Case #3087: Negligence During Delivery in Woman With Cholestasis of Pregnancy
On May 28, the Plaintiff was a 31 year old woman who presented to the Defendant, an obstetrician, for her first prenatal visit after a positive home pregnancy test in April. Her last menstrual period was February 25th and her estimated date of confinement was then established as December 2.
On August 30, she returned to the Defendant for follow-up with complaints of itching and scratching for the past week and laboratory work revealed elevated bile acids. The Plaintiff was then diagnosed with cholestasis of pregnancy and referred to a maternal fetal medicine specialist. Cholestasis of pregnancy carries a significantly increased rise of infant mortality in utero if a pregnancy is permitted to proceed past 38 weeks.
On November 8, the Plaintiff saw the Defendant OB/GYN in follow up. He noted that she needed another ultrasound, additional antenatal testing, and needed to be seen by a high risk specialist. On November 11, the Plaintiff saw the Defendant high risk specialist. He agreed that she had cholestasis of pregnancy, discussed with her the increased risk of morbidity and mortality, and noted that although there was no consensus about the timing of delivery, delivery in the early term should be considered since the majority of in-utero demises occur after 37 weeks. He then discussed the case with the Defendant OB/GYN.
On November 14, the Plaintiff saw the Defendant specialist in follow-up at 37-3/7 weeks’ gestation. He noted a breech presentation and informed the Defendant OB/GYN. On November 19th, the Plaintiff saw the Defendant OB/GYN in follow-up at 38-1/7 weeks’ gestation and the baby still was breech with fundal height of 40.5 centimeters and a fetal heart rate of 150 beats per minute.
On November 21, the Plaintiff saw the Defendant specialist in follow-up at 38-3/7 weeks’ gestation and again at 39 weeks’ gestation on November 25. He noted a biophysical profile of 10 out of 10, a breech presentation at each visit and the Plaintiff was instructed to follow-up with the Defendant OB/GYN on November 26th.
On November 26, the Plaintiff saw the Defendant OB/GYN at 39-1/7 weeks’ gestation. On the evening of November 27th, she was admitted to the hospital for cesarean section delivery of her breech baby.
On November 28 at 2:49 a.m., there was a significant deceleration on the fetal monitoring strips from 150 beats per minute to 90 beats per minute lasting 4 minutes during an episode of uterine tachysystole. Amazingly, instead of performing a cesarean section, the Defendants decided to provide close surveillance so that if the fetal status was non-reassuring, a cesarean section would be performed.
Inexplicably, the Plaintiff was sent home on Thanksgiving Day. There was no medical reason to cancel the cesarean section when the Plaintiff had cholestasis of pregnancy, was in a breech position, had fetal distress which had lasted four minutes (confirmed on the fetal monitoring strip), and was told she was having a cesarean section that morning.
The Plaintiff went home as instructed. The Plaintiff was told to follow up on Sunday, December 1st for a cesarean section if she was still in breech position. Tragically, on November 30, she delivered a stillborn male.