by Sara Bergmanson, Digital and Social Media Specialist, and
Jennifer Templin, Risk Management Representative
Presentation
A 58-year-old woman came to Ob-gyn A for treatment of postmenopausal vaginal bleeding and dysmenorrhea. The patient’s history included obesity, gastric bypass surgery, and right-sided salpingo-oophorectomy. Both surgeries occurred more than 10 years before coming to Ob-gyn A.
Physician action
Ob-gyn A performed an ultrasound that indicated a thickened endometrial lining, which had a normal biopsy, and a uterine fibroid around 2.5 centimeters in diameter. A repeat sonogram and uterine cuttings were benign and consistent with polyps. Treatment with hormonal therapy was unsuccessful.
The patient and Ob-gyn A discussed the risks and benefits of a robotic-assisted total laparoscopic hysterectomy, left salpingo-oophorectomy, and cystoscopy for dysmenorrhea and uterine fibroids. They also discussed non-surgical management and non-treatment as alternatives. The patient agreed to proceed with surgery, and it was scheduled for December 29.
Upon performing the surgery, Ob-gyn A found dense adhesions in the abdomen making trocar placement difficult and converted the procedure to an open laparotomy. Surgery was further complicated by bleeding at the omentum from the failed trocar placement. Additionally, an enterotomy of the small bowel was discovered and repaired.
Before completing the surgery, Ob-gyn A inspected the abdomen, pelvis, and bowel. It was documented that the bleeding stopped and the bowel repair was intact. No other injuries were identified.
At 7:45 p.m. that night, nurses notified Ob-gyn A that the patient was experiencing tachycardia and an EKG was abnormal. At 5:15 a.m. on December 30, the nurses reported concerns about the patient’s blood pressure to the on-call physician, Ob-gyn B. Ob-gyn B ordered a 1-liter bolus of lactated Ringer’s.
By 7:41 a.m. the patient had not improved, and Ob-gyn B contacted Ob-gyn A. At this time, a phlebotomist came and drew labs according to sepsis protocols.
While Ob-gyn A was waiting for lab results, the patient became more hypotensive, tachycardic, and oliguric. Her white blood cell count increased to 16,000 and her creatinine level increased to 2.5. Her estimated blood loss was documented as 1,500 cc leading to concerns of hypovolemic shock.
Intensivist A was consulted, and the patient was transferred to the ICU. Intensivist A suspected septic shock and acute renal failure. Vasopressors were started, and radiology studies indicated a possible bowel injury and free air.
Records regarding the patient’s previous gastric bypass surgery were obtained, revealing she suffered postoperative complications and had a prolonged recovery. (It is believed that this is the cause for the adhesions found in the laparoscopic procedure.)
Ob-gyn A, accompanied by a general surgeon, took the patient back to the OR on December 31. Several other injuries to the patient’s small intestines were found including three perforations within the duodenum, an injury to the Roux limb (jejunum), and three more enterotomies. A large mesenteric defect causing ischemic injury to the transverse colon was also discovered. Additionally, the patient’s gastrointestinal anatomy was significantly distorted, and a bariatric surgeon was consulted. Bowel resections and enterotomy repairs were needed to restore her intestinal tract.
Due to severe amount of edema within the intestines, her abdominal wall could not be closed, necessitating seven more returns to the OR for washouts and re-inspections. The patient became septic and showed signs of respiratory and renal failure. It was felt her condition was terminal and a DNR order was given by her spouse. She died after two weeks in the hospital.
Allegations
The patient’s family filed claims against both Ob-gyn A and Ob-gyn B. It was alleged the hysterectomy was unnecessary and negligently performed. Multiple injuries went unrecognized, leading to a delay in treatment causing sepsis and death.
Legal implications
Weaknesses in Ob-gyn A’s judgment and performance were noted by both plaintiff and defense consultants. It was felt that this patient was not a good candidate for laparoscopic surgery because her prior bariatric surgery had distorted her anatomy. An open procedure would have been more appropriate.
Further harming the defense were questions of whether this patient needed a hysterectomy. Other less invasive treatment options were available, such as dilation and curettage with hysteroscopy or polypectomy.
Had Ob-gyn A obtained copies of the operative reports or more detailed historical information from the patient’s prior surgeries, they could have revealed that she had an increased risk for surgical complications. Obtaining an MRI or CT to become more familiar with the patient’s anatomy may have also indicated the need for an alternative course of treatment.
It was also argued that Ob-gyn A fell below the standard of care for not consulting with a general surgeon during the hysterectomy on December 29. Ob-gyn A failed to fully evaluate the bowel before closing the abdomen and multiple injuries to the bowel were not seen.
Postoperatively, there was a delay in returning the patient back to the OR and seeking a general surgery consult. Ob-gyns A and B were both criticized for not returning to the patient’s bedside and checking her vital signs, even after learning she was under the hospital’s sepsis protocol.
However, the actions of Ob-gyn B were more defensible as the on-call physician who was unaware of the patient’s history and bowel perforation. Ob-gyn B ordered a fluid bolus and quickly alerted Ob-gyn A when it did not have the desired effect.
Disposition
The case against Ob-gyn A was settled and the case against Ob-gyn B was dismissed.
Risk management considerations
As in this case, patients experiencing postmenopausal bleeding should be encouraged to seek treatment with their Ob-gyn for an evaluation.1 Understanding a patient’s medical, family, and social history can assist the physician in the evaluation process and help determine the best treatment options — and what treatments to avoid. Document all relevant patient information that may determine a course of treatment in the patient’s chart.
During discussions with patients about treatment options, risks, and benefits for surgical procedures — including no treatment and non-surgical management — it can be beneficial to supplement your discussion with educational handouts or website links so patients can read information about the procedures discussed. Patients may feel overwhelmed by receiving potentially stressful information. Providing them with written information gives them an opportunity to review it later and often. This way, patients can make a more informed decision based on your conversation and the literature you provide. Document these discussions and any educational materials provided to the patient in the encounter notes. If you use outside resources for educational material, review the material thoroughly to ensure you agree with the information before sharing it with your patients.
In this case, the patient had a body mass index (BMI) of 49, which put her in a category of “extreme obesity.”2 While every surgical procedure carries risk, these risks can be increased in an extremely obese patient. According to the American College of Obstetrics and Gynecologists, “adverse effects after gynecologic surgery, such as surgical site infection, venous thromboembolism, and wound complications, are more prevalent in obese women than in normal-weight women.”3 In addition, the patient had substantial complications after her bariatric surgery that made performance of another abdominal surgery more challenging. A thorough review of those complications might have affected the choice of treatment. Such considerations should be given when having the surgical procedure consent discussions with patients before surgery and documented as such in the patient’s chart.
Sources
1. Auguste TC. Bleeding After Menopause Could Be a Problem. Here’s What to Know. The American College of Obstetricians and Gynecologists. October 2020. Available at https://www.acog.org/womens-health/experts-and-stories/the-latest/bleeding-after-menopause-could-be-a-problem-heres-what-to-know. Accessed March 17, 2022.
2. BMI Chart. National Heart, Lung, and Blood Institute. US Department of Health & Human Services. Available at https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi_tbl.pdf. Accessed March 24, 2022.
3. Gynecologic Surgery in the Obese Woman. The American College of Obstetricians and Gynecologists. Available at https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/01/gynecologic-surgery-in-the-obese-woman. Accessed March 24, 2022.
Sara Bergmanson can be reached at sara-bergmanson@tmlt.org.
Jennifer Templin can be reached at jennifer-templin@tmlt.org.
