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    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.


    The surgical pathology report revealed that the endometrial fragments contained decidua tissue only and no chorionic villi, indicating that no intrauterine pregnancy was removed. The right ovarian mass was a pregnancy luteoma, a benign tumor that usually regresses after pregnancy. The patient appeared stable postoperatively and was discharged home with follow-up at the WHC scheduled on November 9, 2011.

    On November 2, 2011 the plaintiff was recalled to the WHC to check her hCG levels, which had been steadily rising. She was seen by Dr A, who had noted that the hCG had increased to 884.9, which was suggestive of an ectopic pregnancy rather than an abnormal intrauterine pregnancy. The patient had no pain or appearance of an acute abdomen and so she was told to return to the WHC for possible methotrexate therapy.

    On November 4, 2011 the plaintiff returned to the WHC and was seen by non-party Dr C. Her hCG level had risen further to 916.2. The risks, benefits, and adverse effects of methotrexate therapy were explained to the patient and she agreed to try it and was given 85 mg without any adverse effects. Ectopic pregnancy precautions were reviewed and the plaintiff was told to return to the clinic on Day 4 and on Day 7 and then weekly until her hCG levels had dropped to 0. If her hCG levels had decreased less than 15% between Day 4 and Day 7 and there were no other complications, she was to receive a second dose of methotrexate.

    On November 8, 2011 the plaintiff returned to the WHC and was seen by Dr B and nonparty Dr D. On that day, her hCG level was noted to have risen to 1385; however, because she was purportedly asymptomatic she was told to return to have her hCG test repeated 3 days later on November 11, 2011. On that day, she returned to the WHC and was seen by a Dr E. Her β-hCG level was noted to be 1051.0, only a slight decrease from the prior level. The plaintiff complained of bilateral lower abdominal tenderness, and guarding and rebound was noted upon examination.

    A transvaginal pelvic ultrasound revealed no evidence of a viable intrauterine pregnancy, but there was a large amount of complex fluid in the pelvis. Also noted was a left ovarian cyst and a normal right ovary and a large mass-like area in the cul-de-sac extending to the right adnexa, which was a new finding since the October 24, 2011 study. The report also revealed the suggestion of a ring-like tubal structure. Dr E’s impression was a ruptured ectopic pregnancy despite the decline of the β-hCG following methotrexate therapy. The case was discussed with Dr A and the plaintiff was admitted immediately for ambulatory surgery.

    The plaintiff underwent an emergent laparoscopic right salpingectomy and a left ovarian cyst aspiration for a right ectopic pregnancy. The surgery was performed by Dr A. Intraoperative findings revealed a right fallopian tube ectopic pregnancy, 2 simple left ovarian cysts, no pelvic adhesions, and a uterus that was small, mobile, and grossly normal.

    More: Patient refuses cerclage, medication; delivers early

    The pathology report revealed that a segment of the right fallopian tube contained chorionic villi consistent with a fallopian tube pregnancy. The plaintiff was discharged home that day and told to return on November 23, 2011 for a postoperative check. When she came back to the WHC on November 23, 2011 and was seen by Dr A, she was noted to be ambulating, voiding, and passing gas, and that her pain was well controlled with pain medication, which was not needed on that day. She had no fever and her incision was healing well. The result of the ectopic pregnancy in the right tube was noted.

    Dr A prescribed a contraceptive vaginal ring and Ms A was to return to the clinic for routine gynecologic care. However, she chose not to follow-up at the defendant hospital.

    NEXT: Allegations and verdict

    Andrew I Kaplan, Esq
    Mr. Kaplan is a partner at Aaronson, Rappaport, Feinstein & Deutsch, LLP, specializing in medical malpractice defense and healthcare ...


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