Title: Failure to perform a pregnancy test
By: TMLT Risk Management Department
The following closed claim study is based on an actual malpractice claim from TMLT. This case illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. The ultimate goal in presenting this case is to help physicians practice safe medicine. An attempt has been made to make the material less easy to identify. If you recognize your own claim, please be assured it is presented solely to emphasize the issues of the case.
On January 26, a 32-year-old woman came to an ob-gyn with complaints of heavy menstrual bleeding. She reported pelvic pain, dyspareunia, and that she had been bleeding for one month. The patient indicated that her surgical history included three cesarean deliveries, an appendectomy, and breast reduction. The patient had also been undergoing fertility treatments with a number of physicians, and had been diagnosed with endometriosis by another ob-gyn. The previous ob-gyn had performed a PAP smear and a laparoscopic procedure to treat the endometriosis a few days earlier. The patient had also been prescribed birth control pills for the abnormal bleeding.
An ultrasound performed on January 25 indicated that the right ovary appeared normal, but evaluation of the left adnexa was suboptimal due to the presence of severe tenderness. There was small amount of free pelvic fluid, but no other significant abnormalities.
The ob-gyn noted that the patient’s abdomen was soft and tender, and that she had a history of endometriosis. According to the ob-gyn’s testimony, the patient had come to her because she wanted a hysterectomy. The patient indicated that she had been suffering from long-term bleeding and pain after going through countless unsuccessful fertility treatments and wanted the ob-gyn to “take everything out.” The ob-gyn also testified that she encouraged the patient to keep an ovary, but at a subsequent visit the patient stated she wanted both her ovaries removed. The surgery was originally scheduled for one week after the initial consultation, but the patient delayed because she also wanted to have her urologist perform a bladder suspension at the same time. Both procedures were scheduled for February 28.
The ob-gyn performed an exploratory laparotomy and a total abdominal hysterectomy and bilateral salpingo-oophorectomy. During the procedure, she discovered that the left fallopian tube was bleeding with a mass in the mid-portion of the tube. It was believed to be a ruptured ectopic pregnancy. The ob-gyn removed the uterus (which tore completely when clamps were placed), ovaries, and the fallopian tubes. There was a large amount of adhesions around the bladder from the patient’s prior surgeries. A general surgeon was called into to assist due to the patient’s bleeding. The urologist performed the bladder suspension procedures.
The pathology report later stated that there was evidence of an ectopic pregnancy in the left fallopian tube. The report also stated the uterus and ovaries were normal.
The patient’s postoperative course was uneventful and she was discharged on March 2. On April 1, the ob-gyn had the patient admitted for a diagnostic laparoscopy due to extensive pelvic adhesions status post-total abdominal hysterectomy and bilateral salpingo-oophorectomy. The pelvic adhesions were taken down using a laser and blunt and sharp dissection. The patient did well postoperatively. One month after the surgery the patient complained of hot flashes, and the ob-gyn prescribed Estrace tablets.
Approximately 18 months later, the patient came to a new ob-gyn and complained of night sweats and a 20-pound weight gain. She was diagnosed with surgical menopause.
A lawsuit was filed against the ob-gyn. The allegations included failure to perform a pregnancy test before performing the total abdominal hysterectomy and bilateral salpingo-oophorectomy and failure to diagnose ectopic pregnancy. The patient asserted that she would not have agreed to undergo the hysterectomy if the ob-gyn had provided her with other options when the ectopic pregnancy was discovered.
The plaintiff’s ob-gyn expert was critical of the defendant for failing to obtain a pregnancy test before the hysterectomy. According to this expert, the patient’s symptoms on January 26 were consistent with a possible ectopic pregnancy and this should have been investigated. Further, if the ob-gyn had the results of the pregnancy test preoperatively, she could have presented other treatment options for the patient’s abnormal bleeding and subacute pelvic pain.
Several ob-gyns who reviewed this case for the defense stated that it was the standard of care to perform a pregnancy test before performing a hysterectomy in women of childbearing age.
However, one ob-gyn testified that though guidelines recommend a pregnancy test before surgery, in certain situations a physician must use his or her judgment and look at the individual patient. In this case, an ultrasound performed on January 25 did not show any evidence of an ectopic pregnancy. Further, even if this expert had known about the ectopic pregnancy, hysterectomy would still have been his first option, given the patient’s pelvic adhesive disease and a history of endometriosis. The second option would be to remove the tube with the ectopic pregnancy, but that would that would leave the patient with a high chance of ectopic pregnancy in the other tube.
The defendant testified that if she had known about the ectopic pregnancy, the only change she would have made would have been to do the surgery earlier.
This case was settled on behalf of the defendant ob-gyn.
Risk management considerations
This lawsuit involves the allegation that the physician did not meet the standard of care by failing to perform a pregnancy test. The standard of care in medical malpractice suits is determined by the opinions of the physicians reviewing the case, both the plaintiff’s and defense’s experts. As there is often a discrepancy in these opinions, the legal process determines which argument is most accurate or believable and whether the physician met the standard of care.
One way physicians can demonstrate that they are within the standard of care is to explain their reasoning for a diagnosis or plan of care in the medical record. This eliminates the argument later that the physician never considered other options or tests. If the reasoning is documented, those reviewing the case will know that multiple options were considered and may have a better understanding of the physician’s actions. In this case, had the physician explained that the ultrasound ruled out the possibility of pregnancy and that no pregnancy test was needed, it may have convinced those reviewing the case retrospectively that the defendant met the standard of care.
The information and opinions in this article should not be used or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalization can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services. © Copyright 2008 TMLT.