Failure to treat pregnancy-induced hypertension
A 41-year-old woman came to Ob-Gyn A for care during her second pregnancy. The patient’s history included chronic hypertension and lupus anticoagulant syndrome. Seven years earlier, the patient had a premature cesarean delivery due to pregnancy-induced hypertension.
Failure to treat pregnancy-induced hypertension
A 41-year-old woman came to Ob-Gyn A for care during her second pregnancy. The patient’s history included chronic hypertension and lupus anticoagulant syndrome. Seven years earlier, the patient had a premature cesarean delivery due to pregnancy-induced hypertension.
Presentation
A 41-year-old woman came to Ob-Gyn A for care during her second pregnancy. The patient was at 13 weeks’ gestation at this visit.
The patient’s history included chronic hypertension, obesity, and lupus anticoagulant syndrome. Seven years earlier, Ob-Gyn A performed a premature cesarean delivery on the patient due to pregnancy-induced hypertension (PIH).
Physician action
Ob-Gyn A noted that the patient’s blood pressure was being managed by her primary care physician. The patient had been taking hydrochlorothiazide, but it was changed to labetalol and nifedipine due to her pregnancy. Ob-Gyn A also noted that the patient was on heparin and aspirin for lupus anticoagulant. At this visit, the patient’s blood pressure was 142/94 mm Hg.
Ob-Gyn A referred the patient to a Maternal-Fetal Medicine (MFM) physician due to chronic hypertension and advanced maternal age. The patient’s blood pressure continued to be elevated during her visits with the MFM physician, ranging from 126/86 mm Hg at 17 weeks to 142/94 mm Hg at 29 weeks.
An ultrasound at 29 weeks showed the fetus was in the breech position. The patient’s blood pressure was slightly elevated at visits from 30 to 35 weeks. At 36 weeks, it was 150/96 mm Hg.
On the morning of June 3, at 36 weeks and four days, the patient was admitted for a cesarean delivery due to PIH. Ob-Gyn B, who was on call for Ob-Gyn A during admission, evaluated the patient for high blood pressure. The patient had been given 20 mg IV labetalol and Ob-Gyn B ordered an additional 40 mg and repeat BP in 10 minutes. The patient reported a stress headache, but denied blurry vision, shortness of breath, or right upper quadrant pain. Ob-Gyn B documented that pre-eclampsia labs were pending.
Ob-Gyn A performed a cesarean delivery the same day. There were no complications reported. The newborn’s APGAR scores were 8 and 9.
In the first 24 hours after the cesarean delivery, the patient’s blood pressure ranged from 80/93 to 172/100 mm Hg. She was seen by Ob-Gyn C, who restarted labetalol 200 mg/twice a day that had not been restarted after delivery.
During the second postoperative day, Ob-Gyn C’s plan was routine care with discharge planning that included increasing labetalol to 300 mg and restarting enoxaparin. In response to the patient’s increasing blood pressure, Ob-Gyn C started the patient on nifedipine. Her blood pressure range was 176/88, 172/100, and 171/88.
The patient was discharged on June 6 (postoperative day 3). Ob-Gyn C documented that the patient was in good condition and was instructed to follow up in two weeks for an incision check. Her discharge medications included nifedipine XL 90 mg two tablets by mouth for 30 days with two refills; labetalol 200 mg; and enoxaparin 40 mg daily for six weeks. The patient’s blood pressure at discharge was 139/83 mm Hg.
The patient saw Ob-Gyn A on June 23 for a two-week postpartum check. The patient’s blood pressure was not documented, and Ob-Gyn A said she tried to enter the BP values into the EHR system but was unable to.
At her six-week postpartum check on July 18, the patient saw Ob-Gyn C. The physical exam found no issues with her heart and lungs; no edema in extremities; and no tenderness or pain on abdominal or genital exam. The patient was told to return in one year for a well-woman exam. Her blood pressure was 128/78 mm Hg. There was no documentation that the patient was instructed to follow up with her primary care physician for management of her blood pressure and there was no mention of her blood pressure medication or that it was refilled recently.
Two weeks later, the patient was found unresponsive at home. EMS transported her to the emergency department of a large metropolitan hospital. Resuscitative efforts were unsuccessful and the patient died. The cause of death was listed as dilated cardiomyopathy associated with hypertensive cardiovascular disease.
Allegations
A lawsuit was filed against Ob-Gyns A, B, and C. The allegations were failure to diagnose and manage the patient as a high-risk pregnancy due to chronic hypertension and pre-eclampsia and failure to treat the patient’s hypertension in the prenatal and postnatal periods.
Legal implications
The plaintiff’s ob-gyn expert criticized the defendants for failure to diagnose and classify the patient as a high-risk pregnancy with chronic hypertension and severe superimposed pre-eclampsia. This expert claimed the patient should have been given magnesium sulfate before delivery and for a minimum of 24 hours after the delivery. Further, a cardiology consult should have been ordered and an echocardiogram obtained to determine the patient’s cardiac function. The expert stated that failure to do so was a violation of the standard of care and led to cardiovascular decompensation resulting in cardiac arrest and death.
Defense experts who reviewed this case stated that the patient’s death was the result of a sudden cardiac event that could not have been predicted. There was no evidence to suggest that the defendants failed to meet the standard of care. Ob-Gyn A promptly referred the patient to MFM and monitored her closely to ensure she was taking her blood pressure medications. The patient was treated appropriately in the hospital with blood pressure medications and delivery was timely and appropriate. The patient did not exhibit signs or report symptoms of pre-eclampsia and there was no reason to give magnesium sulfate or request a cardiology consult and echocardiogram. Further, the patient did not report any symptoms during the postpartum period that were consistent with cardiomyopathy or heart failure post cesarean delivery.
The defense of this case was challenged by documentation issues. Ob-Gyn A’s notes contained numerous mistakes relating to the patient’s medical history, including misidentifying the patient’s anticoagulation condition and misstating the number of pregnancies. There was no documentation of the type of chronic hypertension the patient had. Ob-Gyn A also did not write an order after the delivery to restart the patient’s blood pressure medications.
The hospital records did not indicate that the patient had a primary care physician, though Ob-Gyn A assumed the physician who had prescribed the patient’s medications before her pregnancy was her PCP. There was no correspondence between this physician and Ob-Gyn A. There was no documentation that the patient was told to return to this physician after the delivery for management of her blood pressure medications.
Ob-Gyn A’s clinic was using two separate EMR systems when the patient was seen for this pregnancy. This made it difficult to retrieve all the patient’s records during the investigation of this case.
Disposition
This case was settled on behalf of Ob-Gyn A. The case against Ob-Gyns B and C was dismissed.
Risk management considerations
The continuity of care in this case between Ob-gyns A, B, and C was severely impeded by poor documentation. If a case proceeds to trial, a jury might be unable to determine if physicians are in good communication if that communication is not properly documented, including recommendations, decision-making, and rationale.
The defense of this case may have been helped if the defendant physicians had followed the following documentation best practices:
- fully document all patient-provider and provider-provider communications, including prescription orders, test results, information shared, and decisions made;
- fully document informed consent discussions with the patient or the patient’s guardian (was this patient informed and fully aware of the consequences of chronic hypertension during pregnancy and the importance of her medications and following up with her PCP?);
- maintain detailed records of all provider-to-provider consultations; the records in this case did not include the name or any consultation notes with the patient’s PCP; and
- avoid using multiple EMR systems; if you are using more than one system (such as during a transition from one EMR to another), regularly audit and ensure that EMR records are synced and contain up-to-date and contemporaneous information. This may necessitate consulting with your EHR/EMR vendor or IT professional.
Disclaimer
Presentation
A 41-year-old woman came to Ob-Gyn A for care during her second pregnancy. The patient was at 13 weeks’ gestation at this visit.
The patient’s history included chronic hypertension, obesity, and lupus anticoagulant syndrome. Seven years earlier, Ob-Gyn A performed a premature cesarean delivery on the patient due to pregnancy-induced hypertension (PIH).
Physician action
Ob-Gyn A noted that the patient’s blood pressure was being managed by her primary care physician. The patient had been taking hydrochlorothiazide, but it was changed to labetalol and nifedipine due to her pregnancy. Ob-Gyn A also noted that the patient was on heparin and aspirin for lupus anticoagulant. At this visit, the patient’s blood pressure was 142/94 mm Hg.
Ob-Gyn A referred the patient to a Maternal-Fetal Medicine (MFM) physician due to chronic hypertension and advanced maternal age. The patient’s blood pressure continued to be elevated during her visits with the MFM physician, ranging from 126/86 mm Hg at 17 weeks to 142/94 mm Hg at 29 weeks.
An ultrasound at 29 weeks showed the fetus was in the breech position. The patient’s blood pressure was slightly elevated at visits from 30 to 35 weeks. At 36 weeks, it was 150/96 mm Hg.
On the morning of June 3, at 36 weeks and four days, the patient was admitted for a cesarean delivery due to PIH. Ob-Gyn B, who was on call for Ob-Gyn A during admission, evaluated the patient for high blood pressure. The patient had been given 20 mg IV labetalol and Ob-Gyn B ordered an additional 40 mg and repeat BP in 10 minutes. The patient reported a stress headache, but denied blurry vision, shortness of breath, or right upper quadrant pain. Ob-Gyn B documented that pre-eclampsia labs were pending.
Ob-Gyn A performed a cesarean delivery the same day. There were no complications reported. The newborn’s APGAR scores were 8 and 9.
In the first 24 hours after the cesarean delivery, the patient’s blood pressure ranged from 80/93 to 172/100 mm Hg. She was seen by Ob-Gyn C, who restarted labetalol 200 mg/twice a day that had not been restarted after delivery.
During the second postoperative day, Ob-Gyn C’s plan was routine care with discharge planning that included increasing labetalol to 300 mg and restarting enoxaparin. In response to the patient’s increasing blood pressure, Ob-Gyn C started the patient on nifedipine. Her blood pressure range was 176/88, 172/100, and 171/88.
The patient was discharged on June 6 (postoperative day 3). Ob-Gyn C documented that the patient was in good condition and was instructed to follow up in two weeks for an incision check. Her discharge medications included nifedipine XL 90 mg two tablets by mouth for 30 days with two refills; labetalol 200 mg; and enoxaparin 40 mg daily for six weeks. The patient’s blood pressure at discharge was 139/83 mm Hg.
The patient saw Ob-Gyn A on June 23 for a two-week postpartum check. The patient’s blood pressure was not documented, and Ob-Gyn A said she tried to enter the BP values into the EHR system but was unable to.
At her six-week postpartum check on July 18, the patient saw Ob-Gyn C. The physical exam found no issues with her heart and lungs; no edema in extremities; and no tenderness or pain on abdominal or genital exam. The patient was told to return in one year for a well-woman exam. Her blood pressure was 128/78 mm Hg. There was no documentation that the patient was instructed to follow up with her primary care physician for management of her blood pressure and there was no mention of her blood pressure medication or that it was refilled recently.
Two weeks later, the patient was found unresponsive at home. EMS transported her to the emergency department of a large metropolitan hospital. Resuscitative efforts were unsuccessful and the patient died. The cause of death was listed as dilated cardiomyopathy associated with hypertensive cardiovascular disease.
Allegations
A lawsuit was filed against Ob-Gyns A, B, and C. The allegations were failure to diagnose and manage the patient as a high-risk pregnancy due to chronic hypertension and pre-eclampsia and failure to treat the patient’s hypertension in the prenatal and postnatal periods.
Legal implications
The plaintiff’s ob-gyn expert criticized the defendants for failure to diagnose and classify the patient as a high-risk pregnancy with chronic hypertension and severe superimposed pre-eclampsia. This expert claimed the patient should have been given magnesium sulfate before delivery and for a minimum of 24 hours after the delivery. Further, a cardiology consult should have been ordered and an echocardiogram obtained to determine the patient’s cardiac function. The expert stated that failure to do so was a violation of the standard of care and led to cardiovascular decompensation resulting in cardiac arrest and death.
Defense experts who reviewed this case stated that the patient’s death was the result of a sudden cardiac event that could not have been predicted. There was no evidence to suggest that the defendants failed to meet the standard of care. Ob-Gyn A promptly referred the patient to MFM and monitored her closely to ensure she was taking her blood pressure medications. The patient was treated appropriately in the hospital with blood pressure medications and delivery was timely and appropriate. The patient did not exhibit signs or report symptoms of pre-eclampsia and there was no reason to give magnesium sulfate or request a cardiology consult and echocardiogram. Further, the patient did not report any symptoms during the postpartum period that were consistent with cardiomyopathy or heart failure post cesarean delivery.
The defense of this case was challenged by documentation issues. Ob-Gyn A’s notes contained numerous mistakes relating to the patient’s medical history, including misidentifying the patient’s anticoagulation condition and misstating the number of pregnancies. There was no documentation of the type of chronic hypertension the patient had. Ob-Gyn A also did not write an order after the delivery to restart the patient’s blood pressure medications.
The hospital records did not indicate that the patient had a primary care physician, though Ob-Gyn A assumed the physician who had prescribed the patient’s medications before her pregnancy was her PCP. There was no correspondence between this physician and Ob-Gyn A. There was no documentation that the patient was told to return to this physician after the delivery for management of her blood pressure medications.
Ob-Gyn A’s clinic was using two separate EMR systems when the patient was seen for this pregnancy. This made it difficult to retrieve all the patient’s records during the investigation of this case.
Disposition
This case was settled on behalf of Ob-Gyn A. The case against Ob-Gyns B and C was dismissed.
Risk management considerations
The continuity of care in this case between Ob-gyns A, B, and C was severely impeded by poor documentation. If a case proceeds to trial, a jury might be unable to determine if physicians are in good communication if that communication is not properly documented, including recommendations, decision-making, and rationale.
The defense of this case may have been helped if the defendant physicians had followed the following documentation best practices:
- fully document all patient-provider and provider-provider communications, including prescription orders, test results, information shared, and decisions made;
- fully document informed consent discussions with the patient or the patient’s guardian (was this patient informed and fully aware of the consequences of chronic hypertension during pregnancy and the importance of her medications and following up with her PCP?);
- maintain detailed records of all provider-to-provider consultations; the records in this case did not include the name or any consultation notes with the patient’s PCP; and
- avoid using multiple EMR systems; if you are using more than one system (such as during a transition from one EMR to another), regularly audit and ensure that EMR records are synced and contain up-to-date and contemporaneous information. This may necessitate consulting with your EHR/EMR vendor or IT professional.
Disclaimer
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