Problem pregnancy

...An ultrasound would have revealed an empty uterus and a suboptimal rise in serum beta HCG levels, leading to a diagnosis of ectopic pregnancy...

 

BACKGROUND: Ms G is a 28-year-old web designer and attends her GP – Dr L – complaining of sharp intermittent (3-4 times per week) abdominal pain in the right iliac fossa. Four months ago she came off the pill hoping to conceive with her long-term partner. Dr L records in the notes: Examination and swab for HVS (high vaginal swab). He then advises Ms G to keep a diary of symptoms and return in a few weeks. Results from the HVS are negative for infection and this is communicated to Ms G.

Just over three weeks later Ms G returns to the surgery and advises Dr L that she recently performed a home pregnancy test which was positive and her last period was about six weeks ago. She is still experiencing intermittent pain and has had some brown spotting. Dr L examines Ms G and enquires as to the nature of the pain which she characterises as "shooting" from the epigastrium to the lower abdomen – and unlike normal period cramps. Dr L refers the patient to the midwife for antenatal care and advises her to return if there is increased bleeding and/or abdominal pain, in which case an ultrasound will be arranged.

Two weeks later Ms G makes an emergency appointment at the surgery. She is concerned that there is still bleeding and also her cramps have returned. Dr L examines the patient and records: Not unwell; abdo non-tender. Refer to EPAU [early pregnancy assessment unit] tomorrow am.

But later that afternoon Ms G begins to experience severe abdominal pain and passes brownish vaginal discharge. An ambulance is called and she is taken to A&E with a diagnosis of probable ectopic pregnancy. A scan reveals a large amount of free fluid in the pelvis and Ms G is taken to theatre. Here she undergoes a laparoscopy and is found to have a ruptured left tubal ectopic pregnancy with significant blood loss. A left salpingectomy is performed. She makes a good recovery and is discharged a week later.

A letter of claim is later received from solicitors acting on behalf of Ms G alleging clinical negligence against Dr L. It states that the patient had informed the GP of her positive pregnancy test in the first consultation and that he failed to ask about the date of her last menstrual period (LMP) and order a further pregnancy test. This would have resulted in referral to an early pregnancy assessment unit (EPAU) and diagnosis, avoiding the later need for surgical intervention.

It is further alleged that Dr L failed to adequately examine the patient in the second consultation, including taking blood pressure and pulse readings to establish whether she was haemodynamically stable. Referral for an ultrasound scan should also have been undertaken and failure to do so constituted a breach of duty.

The letter also alleges that at the third consultation Dr L again failed to assess if the patient was haemodynamically stable and arrange an immediate referral to an on-call gynaecologist, given the persistent spotting and cramps at eight weeks pregnancy.

ANALYSIS/OUTCOME: MDDUS commissions a report from a primary care expert in regard to the alleged breach of duty of care. The expert points out that given the patient’s dates it would be very unlikely that Dr L had been informed of a positive pregnancy test at the first consultation. Most over-the-counter tests will only detect a pregnancy 4-6 days prior to the next expected period. A further pregnancy test would not have been indicated at this stage. However, the expert is critical of Dr L in failing to record a detailed gynaecological history (including LMP) and examination findings.

In regard to the second consultation the expert is again critical of Dr L’s failure to record detailed examination findings and he questions whether such findings might have proved significant in deciding whether Ms G needed an urgent referral, although it is unlikely that the patient would have displayed any clinically significant signs of blood loss at this time. In regard to the third consultation and the need for referral to an on-call gynaecologist (rather than waiting for an EPAU assessment the next morning), the expert notes that Ms G did not appear acutely unwell so an urgent (same-day) referral might not have been warranted in the circumstances.

An expert report is also commissioned from a consultant in obstetrics and gynaecology in regard to causation (consequences of the breach of duty). He states that had an early referral been made an ultrasound scan would have revealed an empty uterus and a suboptimal rise in serum beta HCG levels, leading to an eventual diagnosis of ectopic pregnancy. This would have prompted treatment with either methotrexate or laparoscopy prior to the tubal rupture.

Given these vulnerabilities in the legal defence, an offer of settlement is made by MDDUS on behalf of Dr L.

KEY POINTS

  • Record menstrual history (if relevant) in all gynaecological conditions.
  • Do not discount pregnancy, no matter how unlikely.
  • Do not neglect to record history and examination findings.