Legal Review & Commentary

Ectopic pregnancy goes undiagnosed, patient dies

Jury awards $1.7M verdict

News: A woman who had an ectopic pregnancy and suffered from paranoid schizophrenia went to the hospital complaining of a two-week history of vaginal bleeding. Unable to detect any fetal heart tones or recognize a fetus in utero, an on-call obstetrician/gynecologist discharged the woman. The woman returned to the hospital a couple of days later, but again was discharged when she said she had started to feel better. The woman was subsequently found dead at home. She had bled to death from a ruptured ectopic pregnancy. The woman's estate and the baby's father sued the OB/GYN and the hospital, and a jury awarded damages of $1.712 million, with nothing attributable to the hospital, 40% attributable to the physician, and the remainder attributed to the woman's primary OB/GYN who was not a defendant in the suit.

Background: A 26-year-old woman suffering from paranoid schizophrenia was pregnant. She went to the hospital complaining of a two-week history of vaginal bleeding, although her vital signs were normal and she was not complaining of pain. The triage nurse was unable to detect any fetal heart tones, and she contacted the doctor who was on-call for the woman's obstetrician/ gynecologist. The physician performed an ultrasound showing an empty uterus, which led him to believe that the woman was not pregnant. He discharged her with instructions to follow up with her regular OB/GYN physician when he returned from vacation in a few days.

A couple of days later, however, the patient went to the emergency department of another hospital, where she was treated for severe abdominal pain. A urine test revealed pregnancy. After the woman began to feel better, she was again discharged with instructions to follow up with her regular physician the next day. That night, however, the woman was found dead in her home. Doctors discovered she had an ectopic pregnancy. The woman bled to death as a result of an apparent ruptured ectopic pregnancy.

The woman's parents filed suit against the on-call OB/GYN and the hospital, and they alleged negligence in their failure to diagnose and treat the ectopic pregnancy. The father of the fetus also joined in the suit. A jury found no negligence on the part of the hospital, but they did assign 40% liability to the physician. The remaining 60% of liability was assessed against the patient's regular OB/GYN, although he was not named in the suit, perhaps having settled with the plaintiffs earlier. The jury assessed damages of $1.712 million, only $7,000 of which was attributed to the father. The award was reduced for comparative fault to $684,800 against the on-call physician.

What this means to you: "Some of the facts in this story seem a bit odd, and it is not difficult to understand why the jury awarded such a large verdict," says Lynn Rosenblatt, CRRN, LHRM, risk manager at HealthSouth Sea Pines Rehabilitation Hospital in Melbourne, FL.

A woman goes to an emergency department with a history of vaginal bleeding over two weeks but without pain. The woman apparently knew she was pregnant, but the narrative does not say how far along the pregnancy was. The nurse checked for fetal heart tones, but heart tones most likely would not have been discernable at an early stage of pregnancy. The ultrasound came up empty, indicating that she was not at that moment pregnant, at least with an intrauterine fetus. At this point, says Rosenblatt, the emergency department personnel should have questioned the source of the woman's vaginal bleeding and determined whether other tests could be performed to confirm the woman's claim that she was in fact pregnant.

One obvious conclusion could have been that the woman miscarried, but that possibility was apparently not fully explored. In fact, the narrative does not address whether the ED staff at the first hospital even performed a vaginal exam on the patient or a visual physical assessment.

"Pregnancy brings with it changes in a woman's body that are the result of hormonal interaction. Those telltale signs most likely would have still been discernable even if the miscarriage had occurred two weeks previously," says Rosenblatt. Moreover, in most ectopic pregnancies, there is some tenderness within the abdomen that should have shown itself on palpation, and the signs of pregnancy would have been evident.

Rosenblatt notes that it is difficult to deduce from the facts given whether the woman actually saw a physician on her first trip to the ED. "It appears that she was interviewed by a nurse, who then contacted a physician who had assumed responsibility for another obstetrician. There is no indication that the on-call physician actually saw the patient. The physician may have instead reviewed the details of the nurse's assessment and the results of the ultrasound over the phone," says Rosenblatt.

Because the woman was not technically his patient, he apparently overlooked the degree of responsibility he had for her well-being. "In other words," says Rosenblatt, "he decided he would rather not be bothered by someone with a history of mental illness who clearly was not pregnant [in his mind], but thought she was." In Rosenblatt's opinion, the physician made a fatal mistake in not pursuing the woman's symptoms further.

The on-call physician decided that given the patient's schizophrenia, the negative ultrasound, and the absence of pain, the woman was not pregnant. "But that does not address what was causing the bleeding and if anything needed to be done about it," observes Rosenblatt. If the patient had miscarried, for example, a minor surgical procedure to ensure that the uterus was empty of the products of conception generally would be undertaken. And if the physician is absolutely sure that the patient never was pregnant, then he should have made a more definitive determination as to the nature of the bleeding. "Under those circumstances, how prudent was it to have the patient wait several days before seeing her regular OB/GYN?" questions Rosenblatt.

She also wonders why the patient did not test positive for pregnancy at the first hospital given that she had a positive urine test confirming pregnancy at the second hospital. "Perhaps the first hospital did not administer a test," she says.

When the woman chose to go to a different hospital for follow-up treatment, Rosenblatt questions what, if anything, the patient told the physician at the ED about her experience a few days before. If the woman still had vaginal bleeding, the second hospital should have taken blood work to establish possible internal bleeding. The physician at the second hospital also should have performed a vaginal examination and repeated the ultrasound. And Rosenblatt wonders whether the second hospital was able to rule out a miscarriage and whether an ectopic pregnancy was considered.

"All of these questions should have been answered given that the woman's pregnancy test was positive and she was in extreme pain," says Rosenblatt. "The second hospital should have considered any number of very serious complications before releasing her."

Rosenblatt contends that the second hospital was responsible for providing a more comprehensive assessment of the patient. "A patient with severe pain and bleeding of unknown etiology most likely should be admitted for observation to ensure that the situation is resolving without further complications," she says. Rosenblatt further states that it is inexcusable that this observation did not occur in this case and that the patient then died several hours later from something that is generally considered treatable.

As for the lawsuit, because the scenario does not reveal the particulars of why the attending OB/GYN physician was not named, it is speculative to say why 60% of the negligence was attributed to him. "Most likely there were facts not put forth here that made the jury find against him," says Rosenblatt. "Perhaps it had to do with the inadequacy with which the physician who covered for him handled the case. Either way, the jury apparently felt that the woman's primary attending physician had an obligation that he did not meet."

The second physician was charged with the remaining 40% of the responsibility because he clearly failed to satisfy the standard of care that is commonplace in dealing with the potential complications of pregnancy. "Had he proceeded to answer some of the most basic questions that are always on the forefront when dealing with a pregnant woman who is bleeding," Rosenblatt says, "this woman may have survived a real emergency that generally has positive outcomes."

And finally, the hospital was spared from liability most likely because the jury chose to focus instead on the conduct of the physicians, who were apparently independent contractors with no employer-employee relationship with the hospital. "Had that not been the case, though, the hospital could have also been found liable," says Rosenblatt. Hospitals, after all, are responsible for overseeing the actions of contracted employees, common examples of which are teaching hospitals or where the ED physician is actually in the employ of the hospital.

"This is a sad case for several reasons, not the least of which is the inadequacy of the care provided. But even more, this case speaks to the plight of the mentally ill and the credibility they receive when they present to emergency personnel who have neither the time nor the patience to adequately sort out their stories," Rosenblatt says.

Reference

Jefferson County (TX) District Court, Case No. A-167868.