Failure to communicate diagnosis of ectopic pregnancy

Presentation

On July 11, a 26-year-old woman came to her obstetrician-gynecologist (Ob-gyn A) with reports that on July 9 she went to the emergency department (ED) with pain in her right lower abdomen. Her last menstrual period was on June 29.

Physician action

During this ED visit on July 9, the emergency medicine physician ordered blood work; a pregnancy test; and an abdominal CT scan. The results of both the patient’s CT scan and pregnancy test were negative.

During the July 11 office visit, Ob-gyn A noted the patient’s right adnexa was tender. After ordering a pelvic ultrasound, the patient was diagnosed with vaginitis and scheduled for a follow-up appointment on July 29.

On July 18, the patient called Ob-gyn A’s office and left a message that she was experiencing excruciating pain on her right side. The office called instructing the patient to come to the office for an ultrasound and evaluation. The patient never came in.

On July 21, the patient went to see another physician, Ob-gyn B, on referral from a friend. The patient told Ob-gyn B about pain on her right side and her menstrual cycle history. The physician ordered an ultrasound and urine pregnancy test. The results of the ultrasound were negative, but the pregnancy test was positive with the hCG level at 1264 mIU/mL. (Above 25 is considered positive for pregnancy.) These results were not communicated to the patient.

On August 4, the patient went to an urgent care center with reports of severe abdominal pain. The patient was transferred by ambulance to a medical center where she was diagnosed with a ruptured ectopic pregnancy. The on-call obstetrician, Ob-gyn C, performed a laparoscopic right salpingectomy to remove the patient’s right fallopian tube and ectopic pregnancy.

The patient was discharged the next day. She went to a follow-up appointment with Ob-gyn B on August 19. The patient was noted to be healing nicely.

Allegations

A lawsuit was filed against Ob-gyn B. Allegations included failure to:

• review lab results indicating the patient was pregnant;
• order appropriate follow-up testing; and
• timely diagnose and treat the ectopic pregnancy so the patient could avoid surgical treatment.

Legal implications

Consultant ob-gyns noted that the fragmented nature of the patient’s care contributed to the difficulty in diagnosing the source of her pain. They also agreed that the patient needed follow-up hCG testing; however, they acknowledged that the location of the pregnancy could not be determined by an ultrasound until the patient’s hCG levels exceeded 5,000 mIU/mL.

One consultant stated that had the ectopic pregnancy been diagnosed earlier, it could have been medically treated with methotrexate. However, there was no guarantee the patient would not require surgical treatment. Although the patient did not follow up with Ob-gyn A, she did follow up with Ob-gyn B within the recommended timeframe.

A consultant for the plaintiff noted that Ob-gyn B should have documented the positive pregnancy results and scheduled follow-up hCG and ultrasound testing. This consultant also stated that an early diagnosis could have been medically treated with methotrexate. The patient could have also received a linear salpingostomy to remove the pregnancy instead of the entire right fallopian tube.

The majority of consultants reviewing the case for the defense stated that the surgical removal of the patient’s fallopian tube was unavoidable. These consultants believed that even if Ob-gyn B had noted the hCG results in a timely manner, treatment with methotrexate was not an option for this patient.

Disposition

The case was settled on behalf of Ob-gyn B.

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