31 Y/O female presented to ED on 4-21-2023 reporting slight bleeding the day before admission. She took a pregnancy test at home and it was positive. She complained of some pelvic cramping with some mild brown and pink discharge.. At the time she was G3 P1 with one prior miscarriage.
Test results: WBC normal range; HCG Qnt 878.6; Transvaginal Ultrasound: No intrauterine gestational sac seen, no large adnexal masses, corpus luteal cyst in right ovary. Trace fluid in cul-de-sac. No intrauterine or ectopic pregnancy.
-Pt D/C'd with instructions to follow up for repeat hCG on Monday.
-On 4-24-2023 she represents to ED. cx of vaginal bleeding and cramping.
WBC now high @ 11.9
Transvaginal ultrasound demonstrated a ruptured ectopic pregnancy.
The patient was transferred to a women's hospital where she underwent a laparoscopic surgery the findings of which were " Right ovary normal, but right tube enlarged with ectopicpregnancy with partial rupture with dark blood/tissue extruding from distal fimbrlal end. Moderate amount of hemoperitoneum in anterior and
posterior cul de sac, approximately 100cc. Tuboovarian adhesions noted on the right and in the posterior culdesac and side wall. .A salpingectomy was performed. Pathology revealed: "Received in formalin is a 6 cm in length, fimbriated fallopian tube with a width ranging from 1 cm up to 1.9 cm. The fallopian tube is fimbriated and has a pink - purple, glistening serosal surface. The serosa is intact and is covered in a thin pink adhesions. The fallopian tube is serially sectioned to reveal a
dilated, and blood- filled lumen. The lumen has a diameter up to 1.4 cm which is filled with red blood clot and tan-red papillary structures. Papillary structures of the overall measurement of 0.7 x 0.6 x 0.3 cm. No fetal or embryonic parts are identified.
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QUESTION: Is there causation on this matter assuming Vag Ultrasound No. 1 was misread and the tube was not yet ruptured (would the institution of methotrexate, more likely than not have prevented the rupture.
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No questions yet!
Do you believe there might have been medical error?
If the ultrasound report correctly describes what was seen on the U/S images, then there was no indication of an ectopic pregnancy at the time of the study. If the patient is clinically stable, and this is a desired pregnancy, it is reasonable to proceed with expectant management. Also, based on the patient's initial presentation, she would be a candidate for methotrexate if the patient wanted definitive management. Of course, if the U/S was not read properly and there was evidence of an ectopic pregnancy, then this incorrect reading would constitute medical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the initial U/S was misread, this would lead to a delay in diagnosis of an ectopic pregnancy. It does not necessarily mean the misreading would have caused a rupture of an ectopic pregnancy.
What makes you a good expert for this case?
I am a board certified OB/GYN in practice for 16 years. I often encounter cases that involve patient's in early pregnancy when it isn't clear if there is an intrauterine or an ectopic pregnancy.
How often do you encounter cases similar to this one in your practice?
I often encounter cases that involve patient's in early pregnancy when it isn't clear if there is an intrauterine or an ectopic pregnancy.
Do you believe there might have been medical error?
The initial finding of an hCG of 878, is below the threshold, where you would see in intrauterine pregnancy. As such the women’s symptoms did not suggest anything other than what was done properly that is return in three days to reassess. When she returns to the emergency room, the ultrasound suggests a ruptured ectopic pregnancy. There is no indication with the information provided whether or not a repeat hCG was done, whether a hematocrit and hemoglobin were done, or of the woman’s symptoms. The findings at surgery of 100 cc is not a moderate amount of blood. Had this woman been assessed properly, she may have been a candidate to be admitted for observation only.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, based on my reasoning above, surgery may not have been necessary. If the follow-up hCG was declining, and in hospital observation to make sure she was hemodynamically stable for the next 24–48 hours may all that has been necessary. In this case, the tube was removed, and there is no information provided whether or not it was actively bleeding.
What makes you a good expert for this case?
I am retired, but I had 34 years of active practice and was in a residency program where I was actively teaching medical students and residents. I have encountered dozens and Dozens of ectopic, pregnancy cases. Many of these fell in line with the one presented above. Many of these were handled nonsurgically.
How often do you encounter cases similar to this one in your practice?
The one above may present anywhere is from two per month, to three per month, especially when you’re involved in a residency program.
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