This is not an obstetrics issue. This is a gynecological issue.
Plaintiff - Medical/Diagnostic Care with Defendant Doctor, pre-surgery
Plaintiff was referred by her PCP, to Defendant Doctor, GYN oncologist, to evaluate her history of vaginal bleeding during intercourse X3.5 years.
Plaintiff underwent Hysteroscope/D&C on 6/25/2018. Pathology revealed atrophic endometrium.
On 8/20/2018, Defendant Doctor performed a Condyloma Fulguration w/CO2 laser ablation under anesthesia and prescribed Estradiol .01 mg vaginal cream at bedtime, once a day for one month.
Plaintiff returned to Defendant Doctor on 10/04/2019 c/o vaginal bleeding after intercourse with pain on deep penetration. Defendant Doctor prescribed Estradiol Patch .05 mg to be worn 24/7. Defendant Doctor also recommended laparoscopic hysterectomy. Plaintiff agreed with surgery.
On 10/24/2019, Defendant Doctor performed a laparoscopic hysterectomy, bilateral salpingo-oophorectomy.
Plaintiff continued to experience vaginal bleeding after intercourse and ended up going to another GYN who told her that she did not need a hysterectomy and bilateral salpingo-oophorectomy; that Defendant Doctor amputated the last 2 cm of her vagina which did not resolve the vaginal lesion.
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In review of the records, it was confirmed that Plaintiff had normal ovaries, that Defendant Doctor removed 2 cm of her vagina when he surgically removed her cervix and that Plaintiff only consented to the hysterectomy and Bilateral Salpingo Oophorectomy (BSO). Plaintiff had a history of bleeding from a lesion in her vagina for three plus years prior to the hysterectomy and BSO. Defendant Doctor recommended Plaintiff undergo a Robotic Assisted Laparoscopic Hysterectomy and BSO. After the Surgery, Plaintiff continued to experience vaginal bleeding necessitating further medical treatment from Second Doctor.
According to ACOG, a hysterectomy is recommended when the patient has:
• Uterine fibroids (Plaintiff did not have)
• Endometriosis (Plaintiff did not have)
• Pelvic support problems (Plaintiff did not have)
• Abnormal uterine bleeding (Plaintiff did not have)
• Chronic pelvic pain (Plaintiff did not have)
• Gynecologic cancer (Plaintiff did not have)
Plaintiff did have vaginal bleeding due to a lesion in her vagina, and, she had painful intercourse, which is different than chronic pelvic pain. According to this information from ACOG, Plaintiff was not a proper candidate for a hysterectomy and BSO.
ACOG further states that a woman’s ovaries should only be removed if they are abnormal. Plaintiff’s ovaries were normal and Defendant Doctor knew this before he recommended and performed this surgery. Defendant Doctor removed healthy ovaries from a 49 year old woman. The fact that Plaintiff was menopausal is not a basis to perform this surgery.
Finally, ACOG states that you only remove a portion of the patient’s vagina if you are performing a radical hysterectomy. A radical hysterectomy is only performed if the patient has cancer. Per my reading of ACOG standards, Defendant Doctor should not have cut out 2 cm of Plaintiff’s vagina without her knowledge and permission and only then if he suspected cancer. Even after the Defendant doctor surgically removed 2 cm of her vagina during the hysterectomy and BSO, he failed to remove the lesion in her vagina which had been the cause of the history of bleeding from her vagina.
Files:
Q: What evaluation did the patient have prior to surgery to determine where the abnormal bleeding was from?
A: Information updated for case with pre-surgery care. Initial pathology from hysteroscope/D&C revealed atrophic endometrium.
Do you believe there might have been medical error?
From the above notes, the first physician performed a hysterectomy and BSO in an attempt to discontinue this women’s bleeding. He previously performed a procedure that showed she had an atrophic uterus with no evidence of polyps, and therefore no evidence that the uterus was causing her bleeding. I’ll also assume since it’s not stated for the record, that her Pap smear was within normal limits as well. Therefore, a hysterectomy was not needed as there is identified lesion in the vagina which could’ve been handled much differently and did not require the patient undergoing a hysterectomy and BSO procedure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient underwent an unnecessary procedure in attempt to stop bleeding, for which the procedure had a very low likelihood of resolving since a different source i.e. the vaginal lesion had already been identified as the source of bleeding. Interestingly, the chart does not note whether or not a biopsy of this lesion was ever performed to further illicit the nature of the lesion.
What makes you a good expert for this case?
I have had 34 years of general, Ob/Gyn practice and concentrated strictly on Gyn the last several years up until my retirement two years ago. During this time I worked in a academic institution where medical students and residents were under my teaching. it has always been emphasized to these students and residents, that you must identify a specific cause before you go ahead and recommend procedures. Certainly if there is no reason to perform an invasive procedure such as was performed on this woman, then you simply do not do this.
How often do you encounter cases similar to this one in your practice?
Cases like this while not common, were seeing from time to time. It was always important to perform a full work up to make sure that the bleeding source was not within the uterus and cervix or ovaries. Certainly there was an identifiable lesion, such as in the vagina or the vulva region, a biopsy of these would be necessary to certainly rule out cancer.
Do you believe there might have been medical error?
The patient is a 49-year-old postmenopausal woman with bleeding from a condylomatous lesion that recurred after medical therapy. Total abdominal hysterectomy and bilateral supple ectomy, including an attempt of resecting to centimeters of vagina in order to completely remove lesion and surgically treat the Post Cioital bleeding that the patient was experiencing.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I don’t believe there has been any causation.. I think that physician the treating position attended medical therapy and when that failed there was no other option but to proceed with surgical management. What is not clear is where exactly the lesion was. Typically in these cases when there is post coal bleeding, and these lesions are found they are found at the vaginal Fics generally posterior, which would justify of the vagina up to 2 cm in order to remove the lesion and its totality. Sometimes it’s difficult to see the lesion on a laparoscopic or robotic hysterectomy or lesion may have extended postoperative beyond the area of resection. No pathology is provided. Patient ovaries were normal however she was postmenopausal with a trophic endometrium and no estrogen production and therefore there is in fact evidence to support removal of the ovaries in such situations thereby navigating the possibility of ovarian cancer and fallopian tubes as well .
What makes you a good expert for this case?
I am a board-certified OB/GYN and a board-certified reproductive, endocrinologist and fertility specialist with extensive surgical experience over the last nearly 25 years and a good understanding of the anatomy as well as as a board-certified expert and menopausal medicine understand the hormonal environments in a woman who has postmenopausal and the wrist and benefits Play in a situation like this as well as some of the challenges encountered in the operating room in a situation like this.
How often do you encounter cases similar to this one in your practice?
ThI’s is a very unusual case. Condylomas are often seen in our practice and understand how difficult they are to treat medically. Two centimeters of vagina is not significant to create a shortening of the vagina and the fact that it want tested surgically or medically goes to prove how difficult this condition can be to treat.
Do you believe there might have been medical error?
Based on the description given (missing notes or discussion from the defendant gynecologic oncologist), it seems like inadequate justification/rationale/medical indication was given for the planned/performed operation. If a vaginal lesion had been the cause of bleeding, hysterectomy (and certainly the bilateral oophorectomy), is usually not the indicated surgical management. There may be a possibility that the vaginal lesion is inseparable from the cervix, but this is not stated to be the case, and the patient continued to have bleeding afterwards. While hysterectomy for otherwise unexplained abnormal uterine bleeding may be reasonable if all other investigations and management have been exhausted, this does not seem like a case of abnormal uterine bleeding but rather vaginal bleeding - the defendant doctor even performed a vaginal condyloma ablation. In my opinion, the defendant doctor did not provide adequate justification/basis for the operation, at least to the patient and related to the plaintiff's attorney in this case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient ended up undergoing major surgery - total hysterectomy and bilateral salpingo-oophorectomy, in addition to upper vaginectomy - without adequate rationale and without improvement in symptoms - it was an unnecessary surgery; even if recovery were well, the surgery may still have been unnecessary, and the removal of her ovaries - if normal - can be associated with a (admittedly small) increased risk of heart attack/myocardial infarction, stroke and death.
What makes you a good expert for this case?
I am a gynecologic oncologist, 10 years in practice, first 9 focused exclusively on surgical management, and evaluated similar cases and have performed numerous surgeries - hysterectomy, vaginal/cervical lesion ablation, etc, similar to this case.
How often do you encounter cases similar to this one in your practice?
Post-menopausal bleeding a couple of times a week. Vulvovaginal lesion/condyloma every other week or so. I perform about an average of 5 hysterectomies a week
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