Case Archive
 
OB/GYN
Ref. # 196501

A 32-year-old woman was admitted at 37 weeks gestation with ruptured membranes and mild contractions. The course of labor was uneventful and augmented with Pitocin. A low forceps delivery was performed on a 7 lb. 11 oz. girl. The mother had no episiotomy but endured a third degree laceration which was repaired. In subsequent weeks she suffered from progressively worsening perineal pain, dyspareunia, and a substantially narrowed vaginal introitus. The OB/GYN stated he could not enlarge the introitus and instructed the patient to be careful with intercourse and use lubrication. Five months after the birth she had a small tissue granuloma removed. This provided no relief and the patient sought advice from another physician, who noted on examination a severely constricted vaginal introitus secondary to previous repair of third degree laceration, as well as the absence of the inferior portion of the left labium majus. A perineal revision was performed along with a reconstruction of the tissue planes so that the vaginal introitus was much less tightened. A medQuest OB/GYN reported the repair of the third degree laceration was substandard and clearly contributed to the patient's dyspareunia and anatomic abnormality.

OB/GYN
Ref. # 52587

In a Federal case, a 24-year-old G4 P2 woman with one spontaneous abortion presented to a neighborhood health center for prenatal care. She had a grandmother with diabetes but no history herself. Her previous two deliveries were uneventful. She smoked one pack per day and drank alcohol occasionally. Routine bloods and a sonogram were performed, confirming a 16.3 week pregnancy. At 18 weeks a fuller medical history was a taken and a physical exam was performed. The provider noted the family history of diabetes but did not order a work-up or a Maternal Serum Alpha-Fetoprotein (MSFAP). At 22 weeks the woman was found to be doing well and required a glucose challenge test four weeks later. At 30 weeks the glucose challenge test reported 212 mg/dl. At 32 weeks the woman was found to be spilling 3+ glucose in her urine--the first positive dipstick of the pregnancy. Fasting blood sugar was 163 md/dl. The provider ordered a 3-hour Glucose Tolerance Test (GTT) and gave the patient a copy of an 1800-calorie ADA diet. At 34 weeks the woman's random blood sugar was 135 mg/dl and her urine glucose was negative. She was told to return after an overnight fast for the 3-hour GTT, which was performed eight days later. She was found to have yeast vaginitis. GTT results were: FBS-112; 1 hour-240; 2 hour- 337; 3 hour-223. There is a note that the woman was to go to a high-risk clinic due to the elevated GTT values. The woman returned for her scheduled follow-up visit at 36 weeks. No fetal heart tones were found. She was transferred to a major medical center, where the fetus was ruled an intrauterine demise. The woman was induced with an Oxytocin drip. Her sugars were followed and remained elevated. Her urine toxicology screen was positive for marijuana. Labor was uneventful and vaginal delivery took place in less than 10 hours. The delivery was notable for shoulder dystocia. The placenta was noted to be large, consistent with a diabetic pregnancy. The discharge diagnosis was intrauterine demise at 37 weeks and 2 days due to gestational diabetes mellitus. The autopsy found a 3825 gram female, large for gestational age but without congenital anomalies. Three medQuest OB/GYN experts independently reported that virtually none of the established standards of care for the outpatient management of gestational diabetes were followed. There was a failure to admit the woman to a hospital for glucose control when her fasting blood sugar was 163/mg and a 1-hour glucose challenge test was 212. The woman did not need the 3-hour test, done several weeks later, to confirm the obvious. She had class B diabetes and required insulin. Furthermore, no nutritionist spoke to the patient and no arrangements were made to begin home glucose monitoring. The only monitoring performed was a random glucose test two weeks later at a clinic visit. The woman should have been referred for antepartum surveillance. A non-stress test should have begun at 32 weeks gestation. For a less than compliant patient, hospitalization for rapid control and teaching best achieves therapeutic goals. There was no indication that heightened surveillance as an outpatient was even attempted until it was too late. With appropriate treatment, the fetus would have had an excellent chance of survival and a healthy life. The mother would likely have reverted to a euglycemic (normal blood sugar) state.

OB/GYN
Ref. # 84138

A Pennsylvania woman underwent a total abdominal hysterectomy and suffered ureteral damage. Her attorneys questioned the delay in diagnosing this complication. A medQuest OB/GYN reported a pre-op IVP was recorded as showing normal anatomy of the urinary tract. Negligence included failure to immediately investigate blood-tinged urine during the surgery. Additionally, there were no post-op records that the ureters had been properly protected or checked for patency.

OB/GYN
Ref. # 92828

A 29 year old Illinois woman was admitted in excellent health for a repeat Cesarean section. During the procedure the patient was given two two-gram doses of Cefotan. Post-op she experienced nausea, vomiting, itching and diaphoresis, which was documented by the nursing staff. She was given another two-gram dosage of Cefotan and complained of nausea. Post-op recovery was uneventful and the patient was discharged. Eleven days later at home, she experienced heavy bleeding, general weakness, and numbness in her arms. She phoned the OB/GYN, who diagnosed hypoglycemia. The next day the patient was sicker, pale, and jaundiced. The OB/GYN directed the woman to the hospital lab, where testing showed a hemoglobin count of 5.1 grams, a 7.3 decrease from the post-op count. The patient was sent to the maternity ward, where an ultrasound revealed a hypoechoic mass (hematoma vs. abscess) anterior to the uterus. The OB/GYN was notified of difficulty in cross-matching blood for transfusion due to unexplained antibodies with a positive coombs. The patient spiked a temperature of 102.2 and was given two grams of Cefotan. Shortly thereafter she experienced restlessness, shortness of breath, nausea and vomiting. Her agitation increased and she was transferred to the ICU, where she was intubated. The patient died four and a half hours later. A medQuest OB/GYN found negligence in several areas. The patient's initial post-op reaction was classic hypersensitivity to Cefotan. Post-op, the diagnosis of hypoglycemia was incorrect and should have been made only after ruling out more important pathologies. There was no attempt to diagnose the patient's bleeding, weakness and numbness. The blood bank was never notified of the patient's cephalosporin exposure. During the patient's return to the hospital, timely consults did not occur. There was a needless delay in transferring the patient to the ICU, where the attending critical care physician failed to recognize and treat a critical anaphylactic reaction to cephalosporin. Throughout the woman's treatment, the nursing staff negligently contributed to the failure to diagnose Cefotan allergy, with potential liability on the part of the blood bank as well. The patient's death was preventable.

OB/GYN
Ref. # 47258

A 21 year old Kentucky woman at 40 weeks gestation was diagnosed in early active labor at three centimeters dilatation. The membranes were artificially ruptured and Pitocin infusion was instituted. A nine pound infant was delivered by outlet forceps over a midline episiotomy. Recovery was uncomplicated and the patient was discharged two days after admission. Six weeks later the patient returned to the OB/GYN for a postpartum appointment, where a defect in the rectum was found. A surgeon diagnosed complete obliteration of the distal half of the rectovaginal septum and anterior division of the anal sphincter muscle. The patient required a sphincteroplasty with additional skin flap reconstruction. A medQuest OB/GYN reported the attending OB/GYN negligently failed to identify the muscle injury through a digital rectal exam post-delivery, which would have enabled timely repair. The patient's subsequent surgery and potential complications were preventable.

OB/GYN
Ref. # 45028

A 38 year old South Carolina woman with a history of bilateral mastectomy for fibrocystic disease and hysterectomy for endometriosis consulted her OB/GYN for abdominal pain. A pelvic ultrasound showed a 6 cm cystic lesion in the left pelvic region. A laparotomy with bilateral salpingo-oophorectomy was suggested, with a working diagnosis of endometriosis. The surgery was documented as uneventful. For several days post-op, the patient experienced persistent nausea and an episode of disorientation, and she ran a low-grade fever. Treatment included a Fleet enema, Rocephin, antibiotics and suppositories. The fever resolved and the patient was discharged with prescriptions for Lortab, Flagyl and Keflex and instructions to see the OB/GYN in 12 days. Three days later patient presented to the ER with abdominal swelling, nausea, dizziness and pain. After work-up and surgical consult, the patient was transferred to the CCU. An exploratory laparotomy showed a large defect in the lower sigmoid colon and dense adhesions between the omentum, bowel and pelvic structures. A sigmoid colostomy was performed. For ten days the patient ran a febrile, critical course and was transferred to another medical center, where she was found to be in septic shock with hypodynamic hemodynamics and acute respiratory failure. An abdominal exam showed an open wound leaking charcoal through the inferior part of the incision. After additional surgeries and complications, the patient was discharged. Later that month she was readmitted with acute respiratory failure and bilateral pulmonary infiltrates. After two months of hospitalization, she suffered respiratory arrest and died three days later. A medQuest OB/GYN opined the initial laparotomy was unnecessary. Standard of care required a complete pre-op bowel prep due to suspected adhesions. The bowel injury should have been recognized intra-op. There was a negligent failure in post-op care, in light of the patient's fever and elevated white blood count, and discharge was inappropriate. With appropriate diagnosis and treatment, the patient's complications and subsequent death would have been prevented.

OB/GYN
Ref. # 82428

A 35 year old Pennsylvania woman, G1 P0, underwent uneventful prenatal care including amniocentesis, Level 2 ultrasound, and blood work. She presented to the hospital two hours after contractions began. Her membranes were intact, she was 4-5 centimeters dilated, and 100% effaced, in active labor. The attending OB/GYN ordered IV sedation. An hour later IV pitocin was commenced, followed by spinal fentanyl. Eight minutes later a vaginal exam and artificial rupture of the membranes was performed with a small amount of clear fluid. Contractions were occurring ever 60-90 seconds with good intensity. Pitocin was increased by the OB/GYN in three ten-minute intervals. Fetal monitor strips showed variable heart rate decelerations. Twenty minutes later the patient was encouraged to push, as she was fully dilated. A pediatric neonatal resident was called for back-up and noted that the pattern of late decelerations continued and the mother was still on pitocin. The baby was at +2 station. The head of the infant was delivered; shoulder dystocia was obvious. McRobert's maneuver, suprapubic pressure, and an enlargement in the episiotomy did not produce delivery. The Woods Cork Screw maneuver helped release the anterior shoulder from behind the symphysis. Vacuum extraction was applied and the infant was finally delivered. His injuries included: brachial plexus injury, phrenic nerve damage, Horner's Syndrome and perinatal diaphragmatic paralysis. A medQuest OB/GYN opined it was negligent to increase the pitocin drip with shorter intervals than standard in view of the good labor progress. The pitocin increase led to a rapid first stage of labor in a case of relative cephalopelvic disproportion, which in turn led to fetal distress, manifested by decelerations caused by abnormal uterine contractions. In light of relative cephalo-pelvic disproportion, the attending OB/GYN negligently performed a mid-pelvis vacuum extraction and contraindicated fundal pressure. Finally, excessive force was applied with head traction and in the wrong axis before using the Woods maneuver. The multiple deviations from the standard of care led to the infant's complications.

OB/GYN
Ref. # 82708

A 23 year old Michigan woman delivered her second child by C-section. After four days, during which she ran a low-grade fever, she was discharged. No antibiotics were prescribed. Four days later she returned for her first post-partum exam with no complaints. The staples were removed, the incision looked good. Later at home she began bleeding heavily and phoned the OB/GYN, who advised her to call an ambulance and go to the ER, which she did. After a vaginal exam she was admitted with a diagnosis of late postpartum hemorrhage secondary to subinvolution. Medication included Methergine and antibiotics. An ultrasound ruled out retained products or pelvic hematoma. Hgb dropped from 9.1 to 6.7 by the next morning, when she was discharged with prescriptions for iron and Methergine. Two days later she returned to the OB/GYN, who renewed both prescriptions and advised strict bed rest. On returning home, she began bleeding heavily and was rushed to the ER. An ultrasound showed clots in the uterus. Admitting diagnosis was retained products vs. subinvolution. She was transfused due to orthostatic hypotension and Hgb of 5.5. The attending OB/GYN, an associate of the woman's OB/GYN, performed a D & C. Pathology on the curettage revealed gestational endometrium with scattered muscle bundles. Diagnosis was narrowed to subinvolution. During the next four days the patient experienced several episodes of bleeding. There are conflicting accounts of physician/patient discussions of various procedures to stop the bleeding. Ultimately, the attending OB/GYN performed a TAH. Pathology report showed a .5 cm tissue defect along the horizontal C-section incision with necrotic/gangrenous tissue. The defect was attributed to wound breakdown. A medQuest OB/GYN found negligence on the part of both OB/GYN's in various areas. No wound infection or other source of the patient's low fever was found, and there was continued uterine bleeding, yet a diagnosis of endometritis was not entertained. The D & C was not indicated, as the patient had a C-section where the uterus was easily explored. The D & C disrupted the T-shaped uterine incision, which was already disrupted by endometritis. There was no attempt to control the bleeding through hypogastric artery ligation or embolization. With appropriate care, the patient would not have required a hysterectomy, resulting in uterine and reproductive preservation.

OB/GYN
Ref. # 46058

A Florida woman was admitted to a hospital for a total abdominal hysterectomy and bilateral salpingoophorectomy. Only the right ovary was removed. Four months later the left ovary required removal; the patient developed adhesions which required further surgery. A medQuest OB/GYN reported that the treating OB/GYN documented the need for the removal of both ovaries, yet proceeded to remove the more normal appearing ovary while leaving in the abnormal appearing one. The incorrect surgery was performed, followed by apparent misrepresentations in the patient's records. Furthermore, the patient required Lupron and possibly other medications one year prior to admittance. Such treatment may have shrunk the tumors in the ovaries and prevented the surgeries.




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