Folic acid only

...with pregnancy not explicitly ruled out in the notes, it becomes a case of his word against the patient’s...

A 32-year-old woman attends her GP – Dr H – complaining of nausea and acid indigestion. Dr H had been aware that the woman had a history of urinary tract infections and anaemia for which she had been prescribed iron tablets. He was also aware that she had two previous negative pregnancy tests.

On this occasion Dr H diagnoses reflux oesophagitis for which he prescribes Pariet – a proton pump inhibitor that acts to decrease the production of stomach acid.

One week later the patient returns to the practice complaining of severe abdominal pains and passing vaginal blood and tissue. She suspects that she may be pregnant and having a miscarriage.

Dr H records in his notes: "?Early spontaneous abortion" and calculates that the patient is six weeks pregnant going by her dates. He tells her that at such a date the miscarriage is likely to be complete but should there be further severe pain or heavy bleeding to contact the surgery or go direct to A&E.

Two days later the patient is admitted to hospital with abdominal pain and PV bleeding and it is noted that she was nine weeks pregnant. An ultrasound scan confirms a complete miscarriage and the patient is discharged after the pain and bleeding has settled.

A year later Dr H receives a letter from solicitors acting for the patient claiming medical negligence. The patient alleges that Dr H had been aware of the fact that she might be pregnant and yet had still prescribed Pariet which is contraindicated in pregnancy.

Analysis and outcome

Dr H contacts MDDUS for assistance and strongly refutes the patient’s claim that she discussed the possibility of being pregnant. No mention is made of this in the notes and Dr H states that had pregnancy been mentioned or suspected he would routinely prescribe no drugs other than iron or folic acid.

However, with pregnancy not explicitly ruled out in the notes, it becomes a case of his word against the patient’s.

A solicitor acting for MDDUS examines the file and forms the opinion that the case against Dr H is weak – not just on the disputed timing of the reported pregnancy. The key issue is causation. Guidance on the prescription of Pariet does indicate that it is contraindicated in pregnancy and breast feeding but there appears to be no data linking it with an increased risk of spontaneous abortion. Proving a connection would be difficult on the balance probabilities.

This view is communicated to the patient’s solicitors and a few months later the case is dropped.

Key points

  • Consider the possibility of pregnancy in any woman of child-bearing age to ensure there are no contraindications to prescribing particular drugs.
  • Record asking the question.
  • Evidence most support causation in medical claims.