When a routine prenatal visit is not-so-‘routine’

Facts
A pregnant primigravida had her last menstrual period on August 28, 2014, an assigned due date of June 4, 2015. Her key prenatal visit took place on May 6, 2015. With a gestational age of 36 weeks, the fundal height was listed at 35 cm or 38 cm, as it was difficult to read the doctor’s handwriting. The presentation was vertex and fetal heart rate (FHR) and fetal movement were present. There was no indication of preterm labor and the mother’s cervix was intact. She weighed 119 lb, reflecting a 21-lb gain. Urinalysis was noted as negative. A note initialed by the defendant obstetrician indicated that the woman’s next appointment was scheduled in 1 week but there was no entry in the comment section, which reflected a routine visit with no complaints. The patient’s blood pressure was 91/77 mmHg, inconsistent with all blood pressures checked on past visits, which ranged anywhere from 97/64 mmHg to 126/80 mmHg. 

Shortly after midnight on May 7, the patient arrived at the hospital, and according to a note, had been “referred for emergency delivery.” The notes stated that the woman had come in complaining of abdominal pain, diarrhea, and fever since May 5, 2015 with suspected premature contractions. The initial nursing history note at roughly 2:00 a.m. stated that the patient’s chief complaint was “fatigue, feverish, as per family, with abdominal pain, vaginal bleeding.” 

The resident’s assessment noted that the patient came into labor triage at 36 weeks, feeling contractions, and the “team was called” to evaluate bradycardia upon placing the external monitor. The external FHR monitor showed a rate of 75 and the mother was given oxygen by face mask and an intravenous bolus of fluid. The Neonatal Intensive Care Unit and Anesthesia were notified. An obstetrical ultrasound performed shortly after midnight showed that the fetal heart was visible with cardiac activity, but the rate was bradycardic. The patient was taken to the operating room for a STAT cesarean. Verbal consent was obtained because of the emergency situation. 

The attending’s first note suggested that when the patient presented to triage, she had complaints of abdominal pain and diarrhea, “since the morning.” On external monitor, the FHR was 130 bpm and the maternal heart rate was also 130 bpm, prompting a sonogram. Because the FHR could not be “determined” a STAT cesarean was initiated.

A male fetus was delivered via cesarean with a birth weight of 2625 g, and Apgar scores of 0 and 0. The hospital’s obstetrical notes reflected that the emergent delivery was performed for fetal bradycardia, with an estimated blood loss of 1000 mL. during cesarean followed by virtually uncontrolled vaginal bleeding. Ultimately, the patient was diagnosed with disseminated intravascular coagulation (DIC) with suspected sepsis. The patient’s hematocrit dropped from 36.8% on admission to 12.7%. In the surgical ICU following the cesarean, she received 8 units of packed red blood cells, 8 units of fresh frozen plasma, 2 bags of crystalloids, and 1 unit of platelets. She was also receiving triple antibiotics. Nonetheless, the patient continued to actively bleed vaginally. Hypogastric artery embolization was performed with a note that the uterine arteries had been vasoconstricted previously.

The next note was from gynecology and said the reason for the patient’s cesarean was “suspected abruption/possible sepsis,” and that she developed DIC with vaginal bleeding as a result of suspected uterine atony, with suspected intra-abdominal bleeding, based upon abdominal distension and a bedside ultrasound. The note documented that the cesarean was started at 12:29 a.m. with the baby being delivered at 12:30 a.m. Intraoperatively, the patient’s abdomen was persistently contracted and tense, the uterus was pale, and upon entering the uterus there were clots and frank blood, “likely placental abruption” and the baby was delivered with poor Apgars. The next obstetrical attending note stated that “my review of the case at the time of my arrival, patient had an uncomplicated pregnancy, but presented to hospital for two days of diarrhea and abdominal pain, noted to have fetal bradycardia and triaged.” Initial labs were suspicious for abruption, and the patient essentially arrived with DIC.

On May 7 at 1 p.m. the attending was called to the Intensive Care Unit (ICU) by the obstetrical team because the patient “started” to develop severe vaginal bleeding due to uterine atony, requiring vasopressors. Given failure of conservative measures, she was now believed to have a life-threatening hemorrhage. The decision was made to go forward with a lifesaving salvage hysterectomy. The procedure was discussed with the patient’s sister and family and it was explained that, absent surgical intervention, the woman would not survive owing to the bleeding. 

By May 9, the notes reflected that the patient had apparently developed compartment syndrome of her right hand. On that date, the patient underwent a right-hand fasciotomy with a carpal tunnel release. Fasciotomies of the right volar, forearm, and dorsal hand also were performed.

Also on May 9, the patient developed acute compartment syndrome in her right leg. That led to a right thigh compartment fasciotomy and right calf compartment fasciotomy. While in surgical ICU, the woman also developed streptococcal toxic shock syndrome (STSS). On May 13, she went into acute respiratory failure, which resulted in a fiberoptic bronchoscopy and a percutaneous tracheostomy. 

On June 30, as a result of bilateral ischemic gluteal ulcers, a flapping procedure was performed. On July 22, owing to right index finger gangrene, the patient’s right index finger was amputated through the midline phalanx. On July 27, owing to right foot gangrene, the patient underwent a right below-the-knee amputation. On August 10, owing to left foot gangrene, the patient underwent a left below-the-knee amputation.

Allegations
Plaintiff alleged that at the last prenatal visit to defendant obstetrician, an appropriate history was not taken. The claim was that the doctor failed to learn the length of time plaintiff was exhibiting complaints of lower abdominal pain with fatigue, which would have required immediate delivery. It was also alleged that the attending failed to appropriately evaluate the mother’s abdomen during the visit and did not appreciate that there was fetal tachycardia. A fetal biophysical profile allegedly should have been performed, given the woman’s complaint of fatigue and lower abdominal pain with fetal tachycardia. The contention was that she should have been sent to the hospital on May 6, in that there was enough clinical suspicion of placental abruption as the cause of fetal distress, as exhibited by tachycardia, that it needed to be ruled out. Failure to appreciate placental abruption allegedly led to placental insufficiency, causing damage to the fetus and ultimately death. Failure to appreciate the abruption, the plaintiff claimed, caused uncontrollable hemorrhage, uterine atony, DIC, and STSS, ultimately leading to ischemic limbs and the need for a hysterectomy and significant amputations. All of this led to the death of the child, multi-organ failure in the mother leading to a hysterectomy, limb ischemia, amputation of the left index finger, and below-the-knee amputations of both her legs. This, in turn, led to the need for prosthetics and use of a wheelchair. The plaintiff claimed a loss of earning capacity and the emotional components of all of these damages.

As to the defendant Hospital, the plaintiff alleged it was improper to close the incision following the cesarean when the patient was still bleeding; a delay in transfusing the patient; and failure to appropriately monitor the patient after the procedure, resulting in DIC. In the face of uterine atony, they alleged there was a failure to timely perform a hysterectomy in an attempt to control the bleeding. 

Discovery
Early discussion with defendant OB revealed that he recalled the May 6 visit as a routine scheduled visit not occasioned by any complaints. If the patient had abdominal pain consistent with placental abruption, he did not believe she would have been able to withstand the ultrasound performed by him that day. Pursuant to that ultrasound, however, was a FHR of 194 bpm, which the defendant conceded he should have rechecked prior to sending the patient home. If the FHR did not come down to 160 bpm or below, he would have done a non-stress test to verify the finding and, potentially, would have sent the patient to the hospital for fluids and concern about maternal infection.

Our expert obstetrician wasn’t certain what prompted an ultrasound at 37 weeks but opined that a FHR of 194 bpm is quite abnormal and required immediate attention, i.e., sending the patient to the hospital immediately. A FHR that climbs over 180 bpm, to her mind, should be presumed to be a significant maternal infection, usually chorioamnionitis, and a reading like that is a red flag for maternal sepsis, and defendant OB should have checked the patient’s temperature as well.

She also had critiques for the Hospital co-defendant. She posited they were not having trouble finding the FHR; this was not a case of fetal bradycardia but rather there was fetal demise by the time the patient arrived. In the face of a raging infection, a cesarean would be contraindicated, especially in the face of fetal demise. She believed the proper course of care would have been to start the patient on medications to advance vaginal delivery and deliver the stillborn. Performing a cesarean in the face of a significant ascending infection would allow new entry portals for more organisms and rapidly spread the infection. She posited that ultimately caused the septic shock. 

Placental pathology showed 4+ group A Streptococcus infection, and a similar finding was made and confirmed based upon blood cultures. By performing a cesarean rather than controlling the infection with proper antibiotics, the Hospital staff exacerbated the infection. The expert did not believe that there was ever a placental abruption. She believed that the DIC led to internal placental bleeding, which the doctors mistook for an abruption. The fact that the patient progressed to sepsis not only affected the woman’s respiratory ability, but more importantly, affected and caused a drop in platelets, which impaired her clotting ability. This led to DIC, which was the precursor to the salvage hysterectomy that the patient underwent 1 day later. However, she progressed to necrotizing fasciitis, which ultimately led to limb loss.

The patient had been fitted with bilateral lower limb prostheses. Those records reflected a history of undiagnosed group A Streptococcus infection during pregnancy leading to STSS. 

The verdict

The defendant obstetrician and his practice were responsible for one-third of the settlement and the Hospital the other two-thirds.

Analysis
This was a case of significantly high exposure given the injuries, the favorable plaintiff’s venue and the obvious jury appeal. Sometimes, early analysis and resolution of high-exposure claims such as these is the best option, particularly when there is nothing to be gained by proceeding with formal discovery and depositions, and risk of disclosure of additional damaging evidence or testimony is high. We often harp on the necessity of thorough, accurate, contemporaneous documentation in this column. This case is no different, but here there was also a “failure” by the defendant obstetrician to take time in a busy practice to recognize the potential for danger to mother and fetus and investigate pertinent findings before discharging her home. More often than not, it is those seemingly minor oversights that lead to bigger issues later on and, eventually, litigation.