Beyond routine clinical and lab data analysis concerning prenatal and postpartum obstetrical care, infection-related scenarios and other unexpected complications can arise, posing serious risks and emotionally fraught treatment options to be discussed with patients. Such situations impact the prospective management plan in significant ways.
The following two case studies, which went to trial, outline relevant patient management issues from the perspective of both maternal health and fetal well-being.
Case One: Prenatal Issues
At 22 weeks and three days of gestation, with ongoing appropriate prenatal care, a patient presented with advanced cervical effacement and dilatation, bulging membranes, and initial — although irregular — contraction activity. Notwithstanding the absence of generalized maternal sepsis per lab data and examination, a non-specific infection was the differential diagnosis for the onset of labor. Amniocentesis revealed a negative Gram stain analysis. The mother was appropriately counseled concerning termination of the pregnancy but rejected this plan. Management by cerclage and tocolytic therapy was not indicated, given the progressive status of the cervix. Both obstetric and neonatal practitioners predicted a high risk to the mother’s health as well as severe fetal neurologic complications; notwithstanding these discussions, the mother decided to proceed with the pregnancy.
Bed rest and monitoring ensued over four days in an attempt to achieve more fetal maturity. The mother never exhibited a septic state; the high-risk maternal team did not advise broad-spectrum antibiotics, given the risk of resistant infectious strains (and the nonidentification of a specific organism). A vaginal birth took place at 23 weeks gestation. The amniocentesis culture finally grew out Fusobacterium two days after the birth. This organism has been related to poor maternal oral hygiene, with the amniotic site potential for clinical infection. The pathology analysis of the placenta confirmed an acute chorioamnionitis.
The mother left the hospital without any treatment for the “infection,” but unfortunately the newborn was ultimately diagnosed with severe neurologic complications and was hospitalized for six months.
Case Two: Postpartum Issues
Following a routine vaginal delivery, with an intact placenta as described in the delivery record, a patient presented to the emergency room 10 days after delivery with a life-threatening postpartum hemorrhage. The attending obstetrician considered retained placental tissue and related infection as the cause. The patient’s clinical state — pale, dizzy, with tachycardia — and the accompanying laboratory data — a markedly reduced hematocrit — confirmed the extent of the blood loss.
Initial counseling included an indicated hysterectomy, but given the patient’s desire to maintain future childbearing status, a conservative plan of dilatation and curettage, and uterine packing for its tamponade effect, was undertaken. Embolization of the uterine arteries was to be performed within 24 hours of the packing procedure. The aforementioned significant blood loss caused disseminated intravascular coagulopathy. The hospital record described the cervical tissue as “friable;” during the necessary manipulation, poor consistency and separation of the tissue were noted.
During the packing procedure, vaginal, uterine and bladder tissues were compromised per multiple lacerations. The tears in these tissues necessitated investigation within 24 hours. An exploratory laparotomy revealed significant bladder lacerations, which required extensive repairs. The original planned hysterectomy then became a reality.
Both fact patterns raised liability questions at trial and were successfully defended before a jury. In case one, the extreme prematurity of the newborn was unavoidable; maternal health had to be balanced against the benefits of a few extra days of fetal growth. In case two, the significant obstetrical and urologic injuries were unavoidable in an effort to temporize before the ultimately unavoidable hysterectomy surgery.
These cases raised significant emotional issues, in addition to analysis of obstetrical standards of care. The key to the successful defense was demonstrating to the jury that the treatment options were thoroughly discussed with the patients and that given the choices made, the injuries for which the patients later brought suit against the physicians could not have been prevented.
Bruce G. Habian is a Senior Trial Partner at Martin Clearwater & Bell LLP who specializes in the defense of severe infant neurological injuries. Habian is a Fellow of the American College of Trial Lawyers.