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Please select from the titles below which describe the corresponding sample Case Evaluation Report. By clicking on the title of interest, you will go to that report.
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topics of Medical Malpractice. Please check back very soon!
Obstetrics
Pulling the Uterus Inside–Out with the Removal of the Placenta.
At age 24 this patient came into the Hospital in labor at 37 weeks on 7/15. She previously had two children and two abortions.
Her condition was normal, except for premature labor at 32 weeks treated with steroids and tocolytic (labor stopping) drug therapy. She was also borderline anemic.
Dr. #1 was treating her in the hospital. He ruptured her membranes (AROM) and inserted a monitor for uterine contractions and for fetal monitoring. He checked her at 1952.
She was encouraged to push, and delivered a healthy male baby at 2003. Who delivered the baby? Who tried to remove the placenta? How much delay was there between the delivery and the attempt of removal of the placenta? Who did it? The “Labor and Delivery Summary” shows that the delivery was at 2003 but that the placenta was delivered at 20--. The Nurses were #1 and #2. The Attending Physician was Dr. #2. The assistants were Dr. #3 and Dr. #1.
At 2012 Dr. #3 was in the room an ordered a narcotic injection. At 2020 the Nurses notes show that the “placenta 90% out. Dr. #3 noted uterine inversion. Dr. #4 paged (who is he?). Anesthesia paged.”
She was immediately taken to the Operating Room and placed under a light general anesthesia with the drug Ketamine at 2025. The operative report notes that the attending physician was Dr. #2. Was he there? He is responsible for supervising all her obstetrical care. Also noted were the Resident Surgeons Dr. #4 and Dr. #3.
They said: “We were called to see the patient in the third stage of labor (the “delivery” of the placenta), without the delivery of the placenta. The placenta was present in the vaginal vault (vagina). With gentle traction on the umbilical cord, the placenta was spontaneously delivered through the vaginal vault, at which time a uterine inversion was noted.
Rapid pelvic replacement of the uterus was made, however, reinversion of the uterus could not be obtained.” Then she was taken to the Operating Room where “The surgeon’s hand was placed in the vagina. Gentle steady manipulation was performed until the uterus reinverted.”
The Pathologist noted that this 456 gram placenta was totally removed (“intact cotyledons”).
The operative report is not accurate. Gentle traction would not invert the uterus. Excessive pulling would do it. Furthermore, the standard of care is to wait a few minutes between the delivery at 2003 until the pull on the umbilical cord is done, to allow the placenta to spontaneously separate. If it does not easily separate, a few more minutes delay should occur. If at that point it does not separate, the obstetrician uses their hand (covered by a sterile glove) to peel it off of the uterus.
Sometimes the placenta grows more deeply into the uterine muscle (placenta accreta) and when not recognized, and excessive (negligent) force is used to pull it loose, the uterus can invert (turn inside out like a sock). Since the placenta was removed intact in one piece, she most likely did not have placenta accreta.
Either way, the uterine inversion was from negligently used excessive force. Who did it? What was their level of training at the time? Who was at their side (if anyone), supervising and protecting their patient?
They say she lost 1000 c.c. (two pints) of blood. Her hematocrit (packed red blood cell volume) dropped from 35.1 to 21.8. That is a critical level of anemia and consistent with three to four pints (units) of blood loss. Although she was not in documented shock, there may be some kidney damage. This is best assessed by the creatinine clearance test which is a 24 hour urine collection and one blood test. Her Physician can order that inexpensive study at any time.
Otherwise she recovered physically. On 8/23 she was counseled for a tubal ligation operation which took place on 8/26 with the use of Hulka clips, in the standard manner. No pathology was seen in her abdomen or pelvis.
I suggest that the patient be evaluated by a local Clinical Psychologist with courtroom experience for any residual emotional (psychological) damages. Administration of standardized tests such as the M.M.P.I. (Minnesota Muliphasic Personality Inventory) which have been given to millions of people would further support that opinion before a jury.
For the reasons stated above, I believe those Physicians and the Hospital which is responsible for its Resident (trainee) Doctor employees were negligent and caused preventable injury including her uterine inversion, massive blood loss, psychological damages as well as potential kidney impairment. It did not cause other problems.
You may want to get a copy of the contracts between the Hospital and each Doctor, its existing published rules, regulations and standards regarding training and level of responsibility for patient care, particularly regarding obstetrical deliveries as they existed at the time of her delivery. Note that the Resident Doctor year begins on 7/1. How much delivery experience did each have after 15 days into their new year? Her Admitting (in charge) Physicians were Drs. #5 and #1. Dr. #4 (a Resident) was noted by the Anesthesiologist to be in the Operating Room although Dr. #2 was listed as the Attending Surgeon in the typed operative report. Dr. #3 dictated that report. Who was really there?
I would suggest that you authorize us to obtain an Expert review by a Board Certified Obstetrician now, or after you obtain answers to the questions I raised. We await your instructions.
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Fetal demise at 37 weeks
gestation after cervical cerclage suture was removed.
At age 17, she had a miscarriage at 20 weeks
gestation. She was offered the option of a cervix cerclage procedure
wherein a suture, like a noose, is inserted around the opening of her
cervix (mouth of the womb), and she refused. She delivered a fetus
which died at birth. It had only a weak heartbeat and was too
premature to live.
She stated in that record that she had no
previous abortion but when she came under her obstetrical care for the
pregnancy in question, she noted she had a previous abortion. The
D&C (dilatation and curettage: scraping) abortion procedure can
damage the ability of the cervix to remain competently closed for
holding in future pregnancies.
The office care was good. Because of a
significant concern for an incompetent cervix, she underwent the
cerclage procedure at 12 weeks gestation, the standard time to do that
procedure. Some Obstetricians would require two previous miscarriages
to do this operation, but that is a judgment call issue. In my
opinion, it did not contribute to the fetal demise.
At 37? weeks, the cerclage suture was removed
in the office, on September 16. That is good care.
On September 20, her blood pressure was normal
at 122/82. It was normal in the hospital while in labor, in the
operating room and afterward. She did not have pre-eclampsia (high
blood pressure, abnormal reflexes and protein in her urine). That was
not a cause of the fetal demise.
It is common for labor to begin soon after the
cerclage suture is removed. That causes labor pains. It is acceptable
for a midwife to assist with obstetrical care.
When she arrived in the Hospital, the Nurses and
two Physicians could not identify a heartbeat. The ultrasound
confirmed fetal demise. Labor was allowed to continue but she did not
effectively progress. She had dystocia (failure of progression of
labor). Then an epidural catheter was inserted for pain control and
anesthesia.
During her labor, the membranes were ruptured
and meconium (green/yellow) stained fluid was seen, consistent with
prior fetal distress.
The C-section operation performed on 9/29 at
1505 (3:05 p.m.) by Dr. #1 was properly done, and also found a "heavy yellowish type of mucousy secretion that could possibly be
meconium in the uterine cavity" (from a fetal bowel movement in
utero from distress).
Her blood sugar was normal. She was not a
diabetic out of control, which can cause fetal demise. Her other
laboratory tests, looking for a medical cause of fetal demise, were
normal.
The autopsy on this 6-pound 12-pounce still-born
girl found an "angiomatous malformation" (blood vessel
abnormality) of the umbilical cord with some hemorrhage (bleeding)
into its flesh. The Pathologist concluded that it was the cause of
death (cutting off the oxygen supply from the placenta/uterus). I
agree.
The autopsy also noted: "The skin is
peeling off over the face, ears, back and extremities." That term
is called "maceration." After fetal demise, the dead fetus'
skin in the amniotic fluid will become lose in layers and peel. That
is a very common finding after hours of fetal demise. Also, the forces
of labor (19 hours) will accelerate those changes, unfortunately.
The fetus was dead, and she could not push at
the "wrong time." Her pushing only adds some extra force to
the uterine muscle firmly compressing the fetus. In this case, she
arrived at the hospital with fetal demise already present. They had to
induce labor to extricate it because with excessive delay, toxic
products could cause maternal demise.
When a patient is in pain and calls the Nurse
for pain medication, it should be given in a reasonable amount of
time. That delay did not cause any serious injury .
Having a "minister" who is on the
Hospital Board Administer some Nursing care or be involved in
confidential medical matters is not proper but did not cause injury to
the mother.
No matter how incompetent her Obstetrician may
have been alleged to be in other cases, in this case, there was a
congenital anomaly in the umbilical cord, which unfortunately bled
into its substance. It was not injured with the cerclage suture
removal or the membranes would have to be ruptured (not possible with
a closed cervix, and they were first ruptured in the hospital by Dr.
#2 at 4:30 a.m. on 9/29). Furthermore, she had a congenital anomaly in
the umbilical cord.
Based on all of the above, as well documented in
these records, I do not find substandard care as the proximate cause
of this unfortunate fetal demise.
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Ectopic pregnancy diagnosis
delayed because of vaginal bleeding but surgery takes place before
rupture and hemorrhage.
This patient was pregnant in her right fallopian tube (ectopic
pregnancy), had persistent vaginal bleeding, an ultrasound (sound
x-ray like study) that was consistent with an ectopic pregnancy and
she had emergency surgery at which time the ectopic pregnancy was
removed. It was a cornual ectopic (at the open end of the tube) and
had not ruptured causing severe pelvic/abdominal hemorrhage and death.
On 4/30, at age 31, with a last normal period of
3/16, she was approximately four weeks pregnant and had vaginal
bleeding for two weeks and heavy bleeding for two days. This is
consistent with a spontaneous abortion, or a threatened abortion.
The ultrasound study of 4/30 found: "No
visible intrauterine pregnancy and no gestational sac, fetal pole or
heartbeat is detected." This is consistent with a spontaneous
loss (abortion). At four weeks, it is very unusual for an ultrasound
to detect an ectopic pregnancy. Sometimes it is seen at six to eight
weeks, but by that time it usually erodes through the tube causing
bleeding into the pelvis/abdomen and symptoms of severe pain,
justifying surgery to remove it and save a woman's life.
On 4/30 the HCG (pregnancy hormone blood test)
was 158. This is consistent with an approximate five-week pregnancy.
On 5/3 she came to the emergency room because of
persistent vaginal bleeding. The HCG was 167 (no statistical
difference) and they "correctly" diagnosed "threatened
AB (abortion)." Nothing could be done to save the baby (or the
tube to heal normally even if they operated on that date, for which
there was no medical justification as viewed prospectively).
Because of persistent vaginal bleeding on 5/13
she was to have a "suction D&C" but because her uterus
lining was misshapen by fibroids (benign smooth muscle uterine
tumors), Dr. #1 performed the scrape out with the standard curette
instrument. The pathologist found no fetus or fetal parts, no placenta
(chorionic villi) and no decidua (changes of the uterine lining seen
with a recent spontaneous abortion or ectopic pregnancy). Out of
caution, the pathologist added: "Clinical correlation is
therefore recommended to rule out an ectopic pregnancy."
"The microscopic slides preparation, review and typing of the
report was completed on 5/16."
On 5/16 she returned to the emergency room
complaining of severe right lower abdominal plain and two episodes of
vomiting. The HCG was 201. They concluded she had "abdominal
cramps." That was a negligent diagnosis. An ectopic pregnancy
should have been first on their differential diagnosis list, and an
ultrasound study followed by surgery should have occurred without
delay.
On 5/19 at her office visit she had "pink
vaginal discharge." "Complaining of slight cramping." This was abnormal but not to the level where he would be negligent,
and it would not have made any difference in any event.
On 5/23 she was worse, had an ultrasound that
was suspicious for an ectopic pregnancy with fluid (blood) in her
lower pelvis. The HCG was 106 and because of that ultrasound and her
physical examination pain ("clinical correlation") emergency
surgery took place, removing the cornual ectopic pregnancy by opening
up the end of the fallopian tube (linear salpingostomy), and removing
her appendix, which was inflamed at its tip (it was not appendicitis),
and had to be excised.
The left fallopian tube was normal, as were both
ovaries (cystic changes are normal findings), therefore, her fertility
is 80% of before. There is a small risk of a recurrent ectopic
pregnancy because Dr. #1, following the standard of care, did not
remove the right fallopian tube.
She healed and did well except for her misplaced
upset against Dr. #1.
Even if the surgery would have taken place on
5/16, or even two weeks earlier (for which there was no
justification), there would be no provable (by reliable expert
testimony) difference.
She was fortunate that she only had a small
amount of internal bleeding, did not go into shock, develop kidney
failure or die.
There was obvious hostility with her husband
noted on the record, and a one-hour delay to remove her appendix,
caused by his demand for it to be done by another Surgeon at that same
ectopic pregnancy operation.
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Uterine bleeding and
premature labor at 26 weeks not properly treated, fetal distress with
delayed delivery, resulting in brain damage.
This patient delivered a baby boy on two years
before and had no prenatal care. That delivery was uneventful. The
placenta (after-birth) was normal.
She saw Dr. #1 at his clinic on 3/19. She was
pregnant and wanted to know how far advanced she was. She bled for two
days in October, November and December. That was abnormal. She was 16
years old. They concluded that based on the physical exam she was 16
to 18 weeks pregnant. An Obstetrical ultrasound (sonogram) was ordered
to "get an exact size on the fetus". No further obstetrical
care was done and should have begun in this high-risk (teenage, with
earlier bleeding) pregnancy.
She returned on 3/25 and saw a Family Nurse
Practitioner (FNP) #1. She was "complaining of lower abdominal
pain that she describes as sharp and knife-like times 24 hours. This
is relieved by fetal position and exacerbated by erect position.
Patient denies difficulty with bowels and bladder". The patient
was discussed with Dr. #1 and she was noted to be a "high risk
pregnancy". The urinalysis test said "leukocytes (white
blood cells) moderate". But the urine was discarded before any
microscopic exam could be done. Was this a sterilely collected
mid-stream clean catch specimen? She had no bladder symptoms and did
have sharp pain relieved by position. This is not consistent with a
bladder infection.
Pain in pregnancy is pathologic. This is
consistent with an abruptio placenta: separation of the placenta from
the uterus (womb). Dr. #1 should have seen and examined her under all
these circumstances, and that failure is negligent. An urgent
ultrasound should have been obtained and the patient should have been
advised that if there was any bleeding, to go to the hospital without
any delay. She was given an antibiotic for the presumed urinary tract
infection, and prenatal vitamins. The ultrasound was scheduled for the
next day.
That obstetrical ultrasound showed her pregnancy
to be 24.4 + 1.8 weeks. The fetus including her brain was normal.
There were no brain cysts.
She developed vaginal bleeding since 4/5 and
went to the Hospital #1 Emergency Room where she was in labor, and
uterine contraction (labor) preventing (tocolytic therapy) medication
was begun (magnesium sulphate and terbutaline) without effect, and she
was transferred by ambulance to the Hospital #2. On the way, her
amniotic membranes (bag of water) broke. She was in active labor.
Tocolytic therapy medication is effective only
in early labor before the cervix (mouth of the womb dilates more than
2 or 3 centimeters) and before its thickness thins out (effacement).
The earlier the better.
I do not have the records from Hospital #1 on
4/7. Please obtain them. They began tocolytic therapy. When she
arrived at the Hospital #2 they noted that there was a spontaneous
rupture of membranes (SROM) at 1345, and she had contractions every 2
to 3 minutes. That is strong labor. Uterine contractions can cause
abruptio placenta (the placenta separating from the uterine wall with
clots beneath), or labor can be caused by abruptio placenta. Her
cervix was dilated to 3 centimeters (one inch = 2.54 centimeters) and
was 100% effaced.
The fetal heart rates were in the distress range
(outside 120-160), especially low: it was below 80 to over 180 at 1412
(2:12 p.m.). This requires an emergency delivery, and since the fetus
was in the breech (buttocks first) position, a C-section operation was
safer, and with her consent was done at 1440 with the delivery of the
premature baby at approximately 26 weeks gestation, weighing 915
grams, at 1447. The Pediatricians were in attendance and gave good
care. The Apgar scores were 1 at one minute and 7 at five minutes.
They are low, but are only valid for a full term (40 week) gestation.
Both the mother and baby received antibiotic
therapy because at surgery they noted "purulent fluid,"
consistent with infection. They also noted "evidence of abruption
behind the placenta."
Their obstetrical ultrasound just prior to
delivery did not show any abruption. The amniotic fluid was severely
decreased from the ruptured membranes. It also noted "fetal
growth is not appropriate for this gestation," although the
Pediatricians found this premature newborn to be normal (AGA = at
gestational age).
The Pathologist confirmed the abruptio and
presence of infection: "three vessel vasculitis" and
"marked deciduitis and focal chorioamnionitis."
The premature baby had respiratory distress
syndrome (RDS) from her immature lungs and was on a respirator for a
few days.
Ultrasound studies of her brain and a MRI of
June 9 found "Frank macrocystic encephalomalcia in the posterior
right parietal and occipital lobes corresponding to the ultrasound
report." In my opinion this loss of brain flesh replaced by fluid
filled cysts was related to her fetal distress.
At 13 months of age there were substantial
delays even when computed for her "corrected age." Adoptive
and cognitive skills delay 7% -24%, and "may become more
severe." Her gross motor delay was 60%, her fine motor skills
were a 23% delay, language skills were a 32% delay, and her personal
and social capability had 23% to 32% delay.
She received special education home care and
made some progress, but still had major deficits.
The purulent fluid (pus) seen in the uterine
cavity and infection of the placenta would be consistent with the
amniotic fluid leaking for more than one day. The germs from her
vagina would contaminate the uterus with the membrane sterile barrier
broken. That infection would cause uterine irritability leading to
premature labor. With only leakage the patient would be hospitalized,
placed on bed rest, monitored, and given antibiotic therapy. That
would increase the chance for sealing, not becoming infected, and
allow the pregnancy to continue. The more weeks that pass, the greater
the chance for an uncompromised baby being born.
With monitoring, if there was any fetal
distress, urgent transfer to a high risk center (or transfer there
initially for monitoring), and a timely C-section would take place
without the fetus being subjected to the extremes it sustained which
caused her brain damage.
Bleeding in pregnancy is not normal. It is
consistent with an abruptio placenta. It is an obstetrical emergency.
According to the Statement of Facts, she began
bleeding on 3/28, called Dr. #1 at his clinic and got an answering
machine. They have a duty to be available to their patients. When no
one returned her call she called Hospital #3 and they refused to see
her without pre-approval from Dr. #1. All three health care providers
are negligent.
On 3/30 she spoke to FNP #1 and was told she was "OK." That is negligent care by FNP #1 and her employer.
Her mother called his clinic on 4/1 and was told
that "bleeding is ok." Further negligent care.
Then she continued bleeding until the delivery.
All this put the fetus at risk.
The Hospital #2 record confirms that she had a "history of (h/o) intermittent bleeding over the past 1 1/2
weeks." And that the "Patient presented to Hospital #1 at
0900 hour this AM with complaints (c/o) painful CTXs (contractions) q
(every) 2 minutes which started early this AM."
Even if the tocolytic therapy would have failed,
the fetus would have been delivered without being subjected to
prolonged stress. But it had a chance of functioning if started very
early, or, with bed rest and antibiotics, there would have been a
chance that the leak would seal and the pregnancy continue.
For all the reasons stated above, it is my
opinion that FNP #1, Dr. #1, his clinic and Hospital #3 were
negligent, and their negligence was the proximate cause of the brain
damage of this newborn baby.
Obtain the Hospital #1 records. Also obtain
copies of the fetal monitor strips at both hospitals, and all the
ambulance records.
Also obtain copies of both obstetrical
ultrasounds for review by Obstetrical and Radiology Experts. After
their review I recommend that we obtain a review of these records by a
Pediatric Neurologist to comment on causation.
What is the specialty of Dr. #1? If he is not an
Obstetrician I also suggest a review by an Expert in his specialty,
even though he was functioning as an Obstetrician.
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Fetal distress with
negligent delay in cesarean section delivery, causing increase of risk
of premature newborn intra-cerebral hemorrhage.
There is no question that this child sustained
severe brain damage. I reviewed all the documents and will give you my
opinions below.
The office records reveal that she was a patient
who in the past had received birth control pills. She delivered a
healthy girl weighing 5 pounds 4-1/2 ounces four years earlier. She
had routine office care and a normal delivery.
The next relevant records were from her delivery
two years earlier when she delivered a healthy 5 pound 9-3/4 ounce
girl. The diabetic screening was negative and the office care,
hospital care and follow up was normal. The records reveal that she
was a smoker both during this pregnancy and the previous one, as well
as the one in question. Smoking does increase the risk of intrauterine
growth retardation, which, in fact, was one of the problems with the
previous pregnancy.
According to the office records, two years
later, the patient had the injectable medication, Depo-Provera, on
February 9, after the serum pregnancy test performed the day before
was negative. The laboratory did positive and negative controls,
according to the documents supplied.
Then, she had symptoms consistent with pregnancy
and on March 14th had a positive urine pregnancy test. This was
confirmed by a positive serum pregnancy test on that same date.
Although it would be negligent to use Depo-Provera in a patient who
was pregnant, having a negative serum pregnancy test would allow the
physician to, in fact, assume the patient was not pregnant, and give
her that birth control medication by injection form. In any event, in
my opinion, that would not cause the type of brain damage that was
found in this case.
The patient also had a history of chronic pelvic
pain, but that is not relevant to the subsequent events. That might be
a cause for infertility, which is not what this case is about.
That year, the record shows she was smoking
one-half a pack of cigarettes per day. There were no other risk
factors, and she had a benign pregnancy until August 22, when she was
31 weeks pregnant by dates. The records show that she fell down the
steps the previous night, but there was no bleeding. The physician
correctly ordered a nonstress test on a weekly basis.
On August 22, she underwent the first nonstress
test. Her blood pressure was normal at 118/70. My review of the
records is consistent with their interpretation showing good
variability. Every few seconds the fetal heart rate would change. This
is what is seen in a healthy fetus and is consistent with a healthy
brain and no stress to the fetus. The nonstress test does not use any
stimulation with the hormone drug, Pitocin, to cause uterine
contractions. The nonstress test was ordered to be done weekly because
the weight of the fetus was small for gestational age (SGA). In my
opinion, this does meet the standard of care.
On August 30th there were some red flags. Her
blood pressure had risen significantly to 130/90. This was not
repeated in the obstetrical outpatient record at Hospital #1, and in
my opinion, that would a departure from the accepted standards of
care. The record also shows that the mother was upset and "states
baby has not moved times two days."
Furthermore, the beat-to-beat variability was
poor. I agree. It shows a very blunted, rather straight-line record at
about 160-150 beats per minute. All this, in my opinion, is ominous.
Even if her blood pressure would have returned to normal, the fact
that this fetus had not moved for two days, and that the beat-to-beat
variability was extremely poor, and the fact that Dr. #1 was notified,
in my opinion would require immediate hospitalization and further
intervention.
The nurses' notes show that the patient felt the
baby kick twice and that there was some more fetal movement during
this recording. However, the significant abnormality with regard to
beat-to-beat variability, in my opinion, required some immediate
investigations, which would include hospitalization.
In my opinion, they should have had the
ultrasound biophysical profile study performed. However, Dr. #1
ordered that the nonstress test (NST) be repeated the next day on
August 31st, and on that day, they should do a BPP (biophysical
profile study).
When she returned on August 31st for that
additional evaluation, the record says, "States still has felt no
movement." Her blood pressure taken twice this visit was normal
at 110/70 and 110/60. The X-ray Department called them and told them
that there was no ultrasound available that day because the technician
was ill. Certainly there must be one additional person capable of
performing the study. This was a very serious problem because on
August 31st, there was still no beat-to-beat variability. This puts
great stress on the fetus and increases the risk of multiple
complications, including that of intracerebral hemorrhage. The patient
was admitted to the hospital that day.
Dr. #1 noted in the history, "The last
nonstress test a week ago showed reactive patterns, but on nonstress
test on August 30th, it showed straight line without much variability,
no acceleration, with infrequent fetal movement. The plan was to
repeat nonstress test the next day. The nonstress test on 8/31 showed
the same findings, nonreactive. OCT (oxytocin: Pitocin) followed,
which showed positive means, continuous late deceleration with uterine
contraction. Biophysical came 2 of 8 from the amniotic fluid pocket,
but generally the amniotic fluid itself was minimal. The fetal
breathing or fetal tone were all negative. With all this fetal
distress, emergency section was elected, after using steroids for the
fetal lung maturity, the positive or negative side of this steroid use
was fully discussed with the patient."
The above is not quite accurate. The biophysical
profile was performed on September 1st, not August 31st, and it was on
September 1st that the patient was taken to the operating room for the
Cesarean section operation. And steroid use is controversial and not
usually effective.
The placenta did not reveal any rupture, and had
some changes consistent with some premature aging with fibrosis
(scarring) and placental infarction (gangrene). In my opinion, the
placenta was not that healthy, and it caused the intrauterine growth
retardation. This fetus was in a very unhealthy environment, confirmed
by the very abnormal nonstress test on August 30th. It was not until
two days later that the Cesarean section operation took place.
With regard to the test performed on August
31st, Pitocin was begun at 11 a.m. Decelerations were noted. This is
ominous. With uterine contractions, the fetal heart rate should not
fall significantly. This is consistent with a stressed fetus. The
nurses' notes clearly show, as does my interpretation of the fetal
heart monitor, that there was consistently very poor variability.
Despite this, throughout the night being
unchanged, including minimal variability and decelerations, it is only
until 8:06 in the morning that the ultrasound biophysical profile was
completed and the decision for a Cesarean section was made. The
patient was taken to the operating room at 11:30 a.m.
Following Cesarean section, the mother initially
did well. Unfortunately, she was rehospitalized from September 19-26
because of deep venous thrombosis involving her left leg. This was
properly treated with anticoagulation (blood thinning medication), and
the next year, the study for blood flow and venous thrombosis was
negative. In my opinion, the negligent delay in performing the
Cesarean section for the baby did not affect the risk for the mother
developing the deep venous thrombosis.
The approximate gestational age by dates of the
newborn delivered by Cesarean section was 32 weeks. The breathing was
abnormal in that there was grunting and retractions (sucking in of the
flesh secondary to difficulty in breathing in the air), and that, plus
the x-ray findings consistent with granular-type changes in the lung,
made the appropriate diagnosis of respiratory distress syndrome (RDS).
The baby's initial blood sugar when the
transport team was called was approximately 90 mg percent; this is
normal. However, in a stressed obstetrical delivery, the blood sugar
can drop dramatically, and can cause diffuse brain damage. When he
arrived at Hospital #2, the blood sugar (glucose) was 29, and they
immediately gave the baby intravenous bolus (a large, quick dose) of
sugar (D10W). This is proper care, and in my opinion, the blood sugar
did not drop to that dangerous a low level (generally under 20) to
cause diffuse brain damage, and this child did not have diffuse brain
damage. Furthermore, the oxygen values reported are numerous arterial
and capillary blood gases, and in my opinion, always were within the
safe range. This child did not suffer brain damage, in my opinion,
from low oxygen levels after birth.
During the Cesarean section operation, there was
a very small amount of amniotic fluid, but there was no meconium
staining. Often with fetal distress, the fetus will have a seizure in
utero and have a bowel movement in the amniotic fluid, which turns it
green (meconium). That was not found here.
The umbilical cord was not described as having
any knots, neither by the obstetrician or the pathologist. In fact,
the umbilical cord is described as normal with no knots or strictures
within. In my opinion, the umbilical cord was not the cause of any
problem to this fetus, but the placenta, as I described, was
insufficient in its health, in my opinion, to fully sustain the
pregnancy.
The newborn premature baby was described
neurologically as "normal," and the Apgar score at one
minute was 5, and at five minutes was 7. These are reasonably good
values. The Apgar scores are for 40-week (full-term) babies and
premature babies usually have a significantly reduced Apgar score. It
was the examination by Dr. #2, at Hospital #2, that described the
neurological exam as intact for age and the estimated gestational age
at 32 weeks.
In my opinion, the care at Hospital #2 was good.
This newborn baby did have abnormalities with its clotting studies,
with an elevated prothrombin time and activated partial thromboplastin
time (PT and APTT). Also, the platelet count and fibrinogen was
depressed, and because of that, he did receive proper blood
transfusions with the use of platelets, cryo-precipitate (blood
clotting components) and plasma.
In my opinion, the newborn had sustained fetal
distress of a moderate degree secondary to the impairment of the
placenta as confirmed by the nonstress test and the oxytocin challenge
stress test, significantly increased the risk for this newborn baby
having a bleeding dysfunction.
Because of that bleeding problem, there was
hemorrhage into the brain. This was confirmed by cerebral ultrasound
studies.
On September 6th, there is a mention that there
was an abnormal wrist position, etc., and they were going to ask the
occupational therapist to evaluate the patient's tone of movement in
the morning. That is the first note that I can find of any neurologic
abnormality.
On September 6th, there was an ultrasound of the
brain which says, "Five-day-old male who had tension pneumothorax
(a collapsed lung that was timely recognized and treated with a chest
tube) this morning and now has developed sluggish and asymmetric
pupils and right upper extremity seizure-like activity."
Therefore, it would appear that something happened on September 6,
which was an acute neurologic change. This ultrasound of the brain
revealed hemorrhages within the brain. There was blood clot and
hemorrhage within the substance of the brain, including both frontal
regions, and more extensive on the right, which would cause the
seizures and neurlolgical changes. There were some cystic
(fluid-filled) changes within those areas, and it says, "The
findings are worrisome for extensive periventricular
leukoencephalomalacia."
A repeat ultrasound of the brain on September
8th showed the previous hemorrhage with no additional changes. On
September 11th, another ultrasound showed "continued evolution of
bilateral periventricular leukomalacia with interval formation of
several cysts."
On September 18th, another ultrasound compared
to September 11th showed further progression. In the frontal lobes,
there were areas of necrosis (gangrene) developing. There was further
progression on the ultrasound on September 28th.
On November 27, the ultrasound showed "extensive bilateral periventricular leukomalacia, right greater
than left and more marked in the frontal regions." This was at
three months of age.
An MRI of the brain with no contrast on at 11
months of age confirmed all the findings of the previous ultrasound.
All this was related to the hemorrhage within the brain.
In my opinion, the substantial brain damage of
this child is related to the hemorrhage within the brain. In my
opinion, there was negligence by Dr. #1 in not interceding on August
30th, and certainly by August 31st. He waited an additional two days
from the first significant evidence of a severe problem to perform a
Cesarean section operation.
If he was relying upon the ultrasound technician
who was ill that day to perform the biophysical profile, and if the
hospital was unable to supply an alternate technician, then in my
opinion, the hospital would also be negligent.
This was a fetus that was in a very stressful
situation. The mother also noted the absence of fetal movement, which
is pathologic, and despite all of that, there were substantial delays
in performing this Cesarean section operation. In my opinion, the
fetus kept in that stressful environment for those extra two days was
placed at greater risk for further complications developing, which
would include the intracerebral hemorrhage, despite proper care at the
Hospital #2.
At birth, on September 1st, it notes that the
baby was given "Aquamephyton 1 mg." This is the correct
medication to give a newborn to decrease the risk of hemorrhage. This
is vitamin K, and it helps the liver produce the clotting substances.
But in a stressed fetus, there are biophysical changes in the body
that do increase the risk of intracerebral hemorrhage.
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Post-partum (after
delivery) bleeding and question of a retained placenta (after-birth).
This 18-year-old girl previously had a vaginal
delivery and became pregnant again. The obstetrical sonogram
(ultrasound) on 3/3 showed a viable fetus estimated to weigh 264 grams
and the placenta (afterbirth) was unremarkable.
She miscarried and delivered a non-viable fetus
at home seven minutes before the ambulance arrived. In the hospital
they described the fetus as otherwise normal and "the fetus and
placenta were intact."
The Pathologist examined the specimens and noted
the fetus weighed 225 grams and the placenta weighed 195 grams and
measured 12.5x11.5x2 cm (one inch = 2.54 centimeters). The "placenta is ragged and torn". However, the normal
appearance of a placenta has very irregular borders.
She stopped significant bleeding and appeared
otherwise normal during her hospital stay.
Because, after she went home, bleeding
persisted, there was concern for some fragments of retained placenta
(products of conception). An ultrasound on 4/22 was consistent with
that diagnosis, so she underwent a D&C (dilatation and curettage:
scraping of the uterine lining) on 4/22.
At surgery they found "a moderate amount of
blood with minimal amount of products of conception". The
pathologist who found only 4x3.5x0.6 cm flesh also confirmed this and
microscopically there were "focal areas suggestive of retained
products of conception".
She did well and was sent home.
I find no departures from the standards of care.
The placenta was evaluated and found "intact".
When bleeding persisted she had an indicated
D&C which found only minimal areas suggestive of small pieces of
placenta. This was not a large piece missed, which would be negligent.
There will probably be no damages for her future fertility.
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