Failure to test for pregnancy

Presentation

On July 6, a 35-year-old patient came to her ob-gyn for her annual well woman exam.  She reported urinary incontinence with coughing and straining, heavy irregu­lar bleeding while taking birth control pills, and cramping.

Physician action

The ob-gyn performed a pelvic exam, and noted the patient’s last menstrual period (LMP) was June 18. In response to her symptoms, the physician recommended a hysterec­tomy and bladder suspension, which was scheduled in August. 

The patient began seeing the physician 11 years earlier for prenatal and gynecological care. Seven years later the physician removed an IUD because of excessive bleeding, and discussed removal of her uterus if the removal of the IUD did not solve the prob­lem. However, the bleeding ceased and there was no further discussion of a hysterec­tomy. The patient was using a contraceptive pill for birth control. 

On August 22, the patient was admitted to the hospital with diagnoses of stress uri­nary incontinence, menometrorrhagia, and pelvic relaxation. After informed consent was obtained, the ob-gyns performed a hysterectomy. After the patient’s uterus was removed, it was described as “very large, about 12 weeks.” 

The ob-gyn suspected a pregnancy at the time the uterus was removed. He later received a phone call from pathology, confirming the pregnancy. The physician told the patient about the preg­nancy the following morning. 

Allegations

A lawsuit was filed against the ob-gyn, alleging that a hysterectomy was performed without obtaining a preoperative pregnancy test. The hospital was also named in the lawsuit. 

Legal implications

Although the ob-gyn did not feel a pregnancy test was necessary be­cause the patient reported she could not be pregnant, some TMLT consultants and the plaintiff’s expert were critical of the physician for performing a hysterectomy without ordering any type of pregnancy test as part of the preoperative lab work-up. As one reviewer commented, for the menstruating woman of childbearing age, “it is the standard of care to obtain a pregnancy test prior to any gynecologic surgery, especially a hysterectomy surgery, at the time preadmission laboratory studies are obtained.” 

Peer reviewers were also critical of the physician’s discharge summary and the phy­sician’s suggestion that the patient should have known that she was pregnant when she was called and told the date of the surgery. Upon the reviewer’s analysis, the patient had reported and the physician documented that her LMP was June 18. Therefore, on July 6, the patient would not have missed a period, and would not have suspected pregnancy.

In addition, the discharge summary included wording that may have been perceived as inflammatory. The ob-gyn noted the patient’s “hysterical reaction” to hearing about the pregnancy loss as a result of the hysterectomy was “inappropriate” for the situa­tion. Reviewers felt this language blamed the patient for not realizing that she was preg­nant and was accusatory of her behavior when she was made aware of the pre-existing pregnancy. 

Although some defense expert opinions supported the physician, citing that he met or exceeded the standard of care, ultimately the plaintiff’s attorneys argued that the loss of the patient’s unborn fetus and the accompanying pain and suffering were directly and proximately caused by the negligent care she received from the physician. They argued that, based on reasonable medical probability, if the physician had ordered a pregnancy test before performing a hysterectomy, the test would have been positive and the physi­cian would have canceled the surgery. Ultimately, the patient would have had the option to make a decision regarding continuation of the pregnancy. 

Disposition

This case was settled on behalf of the ob-gyn. The pa­tient also settled with the hospital.

Risk management considerations

Although the ob-gyn did disclose the unexpected outcome to the patient and document the conversation, it is suggested that the physicians avoid language in the medical record that may be perceived as negative toward the patient. 

In this case, it was suggested that a pregnancy test could have been ordered on several occasions: at the doctor’s office; with preoperative laboratory testing; and from standing anesthesia orders. Adding a question to the patient encounter forms regarding pregnancy status may prompt physicians regarding risks that may need to be assessed. 

The removal of a pregnant uterus at the time of surgery is an unusual occurrence. Factors such as obesity and the use of birth control pills may make the diagnosis of pregnancy more difficult. Pregnancy testing is advisable when planning gynecological surgery in women of reproductive age.