In 2010, client had a miscarriage and had a septum in her uterus that was surgically corrected. She also had a history of uterine fibroids and cysts. She had two IVF egg retrievals and 4 embryo transfers. Client had 1 c-section prior to the incident.
On December 3, 2024, she had a c-section for placenta previa. There was manual removal of the placenta & notes indicate it was intact. EBL was 620 ml. There isn’t a surgical pathology of the placenta although notes indicate “Prepare to send placenta tor histology following delivery, as indicated.” Rather, it looks like the placenta was sent to the “registry.” There isn’t a surgical pathology of the placenta although notes indicate “Prepare to send placenta tor histology following delivery, as indicated.” Rather, it looks like the placenta was sent to the “registry.”
No signs & symptoms of placenta accreta post-delivery. She had diffuse upper abdominal pain with distention on post-operative day (POD) #1 that resolves by POD #2. Discharged on POD #3.
On December 15, 2024, she was admitted with c/o vaginal bleeding since 0545 hours. An US was done and Misoprostol ordered. She was discharged at 1238 hours with instructions to return for heavy bleeding. At 1845 hours, she returned with heavy vaginal bleeding & was taken to the OR for laparoscopic D & C, but she continued to bleed excessively. Procedure changed to an exploratory laparotomy. Uterus was boggy, globular, not involuted since delivery. Supracervical hysterectomy done.
Files:
Q: What were the ultrasounds of the placenta previa prior to C-section showing? Any signs of a creta? What did the ultrasound prior to the diagnostic laparoscopy show?
A: —
Q: Why does she believe she had placenta accreta? Did the operative note indicate anything such as an adherent placenta?
A: —
Do you believe there might have been medical error?
Up to 50% of placenta accreta spectrum cases go undiagnosed until delivery or postpartum, even in patients with known risk factors such as placenta previa and prior cesarean delivery. Delayed postpartum hemorrhage from unrecognized placenta accreta spectrum can occur days after delivery and may require emergency hysterectomy. When placenta accreta spectrum is not diagnosed before delivery or during delivery, and the placenta appears to deliver completely at cesarean without hemorrhage, the clinician is going to have low index of suspicion for accreta.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the placenta delivered intact, and there was no hemorrhage at delivery, the likelihood of delayed hemorrhage due to placenta accreta is low. Not zero, but very low. We do give patients hemorrhage precautions when they leave the hospital. However, the standard of care was met in this case. While unfortunate, this was not a deviation. Furthermore, if accreta had been diagnosed at delivery, there was a high likelihood that the same outcome, hysterectomy, would have been recommended. Difficult to say that damages are necessary when the same outcome would have occurred.
What makes you a good expert for this case?
Full time OBGYN hospitalist for 13 years; 6 years of full scope practice prior. Have reviewed over 400 cases; expert for medical board, experience with case reports, depositions and trials.
How often do you encounter cases similar to this one in your practice?
This is a rare occurrence. I have not encountered this exact scenario, though I have had many patients re-present in the postpartum period with bleeding that we assume, based on clinical history to be likely due to focal accreta. The decision at that point has always been for IR embolization, but if severe enough or patient unstable, hysterectomy would be indicated.
Do you believe there might have been medical error?
A non uncommon clinical occurrence Pathology from the uterus would be critical to review
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above comment. The pathology is needed.
What makes you a good expert for this case?
I am a board certified OBGYN and Gyn oncologist An obstetrician should also review it
How often do you encounter cases similar to this one in your practice?
See above. As a Gyn Onc I get called in for these cases.
Do you believe there might have been medical error?
Pathology reports of either the original placenta or more importantly the hysterectomy would be helpful. Patients with prior uterine manipulation/procedures can be at higher risk of placenta accreta spectrum disease. Based on description of c-section, given that the placenta could be removed and there was no excess bleeding seen, clinically it does not appear to have been a significant accreta - would otherwise hemorrhage at that time. Maybe there was focal accreta. At the second surgery - if the bleeding is thought to be due to uterine involution (uterus not contracted down to stop bleeding), that alone could explain the hemorrhage. Placenta accreta should not cause bogginess of the uterus per se. Pathological examination of the uterus, which must've been done, likely can answer whether or not there was focal accreta. Even if there were focal accreta, however, if it were not bleeding, it can be difficult to justify the standard treatment for accreta, which is hysterectomy.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above; pathological examination would tell us if there was accreta in the first place, and management based on intraoperative findings at time of c-section seems justified as there was not increased blood loss/hemorrhage at time of surgery based on description.
What makes you a good expert for this case?
Gynecologic oncologist with 11 years of experience, actively involved with accreta team at large academic center
How often do you encounter cases similar to this one in your practice?
As a gynecologic oncologist actively involved with our accreta team, I am involved in placenta accreta spectrum disease cases about once a month or so
Do you believe there might have been medical error?
In the case of placenta accreta, the placenta is difficult if not impossible to remove at delivery. This was not the case for this patient. Also, if placenta accreta had been present at time of delivery, it may have been necessary to perform a hysterectomy to prevent excessive bleeding. Hysterectomy would be considered appropriate management of heavy bleeding due to accreta. Pathology of her uterus after hysterectomy would indicate whether there was evidence of placenta accreta.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
In the case of placenta accreta, the placenta is difficult if not impossible to remove at delivery. This was not the case for this patient. Also, if placenta accreta had been present at time of delivery, it may have been necessary to perform a hysterectomy to prevent excessive bleeding. Hysterectomy would be considered appropriate management of heavy bleeding due to accreta. Pathology of her uterus after hysterectomy would indicate whether there was evidence of placenta accreta.
What makes you a good expert for this case?
I am a board certified OB/GYN with 19 years of clinical experience
How often do you encounter cases similar to this one in your practice?
Placenta accreta cases are rare in my practice.
Do you believe there might have been medical error?
I do think the placenta should’ve been sent at the time of C-section. Before we make additional assumptions, it would be probably useful to see the prenatal ultrasounds. Also detail details from the ultrasound that was completed on the day of re-admit.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It’s hard to say there are sometimes people who have uterine aneurysms that unfortunately, even after normal sewing up of the uterus after this section, just continue to bleed and fill up the uterus with blood, causing bogginess and atony
What makes you a good expert for this case?
I have been in this career for 10 years
How often do you encounter cases similar to this one in your practice?
This should be a rare event so not overly often. The timeline is a little strange that she showed up more than a week after with bleeding… perhaps there were some placenta retained even though that the op note said removed intact.
Do you believe there might have been medical error?
With the information provided, there is no indication that there was placenta accreta. This is something that can often be seen on imaging during the pregnancy, and then at delivery (especially during a cesarean section, when you can actually visualize and feel the adherence of the placenta).
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is no indication based on the information provided that a medical error occurred. The placenta was noted as being intact. She was managed appropriately when she returned days later with bleeding.
What makes you a good expert for this case?
As a board-certified obgyn, I have performed thousands of c-sections over the past 15 years, including those with previously undiagnosed accretas. I am well aware of the unpredictable nature of obstetric hemorrhage, including delayed hemorrhage, as well as the management options.
How often do you encounter cases similar to this one in your practice?
Delayed obstetrical hemorrhage is not very common, but c-sections are. I am not currently practicing obstetrics but when I did, accretas were and are also quite rare.
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