Should this ectopic pregnancy have been diagnosed earlier?
TVS showed no evidence of a viable intrauterine pregnancy but the patient’s β-hCG levels complicated the picture.
On October 24, 2011, a 29-year-old patient presented to the defendant hospital’s emergency department complaining of a 4-day history of vaginal bleeding and lower abdominal pain. She was in no acute distress, and had no vomiting, diarrhea, dysuria, or headache. Her complaints were of dizziness and mild shortness of breath. An ultrasound had been performed and blood samples had been drawn when the patient was seen at the codefendant hospital 2 days earlier.
The woman was told that the imaging showed no intrauterine pregnancy. Her blood sample, however, revealed a beta-human chorionic gonadotropin (β-hCG) level of 313 and rising, which correlated with her last menstrual period (LMP) on September 9, 2011. A basic metabolic panel, coagulation study, and urinalysis were normal, and testing for gonorrhea and chlamydia was negative. Urinalysis did show many bacteria. The patient’s hematocrit (HCT) was 33.2 and her hemoglobin (Hgb) was 11.1. Physical examination by the emergency medicine attending physician found that the patient’s abdomen was soft with mild left quadrant tenderness but no guarding or rebound. The attending noted mild vaginal bleeding and that the cervical OS was closed. Abdominal and transvaginal pelvic ultrasound were performed and revealed no evidence of an intrauterine pregnancy, no focal uterine masses, a small amount of free fluid in the cul de sac, a small right ovarian cyst, and a normal left ovary. The impression was ectopic pregnancy rather than spontaneous abortion.
Because the patient had no pain or active vaginal bleeding she was discharged home with information about ectopic pregnancies. She was also told to follow up in the women’s health center (WHC) in 48 hours. On October 26, 2011, the plaintiff presented to the WHC as directed and was seen by co-defendant Dr A, who noted that her ultrasound was negative for intrauterine pregnancy. The plaintiff had no pain but was having a small amount of vaginal bleeding. Dr A’s impression was likely complete abortion but he noted that an ectopic pregnancy could not be ruled out. Blood was drawn for an hCG level and the patient was to be called with the result. The β-hCG blood level was to be followed until it was down to 0. Instructions regarding ectopic pregnancy were given to the patient. No complete blood count was ordered.
On October 28, 2011, the plaintiff came back to the WHC for follow-up to evaluate a rising hCG level. She was again seen by Dr A, who had noticed that the β-hCG level drawn on October 26 was 421.4 and more elevated than 2 days earlier. Additional blood samples were drawn for another β-hCG level and the result was 447.1, another increase. The woman’s HCT was 32.9 and her Hgb was 11.4. The risk of a possible ectopic pregnancy was discussed with the patient, who expressed that she understood. The treatment plan that day included dilation with suction and curettage and the risks of the procedure—including bleeding, infection, uterine perforation, and damage to the bowel and bladder—were discussed with the patient. The need for possible methotrexate therapy versus a laparoscopic procedure in the future was also discussed.
The plaintiff was admitted that day to the ambulatory surgical unit (ASU) and signed a consent form for a possible salpingectomy. She underwent a diagnostic laparoscopy and dilation and curettage (D&C) and excision of a right ovarian mass. The surgery was performed by Dr A, assisted by defendant PGY-1 ob/gyn Dr B. Intraoperative findings are partially noted in the operative report dictated by Dr B and signed by Dr A, which fails to mention the intraoperative appearance of the fallopian tubes despite the patient being consented for a possible salpingectomy.
Laparoscopy showed an 8-week-size anteverted uterus, 50 cc of hemoperitoneum, 1- to 2-cm right ovarian mass, normal left ovary and left adnexa, and a grossly normal upper abdomen. Pathology specimens included endometrial curettings and a right ovarian mass.