Patient with diagnosed with placental accreta and HELLP syndrome was scheduled for a C-section/hysterectomy. OB/GYN surgeon made no notations regarding identification or protection of ureters in his operative note, which describes the surgery as otherwise uncomplicated. Patient was subsequently diagnosed with injury to the ureters bilaterally, and physician claims just known risk and complication despite complete absence of evidence of proper identification of ureters during surgery or steps to limit risks of injury to ureters. Surgeon and 2 residents were involved in procedure with no specific recall of who performed what roles during the surgery. Subsequently required stent placement, nephrostomy tube and multiple hospitalizations for UTIs, and kidney/bladder infections
Looking for experience with placental accreta cases
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Q: What was the nature of the injuries?
A: bovie cautery (defense will claim thermal spread)
Do you believe there might have been medical error?
If they have performed a c/hyst at the time of placental accreta with removal of the cervix, ureters must be identified at all times and ureteral injury is possible but identification at the time is critical instead of delayed identification. A supracervical hysterectomy would be more ideal during this time of urgency. Route and mode of hysterectomy is critical. Ureters must be coursed and made sure not dilated.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
it is extremely difficult these cases due to risk of hemorrhage, bleeding, and visualization coupled with extremely narrow space and contracted adjacent tissue to the uterus at the time of surgery. However, if scheduled c/hyst for accrete, bilateral ureteral stents are recommended to be placed prior to surgery. Inexperienced surgeons and lack of preoperative use of urology with increased incidence of ureteral injuries are precursors for causation
What makes you a good expert for this case?
Critical care OBGYN hospitalists-Medical Director Chief of Staff Chief of Peer Review Perform complex cases on a daily basis. actively practicing expert witness experience with multiple cases Just matriculated into law school as well
How often do you encounter cases similar to this one in your practice?
on a routine basis, I encounter such high risk patients on a daily basis from abruptions, unknown accretas, requiring c/hysts
Do you believe there might have been medical error?
First off, a hysterectomy performed at the time of cesarean section is much riskier because of the increased blood flow and engorgement of the tissues due to the pregnancy status. While injury to a single ureter is a significant complication, injury to both ureters gives rise to the question of whether or not simple precautions taken during the surgery were indeed followed. Palpation of the yards, or better still visualization by opening up the broad ligament area, would indeed have prevented this. Finally, it is unknown, whether a cystoscopy was performed after the surgery to further ensure integrity of the ureters.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The ureters, according to the information given, had thermal damage. This indicates that cautery was used in the vicinity of this vital structure. Given her pregnancy status, and knowing the anatomy, Bovie cautery should never have been used in the vicinity of this structure since ligation would be a much more effective method of securing hemostasis without leading to any thermal injury.
What makes you a good expert for this case?
Although retired, I had been an active practice in a teaching hospital with residents for 34 years. I’ve done numerous hysterectomies in addition to several cesarean, planned hysterectomies. The ladder, especially in a setting of placenta accreta, is always advisable to have a multidisciplinary team available such as a oncologic surgeon, and possibly a urologist given the nature of the pregnancy status and the possible complications related to this.
How often do you encounter cases similar to this one in your practice?
Fortunately placenta accreta is a rare instance, and we may see one or two of these a year. Since we also cover the Resident practice, we see a handful of these a year in addition.
Do you believe there might have been medical error?
Ureteral injury is a recognized complication of cesarean hysterectomy for placenta accreta, particularly in complex cases involving HELLP syndrome. Literature reports ureteral injury rates of approximately 1–8% in cesarean hysterectomy for placenta accreta spectrum, substantially higher than those of routine hysterectomy. However, bilateral injury is less common than unilateral injury, though more likely when anatomy is severely distorted, such as when patients have previous surgeries or other indications for scarring (e.g previous pelvic or GI infection). The absence of specific language regarding ureter identification does not prove that ureters were not considered, but detailed documentation is expected, especially in complex surgery and in academic training centers. Determination of whether care met the standard of care requires a comprehensive review of the full medical record, operative details, and clinical context, and cannot be ascertained solely from this clinical vignette.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This case could be difficult to prove in court because ureteral injury is a well-recognized complication of cesarean hysterectomy for placenta accreta spectrum, particularly in complex clinical settings such as HELLP syndrome where distorted anatomy, hemorrhage, tissue friability, and urgency may limit visualization despite reasonable surgical technique. Courts generally require proof not only that an injury occurred, but that the injury resulted from a deviation from the standard of care, rather than from the inherent risks of a high-acuity procedure. Operative notes do not always explicitly document identification of the ureters, even when appropriate surgical awareness was exercised, and defendants may argue that the absence of specific documentation does not establish that proper technique was not employed. Additionally, juries may find persuasive that this surgery represents one of the most technically challenging procedures in obstetrics, often involving altered anatomy and significant bleeding, which increases the likelihood of unavoidable injury even in the hands of experienced surgeons. As a result, distinguishing between a known complication and negligent surgical technique may be more difficult, which is why I answered, "less likely than not."
What makes you a good expert for this case?
I don't perform scheduled Cesarean hysterectomies for accreta, though I do perform cesarean hysterectomies. I'm likely not a great expert for this case but I like answering these questions.
How often do you encounter cases similar to this one in your practice?
As above, I don't do scheduled cesarean hysterectomies.
Do you believe there might have been medical error?
Based on the limited information provided, I believe there was a significant possibility of medical error. While ureteral injury is a known risk during cesarean hysterectomy for placenta accreta, but the posted summary states that the operative note contained no documentation of ureteral identification or protection, even though both ureters were reportedly injured. The case description also notes that the surgeon and residents could not later specify who performed which portions of the surgery. In a complex operation of this kind, careful attention to ureteral anatomy and adequate documentation of key surgical steps would ordinarily be expected. The bilateral nature of the injuries, together with the absence of documentation describing efforts to identify and protect the ureters, raises substantial concern that the standard of care may not have been met.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The reported bilateral ureteral injuries are directly linked to the surgical procedure (cesarean hysterectomy) and are the proximate cause of the patient’s subsequent complications, including the need for stents, nephrostomy placement, recurrent hospitalizations, and infections. These are well-recognized sequelae of ureteral injury. Given the nature and extent of the injuries, and the absence of an alternative explanation, it is highly likely that the surgical event caused the patient’s injuries and downstream complications. Even acknowledging that ureteral injury is a known risk of this procedure, the injuries themselves—and the resulting morbidity—are causally related to the operative course.
What makes you a good expert for this case?
Board-certified OB/GYN with extensive experience in high-risk obstetrics and complex pelvic surgery, including cesarean deliveries and hysterectomy. My clinical practice routinely involves management of obstetric complications such as placenta accreta and hypertensive disorders of pregnancy. I am familiar with the standard of care for surgical technique, identification and protection of pelvic structures such as the ureters, and the expected documentation of these procedures. I also have experience reviewing medical records and providing expert analysis in medico-legal cases, allowing me to evaluate both clinical decision-making and operative documentation in this context.
How often do you encounter cases similar to this one in your practice?
In my practice, I routinely manage high-risk obstetric patients and perform cesarean deliveries, including cases with complex surgical anatomy. In my career spanning 28 years, I've seen, reviewed and managed approximately a dozen or so urologic injuries. In addition to my own practice, I've also served as a peer reviewer for multiple hospitals and I'm well aware as to the standard of care in these cases.
Do you believe there might have been medical error?
The ureters are close to the uterus and with the expansion of the uterus that occurs in pregnancy and postpartum, it is easier to cause injury. Even with careful evaluation of position of the ureters, it remains a risk. This risk cannot really be effectively reduced, even experienced surgeons have this risk.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. It is a known risk of surgery
What makes you a good expert for this case?
I am a practicing full time academic OB/GYN
How often do you encounter cases similar to this one in your practice?
I have had a similar case Cesarean hysterectomy resulted in ureteral injury.
Do you believe there might have been medical error?
Multiple questions need to be addressed. First – was this placenta accreta suspected on prenatal ultrasound, or was this a previously undiagnosed accreta? If suspected prenatally – what was the planning that went into her delivery? Were other surgical specialties included? Specifically, urology and/or gynecologic oncology or other surgical support? Was there multidisciplinary planning? How many weeks was this patient when she delivered? For prenatally suspected placenta accreta spectrum, delivery is generally recommended at 34-36 weeks. I see she developed HELLP syndrome so this may have been an unplanned delivery, but nevertheless, multidisciplinary would have been key. If not suspected prenatally, there may be a standard-of-care issue there depending on what her risk factors were, who she was having scans with (general OB or MFM), and what the images showed. In which case, the doctor would have been in an unplanned cesarean delivery with an unanticipated diagnosis of placenta accreta – by nature, this does not allow for multidisciplinary planning. The question then becomes regarding the OB/GYN and practice environment. Does this OB/GYN practice GYN also? Do they routinely do hysterectomies, or cesarean-hysterectomies? And regarding practice environment, was surgical support available, and if so, would it have been appropriate to call? What was her intraoperative anatomy like? Was a cystoscopy done? Yes, ureter injury is known to be a possible complication of hysterectomy, but measures are generally taken to identify and lateralize the ureter. If this was an unanticipated massive hemorrhage with huge blood loss, surgeons might have been working quickly to stop the bleeding which is acutely life-threatening, in which case there may not be time to safely dissect the sidewall and identify the ureter. If this is a hospital with an OB/GYN residency program, chances are they have other specialties like urology which could have been called if there was an anticipated or recognized issue. But non-recognition sounds like a problem.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Hard to say given the description but at the end of the day, the patient had a cesarean hysterectomy and bilateral ureter injuries. Ureter injuries are a known complication of hysterectomy, but it is not just made known to the patient, it is also known to the doctor, and there are surgical steps to protect the ureter. Particularly with an anticipated placenta accreta, plans can be made ahead of time to minimize risk to the ureters. These include stents or U-caths which can be placed to make the ureters more easily identifiable (Urology would generally do this) to minimize risk of injury.
What makes you a good expert for this case?
I am a maternal-fetal medicine subspecialist and practiced as a general OB/GYN prior to going for MFM fellowship, so have clinical experience as a general OB/GYN managing patients within a larger system. As an MFM, I am primarily involved in inpatient obstetrics / antepartum, as well as maternal consults for, amongst other things, delivery planning, as well as prenatal ultrasound. At my institution (>7,000 deliveries per year), I am Associate Director for Perinatal Quality and routinely review cases in for standard of care. Also work with hospital Quality on quality metrics and higher level root cause analyses.
How often do you encounter cases similar to this one in your practice?
Obstetrical GU tract injuries are rare and thankfully so. They usually involve the bladder. Rarely the ureter. Placenta accreta spectrum – approximately 15-20 per year.
Do you believe there might have been medical error?
The injury itself, without documented distortion of ureters leading to diseased anatomy being the culprit, is likely res ipsa loquitur of medical error. With cesarean hysterectomies, due to distorted anatomy, identification of ureters at time of surgery - whether before or after the hysterectomy is done - should have been done. While fundal accreta and scheduled nature of the cesarean hysterectomy likely means cervix/lower segment was not very distorted, pregnancy overall still likely would have distorted the anatomy and ureters should have been evaluated.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the ureters were not identified during the hysterectomy and were noted to have been injured after, the injury is likely due to unrecognized injury at time of hysterectomy
What makes you a good expert for this case?
I am a gynecologic oncologist at a lage academic center and am routinely involved in placenta accreta cases and cesarean hysterectomies, about a case every 1-2 months.
How often do you encounter cases similar to this one in your practice?
I am a gynecologic oncologist at a lage academic center and am routinely involved in placenta accreta cases and cesarean hysterectomies, about a case every 1-2 months.
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