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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.

     

    Allegations

    The plaintiff asserted that during the diagnostic laparoscopy, Dr A and Dr B should have detected the ectopic pregnancy in the right fallopian tube. Her attorneys claimed that based upon the plaintiff’s abdominal pain, vaginal bleeding, and β- hCG levels, and absent evidence of intrauterine pregnancy on ultrasound, the defendants should have presumed ectopic pregnancy and adequately evaluated the fallopian tube before discharging the patient, thus avoiding rupture.

    Discovery

    At the deposition, the patient claimed that once her tube ruptured she was told by a physician at the defendant hospital that she would never again get pregnant but “could adopt.” She then revealed that she in fact became pregnant a year after the incidents at issue and suffered another ectopic pregnancy. She claimed no knowledge of discussions regarding the possibility of extrauterine pregnancy before the rupture was diagnosed, despite defendants’ testimony and hospital record entries regarding such discussions.

    Our obstetric expert opined that the patient’s symptoms of lower back pain and blood in her urine with a positive pregnancy test could have been indicative of an early intrauterine pregnancy, a spontaneous abortion, or an ectopic pregnancy. A β-hCG level of 351 miu/mL correlates to a 4-week pregnancy from a woman’s LMP and at that early stage it is impossible to see it on ultrasound due to the minuscule size of the fetal sac, they pointed out. The “discriminatory zone” of β-hCG is the level above which an imaging scan should reliably visualize a gestational sac within the uterus in a normal intrauterine pregnancy. It is not until a β-hCG level reaches 1500–1800 mIU/mL that a gestational sac would expect to be visible with transvaginal ultrasonography (TVUS).

    Next: Was this forceps delivery appropriate?

    The plaintiff ’s β-hCG levels remained well below the “discriminatory zone,” making it impossible to see a fetal gestational sac using TVUS. Because it was too early to see a fetal gestational sac, it was impossible to make the diagnosis of an intrauterine pregnancy or spontaneous abortion, so the physicians appropriately decided to monitor the patient’s β-hCG levels, stressing the signs and symptoms of ectopic rupture that could herald a potentially life-threatening complication and advising the patient of the need to return for medical follow-up.

    When the patient returned on October 28, Dr A examined all of the adnexal structures, carefully inspecting both fallopian tubes, but the ectopic pregnancy was too small to discriminate in the fallopian tubes at that level of development and β-hCG level. Postoperatively, when plaintiff ’s β-hCG levels continued to rise, methotrexate was appropriately administered according to protocol.

    When the patient subsequently returned her levels had risen and she properly underwent exploration, at which time the ectopic pregnancy was identified.

    Resolution

    Armed with expert support, the defendants moved for dismissal prior to trial. While the plaintiff contended that her symptoms should have raised the defendants’ index of suspicion for ectopic pregnancy, their expert could not refute the defendants’ contention through expert affidavit that the β-hCG levels on initial presentation were too low to support anything other than a nonviable pregnancy, whether ectopic or intrauterine.

    In other words, even if the fallopian tube had been explored no viable pregnancy would have been located and thus plaintiff ’s result would have been the same.

    The verdict

    After oral argument before the court, the case was dismissed. The court agreed with the defendants’ experts that given the facts the patient’s result would not have been altered by earlier intervention.

    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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