A 34 year old woman was brought to the hospital after home delivery of a term infant.

She had a retained placenta and was soon booked for manual removal and D&C in the OR.

The anesthesiologist went to evaluate her.

There was also around 200ml of visible blood in the sheets.

After a brief discussion with the obstetrician the patient was brought quickly to the OR where she received a general anesthetic.

Hemodynamics seemed to stabilize throughout the procedure.

The D&C lasted only 19 minutes.

However, at the end of the procedure her blood pressure acutely worsened to 70/40 with a HR of 110.

As extra help came the patient was resuscitated with blood, albumin, and crystalloid.

BP was slow to improve.

Uterotonics were given, there was minimal blood from the vagina.

A pelvic ultrasound was done and even a FAST scan performed.

It remained unclear why she was hypotensive.

An hour passed - she was still in the OR.

3U PRBC had been given, the HCT was 27.8.

Another hour - the team was still resuscitating her and deciding what to do with her.

Several OB/GYNs and anesthesiologists were present.

Her systolic pressures ranged from 70-90s.

Discussions were had:

After several more PRBCs she was brought to the ICU intubated with a diagnosis of postpartum hemorrhage.

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She arrived to the ICU at 17:30 and would be there for several hours.

Here is a collection of some ICU times, blood pressures, temperatures, and heart rates.

After several hours of further worsening despite massive transfusion, the OB/GYN brought her back to the OR along with a general surgeon for an exploratory laparotomy.

A large retroperitoneal hematoma was found and an emergency hysterectomy performed.

However, the bleeding still was not controlled.

Vascular surgery was emergently called.

The vascular surgeon arrived.

Soon after clamping the patient went into cardiac arrest.

She was resuscitated several times, but died in the operating room.

On specimen exam the aorta had evidence of dissection.

The patients husband sued the team involved including the anesthesiologist.

Here are the allegations against the anesthesiologist.

An OB/GYN expert was hired who criticized the D&C, and the decision to bring her to the ICU.

The plaintiff’s attorney also hired an anesthesiology/ICU expert.

The defense hired an anesthesiology expert of their own.

Here are the medical examiners findings regarding vasculature.

Learn from malpractice cases that other anesthesiologists have faced.

Identify common medicolegal pitfalls so that you can be prepared for when you are sued.

One of the involved OB/GYNs has had roughly 20 malpractice claims against him.

He lost his license in one state, and required remedial mentorship in another. Below is a warning letter from the North Carolina Board.

Outcome

The case was settled for $3 million dollars.

The hospital paid the settlement, all physicians were dropped.

MedMalReviewer Analysis

1. This case was complicated by the fact that it was a home delivery and EMS noted blood all over the floor. The physicians involved were unsure how much blood the patient had lost prior to the OR. She was first seen to be hypotensive during anesthesia consent. The blood pressure pre op at this time was 76/65. The team thought it must be a postpartum hemorrhage, and expected her to improve with resuscitation. A reasonable thought early on. This was an otherwise normal pregnancy in a healthy patient.

2. Notice the plaintiff’s expert points out how the anesthesiologist did not request additional consults or tests, and went along with what the OB had to say. While he raised concerns verbally, he deferred to OB, and that does not save him here. There may be some who feel ordering CTs or involving other surgical services is a surgical decision. In the context of this case this is a team based decision, and you are going to share the liability for the outcome. A CT was discussed once in the ICU, but she was deemed too unstable to travel.

3. She was hypotensive from the start. I do not believe a D&C caused an aortic injury as the plaintiff OB expert describes. Something was off right from the beginning. As I am sure many readers are aware, aortic dissection has been described during labor and delivery.

4. The lengthy malpractice history and medical board letters against the OB were not a good look. At trial the plaintiff’s attorney will attempt to bring this up to jurors (although the defense will argue that it is not relevant to this case and attempt to ban mention of his past). He is difficult to defend given the previous malpractice cases spread out over many states, loss of a state license, his requirement for remediation, and a letter of concern from a medical board. Jurors will not be sympathetic to this physician. They may even see it as their societal duty to hand him a guilty verdict. Worsening the matter is a very sympathetic plaintiff… the father of a newborn who lost his wife in childbirth. I am not surprised this case did not go to trial and settled instead.