelling discharge, vaginal spotting, and fever for three days. TVUS was performed and the IUD was again noted to have the distal end within the posterior myometrium. The IUD had not changed position since the patient’s prior TVUS in July. She was discharged from the ED with one dose of azithromycin and acetaminophen/oxycodone and was scheduled for an appointment at the women’s health center the next morning.

The plaintiff presented to the women’s health center as scheduled and was seen by co-defendant, Dr. A. An IUD removal was scheduled for the following day.  

On August 10, 2009, the patient returned to Defendant Hospital. Per the operative report, two attempts were made to remove the IUD with forceps and an IUD hook, but they were unsuccessful. Subsequently, a hysteroscope was introduced into the uterine cavity and normal saline was used to inflate it. The IUD strings were identified, and the device was removed. Of note, there was a 900-mL normal saline deficit noted at the end of the procedure and the operative report specifically indicates “suspicion for perforation given the deficit.”  

Postoperatively, positive abdominal distention was noted, the abdomen was non-tender, and there was no vaginal bleeding. After transfer, the patient’s abdomen was still distended, semi-firm, and there was some vaginal bleeding. At 6 PM, the plaintiff’s hematocrit was 36.5 and her hemoglobin was 12.5. At 6:36 PM the woman was resting in bed and denied pain, shortness of breath, nausea or vomiting. Her abdomen was soft, non-tender, and there were positive bowel sounds. Dr. B noted that the plan was to discharge the patient home on ibuprofen and ciprofloxacin. At 7 PM, there was no vaginal bleeding, the plaintiff had not voided, her pain was 2/10, her oxygen was discontinued, and she was out of bed to a wheelchair. At 7:45 PM, she was discharged with instructions for activity as tolerated. Dr. B instructed the plaintiff to return to the hospital if she experienced fever, chills, abdominal pain, or weakness. An appointment was scheduled for later in August.  

The following day the plaintiff returned to Defendant Hospital with complaints of diffuse abdominal pain, tenderness, decreased bowel sounds, and guarding. On admission, her hemoglobin was 10, hematocrit was 29.9, platelets were 200, and white blood cell count was 11.2. An abdominal computed tomography (CT) scan was performed and the findings were compatible with intraperitoneal rupture of the uterus with free air and a hemoperitoneum seen. Following the CT, the plaintiff was seen by Dr. A at which time there was a discussion about the CT findings and the options of conservative management versus surgical intervention. Dr. A noted that she would proceed with a diagnostic laparoscopy and possible laparotomy. The risks of surgery were discussed.   

Intraoperatively, a clot in the uterine fundus was removed, and a defect, approximately 2 - 3 cm in the uterine fundus and right side of the uterus, was identified. It was then decided to perform a laparotomy. The uterus was exteriorized and repaired. A 5- x 3-cm right ovarian cyst was also identified, and a cystectomy was done without any complications. The next day Dr. A discussed with the patient that the perforation likely happened at the time her IUD was removed, the procedure extended it, and the area clotted, providing a tamponade. There was also a discussion of postponing pregnancy at least one year and then only delivering via cesarean.  

That evening, the patient complained of dizziness and difficulty passing gas, her abdomen was distended, and there was a tympanic note on percussion. The following morning, August 13, the patient’s abdomen was noted to be distended, tympanic, had mild bowel sounds, and there was no pain on pressure and neither guarding nor rebound. One unit of packed red blood cells was administered for symptomatic anemia. The next day  a repeat abdominal/pelvic CT was performed which evidenced repair of the uterus, an ileus, and residual hemoperitoneum. There were no signs of perforation. By the morning of August 15, the plaintiff was noted to be feeling and looking much better, and her abdomen was much less distended, soft, and non-tender, with positive bowel sounds.  

The patient remained at Defendant Hospital three more days. Discharge instructions included a follow-up appointment with Dr. A on September 1, but the plaintiff never returned.

In November 2009, the plaintiff presented to Hospital B’s ED. She complained of vaginal bleeding for the past three weeks and chronic pelvic pain since her Defendant Hospital admission in August. Pelvic ultrasound and TVUS showed that her endometrial cavity was distended with blood and/or exudate. She was diagnosed with pelvic pain and discharged the same day. Short-term follow-up of six weeks was recommended to assess for resolution. 

Three days later, the plaintiff returned to the ED at Hospital B with complaints of lower abdominal/pelvic pain since the previous night with vaginal spotting that started that day. According to the records, she had presented to the gynecology clinic earlier that day; they were unable to remove the blood from the uterus, so she was referred to the ED. 

Four days later, a consent form was signed for a cervical dilation, possible uterine suction/curettage, possible laparoscopy, and possible laparotomy. Risks of the procedure were discussed. Dr. C performed a dilatation and curettage for hematometra (collection of blood in the uterus). The pathology report noted small fragments of superficial endometrium with progesterone effect, stromal breakdown and reactive changes mixed with blood clots. The patient was discharged later that day with prescriptions for ibuprofen for pain and methergine for the bleeding.  

The plaintiff presented on December 15 to the Hospital B gynecology clinic for a follow-up appointment with a complaint of mild uterine/suprapubic tenderness. Oral contraceptives were prescribed for her complaints of vaginal bleeding. 

On January 5, 2010, a pelvic ultrasound showed that the distended endometrial cavity, which was seen on the November ultrasound, had resolved. On January 11 the plaintiff complained of vaginal bleeding for the past six months. Her examination was consistent with pelvic inflammatory disease (PID). Antibiotics for 14 days were prescribed. By January 19, she felt better but still complained of abdominal pain. She was informed that a hysterectomy would be the last alternative for management of her pain.

Ten days later, the plaintiff presented to the ED on referral from the gynecology clinic with complaints of abdominal pain 7/10 and vaginal bleeding. She described intermittent heavy vaginal bleeding and severe abdominal pain since the IUD removal in August 2009. She was admitted for pelvic inflammatory disease (PID) and IV antibiotics were started. She was given acetaminophen/oxycodone for the pain. She expressed a desire for a hysterectomy, but the physicians recommended conservative treatment with antibiotics.

On February 2, the plaintiff plateaued on the antibiotics. She signed a consent form for a diagnostic laparoscopy, diagnostic hysteroscopy, possible lysis of adhesions, possible lysis of synechiae and other indicated surgical procedures. Risks of the procedures were explained. 

The following day, laparoscopy revealed bowel and omental adhesions to the anterior mid-abdomen between the umbilicus and the pelvis. There were also adhesions of the bowel and omentum to the left lateral abdominal wall. The uterus was noted to be within normal limits with mild filmy adhesions to the adnexa. During enterolysis in the area of the left lateral abdominal wall, an incision was made into the peritoneum secondary to dense adhesions of peritoneum to the bowel. During the enterolysis, brisk bleeding was noted, suspected to be from the left epigastric artery. Due to poor visualization the decision was made to convert the procedure to an exploratory laparotomy. The plaintiff was discharged on February 6. 

In April, the plaintiff presented to the ED with lower abdominal pain/cramping. She stated that the pain was similar to the pain she experienced in January but stronger. Despite her complaint of vaginal bleeding since March 25, she stated that the bleeding had now resolved. A CT scan of the abdomen and pelvis showed a small hiatal hernia; a tiny right hepatic dome hypodensity that most likely represented a cyst; and an up to 1.9-cm left ovarian cystic structure that most likely represented a physiologic cyst. The diagnosis was abdominal pain possibly related to recurrence of adhesions. The woman was discharged later that day. 

On April 28, the plaintiff returned to the ED for complaints of vaginal bleeding for one day. She indicated that her last menstrual period (LMP) was on April 5, 2010. She was discharged with a diagnosis of vaginal bleeding. 

Later that year, on December 14, the plaintiff complained of vaginal bleeding since December 3 and pelvic pain. Extended-cycle levonorgestrel and ethinyl estradiol tablets had been prescribed for chronic pelvic pain, but she had stopped taking the medication in November. The assessment was possible PID and chronic pelvic pain with no specific etiology of findings except for adhesions. Ceftriaxone and azithromycin were given. An extensive risk, alternative and benefit conversation was had with the plaintiff regarding a hysterectomy. She was to obtain a second opinion. 

One week later, the woman complained of chronic pelvic pain and the physician noted that the “patient strangely desires [a] hysterectomy.” She was advised against a hysterectomy. She was treated for PID, but it was noted that PID was unlikely the cause of the chronic pain. 

On January 4, 2011, the plaintiff still complained of pain and stated that the bleeding improved. She was admitted for IV antibiotics and again said she desired a hysterectomy. Pelvic ultrasound noted a right adnexal cystic lesion. The woman underwent a laparoscopic hysterectomy, left salpingectomy, and lysis of adhesions on January 10, 2011.

In July 2011, the plaintiff presented to the ER with complaints of right-sided abdominal pain with nausea and dysuria. The pain was 8/10 and morphine was given. She later reported abdominal pain in the right lower quadrant for the past three days, on and off, which became constant the night before. A CT scan of the abdomen and pelvis showed a 4.7-cm right ovarian cystic structure. Pelvic ultrasound showed a 4.1-cm hemorrhagic right ovarian cyst with a small amount of associated hemoperitoneum. The patient was discharged home with pain medication.

NEXT: Discovery

Discovery        

The plaintiff alleged a failure to recognize the evidence of uterine perforation at the conclusion of the August 2009 procedure; that Dr. A failed to perform an ultrasound at the conclusion of the August 2009 procedure after the 900-mL fluid deficit was noted; that Dr. A discharged the plaintiff on August 10, 2009, without repairing the uterus; that Dr. A failed to timely repair the plaintiff’s uterus; that there was a failure to timely prescribe/administer antibiotics; a failure to timely perform surgery when the plaintiff was found to have a hemoperitoneum and blood in the abdomen; and that the failure to timely repair the plaintiff’s uterus resulted in the plaintiff having to undergo several surgeries including a hysterectomy. In particular, plaintiff asserted that her multiple surgeries, perforation, and hematoma/bleeds resulted in massive adhesion formation, which contributed to her chronic, unrelenting abdominal pain and discomfort.

The expert on behalf of the hospital felt that the attempt to remove the IUD in office was correct, however, when the attempt was unsuccessful, surgical removal was appropriate. She felt that the perforation was timely suspected/recognized due to the noted fluid deficit. Post-IUD removal, the defendants properly monitored vital signs for indication of a bleed and given that the plaintiff was clinically stable, it was appropriate for her to be discharged with instructions to return to the hospital if she experienced any pain or bleeding. Further, the expert felt that the plaintiff had a non-bleeding perforation that became symptomatic after she was discharged. There was no link, directly or indirectly, between surgical removal of the IUD and the plaintiff’s hysterectomy. In fact, plaintiff did not need a hysterectomy but insisted on one and the diagnosis of adenomyosis on pathology following the hysterectomy and, in retrospect, was the likely cause of the plaintiff’s chronic pelvic pain, heavy bleeding, and formation of adhesions. 

Trial

Plaintiff’s counsel argued that Dr. A discharged the plaintiff despite a suspicion of a perforation and that the discharge resulted in the plaintiff developing adhesions, which were the source of her continuing abdominal pain. Dr. A acknowledged that she suspected a perforation post-IUD removal, however, the monitoring post-procedure assured Dr. A that plaintiff was stable and could be discharged. The doctor also acknowledged that blood in the peritoneum could be an irritant and could result in formation of adhesions. Dr. A maintained that it was appropriate to monitor post-IUD removal even in light of a suspected perforation, given that the plaintiff was stable at discharge. In addition, the co-defendant reported that the patient had a number of conditions and procedures unrelated to the IUD removal that could have caused her adhesions. 

Plaintiff’s expert testified on direct examination that Dr. A departed from accepted standards of care by discharging with a suspected perforation without further investigating the status of the perforation. The expert explained that the hysteroscope used for the IUD removal could have been reinserted and then used to repair the perforation. Had Dr. A taken those steps, per plaintiff’s expert, the plaintiff would not have suffered a continuous bleed resulting in a hemoperitoneum and formation of peritoneal adhesions. On cross, he was confronted with prior testimony from a case where he was a defendant and had suspected a uterine perforation and did not use a hysteroscope to investigate or repair a patient’s uterus. The doctor also acknowledged that prior abdominal surgery, a cesarean with a vertical scar, PID, Gardnerella vaginalis, and adenomyosis could all cause adhesions and that this plaintiff had all of those conditions. He acknowledged that one cannot distinguish between which adhesions cause pain and which will not.  

The patient essentially testified that since her IUD removal, she had and continued to have abdominal pain. On cross, she acknowledged that over the past six to seven years despite presenting to Hospital B numerous additional times, she never complained of abdominal pain, did not seek treatment for her abdominal pain, did not request medication for her abdominal pain, and never saw a gastroenterologist or surgeon about her abdominal pain. 

Verdict

Plaintiff’s counsel asked that the jury return an award of $2.6 million for past pain and suffering and $1.8 million for future pain and suffering. After two days of deliberations, the jury returned a unanimous verdict on behalf of the defendants.