Presentation
A 28-year-old pregnant woman came to an obstetrics clinic for prenatal care on April 27. Routine labs and sonogram were performed. The sonogram images were unclear, but showed the possibility of twins.
Physician action
On May 18, the patient returned to the clinic to consult with an ob-gyn, who told the patient the sonogram indicated that the twins were monochorionic diamniotic — identical twins who shared a placenta but not an amniotic sac. This discussion was not documented.
During follow-up visits on June 15 and July 13, sonograms were performed, but the findings were not documented.
On July 29, at 20 weeks gestation, the patient returned and a complete sonogram was performed. The cervix was 2.8 cm (normal is 2.5), two sacs were seen, and one placenta seen. There was no recorded disparity between the twins in terms of anatomy, heart rates, or amniotic fluid.
The patient was referred to a maternal fetal medicine specialist (MFM) for consultation in two weeks. The patient claimed she was unaware of this appointment, until she received a reminder card in the mail.
On August 9, the patient called the ob-gyn’s clinic and reached the after-hours answering service. She reported pain, abdominal tightness, and constipation. The medical assistant who took the call recommended over-the-counter laxatives and instructed the patient to go to Labor and Delivery if pain persisted. The phone conversation was not documented or relayed to the ob-gyn.
On August 18, the patient went to the MFM, who conducted a comprehensive ultrasound exam. Twin A’s amniotic fluid was severely increased and Twin B’s amniotic fluid was absent. Twin-to-twin transfusion syndrome (TTTS) was diagnosed. The MFM recommended ablation of the communicating vessels.
The MFM told the patient that if she began having contractions before the ablation that amnio-reduction would be necessary. He wanted to avoid amnio-reduction before intrauterine surgery due to the risk of premature rupture of the membranes.
On August 19, the patient was admitted to the hospital for an ablation procedure. She was at 22 weeks gestation, and was experiencing intermittent contractions. An ultrasound indicated massive polyhydramnios and the cervix was completely effaced with dilation of approximately 1 cm. The patient had short cervical length at 9 mm with very little cervical tissue.
That day, a maternal amnio-reduction surgery was performed. Regular uterine contractions and leakage of amniotic fluid were noted. The cervix was dilated 2 cm and the membranes were 80% effaced. Selective termination of one of the twins was discussed with the patient and her husband, but this option was declined. The patient continued experiencing contractions following apparent rupture of membranes.
On August 23, the patient was transferred to Labor and Delivery for initiation of delivery. Twin A died 43 minutes after delivery and Twin B died approximately five minutes after delivery.
Allegations
A lawsuit was filed against the ob-gyn and the clinic. Allegations included:
- failure to provide proper medical treatment and to monitor the patient every two weeks;
- delay in referring the patient to a specialist;
- failure of the clinic to properly conduct and perform ultrasounds;
- negligence in allowing a medical assistant to act as a nurse and provide medical advice during an after-hours call; and
- failure to recognize symptoms from the August 9 phone call that ultimately resulted in the death of the twins.
Legal implications
The plaintiff’s experts stated that the patient should have been seen every two weeks, and that a referral to an MFM should have occurred earlier in the patient’s care. They felt that had TTTS been diagnosed earlier, this outcome might have been avoided. Experts for the defense felt that the ob-gyn met the standard of care, and that the outcome was unavoidable.
Consultants on both sides felt the documentation by the clinic and physician was inadequate. There were multiple visits where the ob-gyn did not make any notes or initial the chart. There was no documentation indicating that the patient was advised of the appointment with the MFM. Also, the phone call on August 9 was not logged or relayed to the physician.
Plaintiff’s experts were also critical of the clinic for allowing an MA to triage after-hour phone calls. There were no written protocols or procedures to assist the MA when taking call. In addition, the clinic commonly referred to MAs as “nurses.” The patient testified that the MA identified herself as a nurse during the August 9 phone call, and she considered the advice given to be a prescription from the physician.
Disposition
The case was settled on behalf of the ob-gyn and the clinic.
Risk management considerations
Twin pregnancy has high risk for complications. Monochorionic twins share a fetoplacental circulation. This puts them at risk for complications — such as TTTS — which can be lethal or associated with serious morbidity. (1)
Fully educating patients about all risks associated with twin pregnancies is recommended. In addition, a referral to a maternal fetal specialist may be warranted. Any education or referral information discussed with the patient should be clearly documented.
Lack of documentation was a significant weakness in this case. All prenatal forms should be filled out according to guidelines provided by the American Congress of Obstetricians and Gynecologists (ACOG).
In addition, documenting after-hour calls — including any instructions given to the caller or patient — may be of great assistance to a physician in the event of a claim. All patient calls must be relayed to the treating physician so that any changes in a patient’s condition are identified and necessary follow up is started.
Medical liability claims often involve mistakes or omissions by office staff. Medical advice provided by either an unlicensed staff member or a licensed staff member acting beyond his or her scope of expertise could be construed as practicing medicine without a license. A telephone triage protocol is recommended when speaking with patients.
It can be confusing when a physician’s office does not differentiate between MAs and nurses. If an MA allows patients to think he or she is a nurse, the patient may make health care decisions they would not make otherwise. Also, a nurse has the education and background to recognize conditions that an MA might not.
The Texas Occupations Code states that, unless a person holds a nursing license, a person may not use the title “nurse,” or any other designation tending to imply that the person is licensed to provide nursing care. (2) Doing so can be considered false representation of training and licensure.
Sources
1. Chasen ST, Chervenak FA. Twin pregnancy: Prenatal issues. UpToDate. May 10, 2017. Available at https://www.uptodate.com/contents/twin-pregnancy-prenatal-issues. Accessed August 2, 2017.
2. Texas Occupations Code. Subchapter F. License Requirements; Section 301.251. License Required. Occupations Code. Title 3. Health Professions. Subtitle E. Regulation of Nursing. Chapter 301. Nurses. Subchapter A. General Provisions. Available at http://www.statutes.legis.state.tx.us/Docs/OC/htm/OC.301.htm. Accessed August 2, 2017.
