Category Maternal Wrongful Death

In this blog, I’ll be reviewing the incidence of cardiovascular disease (CVD) in pregnancy, and postpartum.  Additionally, I’ll present a case presentation in an effort for the reader to reflect on the learned knowledge from the blog post in the context of the presented case. I’ll also address the challenges associated with diagnosing CVD in pregnancy, and postpartum, while highlighting the signs, and symptoms as well as risk factors for CVD. In closing, I’ll conclude with key takeaways.

Incidence: Cardiovascular disease (CVD) is one of the leading causes of maternal mortality in the United States accounting for >33% of all pregnancy-related deaths in the U.S.  One of every three intensive care admissions in pregnancy, and the postpartum period are related to CVD. CVD is under-recognized in pregnant, and postpartum women with rates higher among African-American women.

It’s estimated that 25% of deaths caused by cardiovascular disease in pregnancy or during the postpartum period may have been prevented if CVD had been diagnosed earlier.  Only a small fraction of women who die from CVD have a known diagnosis of CVD prior to death.  The majority of women who die from CVD present with symptoms either during pregnancy or after childbirth

CMQCC, 2017. CARDIOVASCULAR DISEASE IN PREGNANCY AND POSTPARTUM TOOLKIT

Diagnostic Challenges and Signs/Symptoms: Signs, and symptoms of normal pregnancy, and postpartum mirror CVD making it difficult to diagnose.  This is due to the normal physiological changes that occur in pregnancy, and the postpartum period.  However, a diagnosis of CVD should be suspected when symptoms are severe (see red flags below) with vital sign abnormalities, and underlying risk factors.  Having an increased awareness of the prevalence of CVD, and a high index of suspicion, along with preconception counseling, and referral to a higher level of care can prevent adverse maternal outcomes. 

CMQCC, 2017. CARDIOVASCULAR DISEASE IN PREGNANCY AND POSTPARTUM TOOLKIT

Risk Factors: Risk factors for the development of CVD in pregnancy, and postpartum include polycystic ovary syndrome, infertility, adverse pregnancy outcomes such as hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and intrauterine growth restriction. 

Key Takeaways:

• Symptoms related to the normal physiological changes of pregnancy should improve in the postpartum period.
• The highest risk period for CVD worsening is between 24-28 weeks of pregnancy or postpartum.
• Emergency Room visits for dyspnea (shortness of breath) should heighten suspicion level for CVD.
• Postpartum dyspnea or a new onset cough should heighten suspicion for CVD.
• New onset asthma is rare in adults.
• Bilateral crackles are likely related to congestive heart failure (CHF).
• Bilateral infiltrates on chest x-ray may be due to heart failure rather than pneumonia.
• Hypertension and diabetes in pregnancy increases the risk of CVD.
• Healthy lifestyle changes can reduce future CVD risk by 4-13%.

References:

ACOG, 2019. Pregnancy and heart disease.

AHA, 2020. Cardiac arrest in pregnancy in-hospital ACLS algorithm.

AWHONN, 2023. Obstetric patient safety ob emergencies workshop, 3^rd ed.

CMQCC, 2017. Cardiovascular disease in pregnancy and postpartum toolkit.

P.S. COMMENT AND SHARE: What is your experience with cardiovascular disease in pregnancy or in the postpartum period?  Have you been involved in an adverse outcome as a result of a CVD diagnosis, or failed diagnosis?

Learning From Lawsuits: Verdict Review – Wrongful Maternal Death Case Involving Preeclampsia,

In an effort to help improve maternal health outcomes, we need to be open minded to learning from lawsuits, and implementing necessary change in an effort to prevent recurrence.

In this blog, I’ll be discussing preeclampsia.  I’ll review symptoms of preeclampsia, as well as the incidence, and I’ll introduce a lawsuit involving a maternal death as a result of severe preeclampsia.  In closing, I’ll identify key clinical takeaways regarding the standard of care specific to timely diagnosis, treatment, and follow up when caring for women with a diagnosis of preeclampsia.

Preeclampsia Definition: Preeclampsia is a disorder of pregnancy associated with a new onset of hypertension, which can affect every body organ.  The onset occurs after 20 weeks of pregnancy;  It can also develop in the weeks after childbirth.  Symptoms can include:

• swelling of the face or hands
• headache that will not go away with rest, hydration, Tylenol
• seeing spots or changes in eyesight
• pain in the upper abdomen or shoulder
• nausea and vomiting (in the second half of pregnancy)
• sudden weight gain
• difficulty breathing

A woman with preeclampsia whose condition is worsening can develop “severe features”. Severe features include:

• low number of platelets in the blood
• abnormal kidney or liver function
• pain in the upper abdomen
• changes in vision
• fluid in the lungs
• severe headache
• systolic pressure of 160 mm Hg or higher or diastolic pressure of 110 mm Hg or higher

Incidence: preeclampsia complicates up to 8% of pregnancies globally.

• Annually, 16% of global pregnancy related deaths can be attributed to hypertensive disorders.
• In the U.S., between 2017-2019, hypertensive disorders caused 6.3% of pregnancy related deaths. 

Case Facts: The plaintiff’s decedent was a 34-year-old who was hospitalized at Samaritan North Hospital due to preeclampsia at 36 weeks gestation.  The patient was under the care of a board-certified family physician who had minor privileges to deliver uncomplicated pregnancies.  The family physician saw the patient in her office for a routine prenatal visit.  At that time, the patient reported a headache and cough.  The patient’s blood pressure was increased from her baseline to 130/90, and she had a 6.8-pound weight gain since her last visit.  The patient was advised to return to the office in two weeks.  Two days later, the patient contacted her family physician, and reported vaginal bleeding and a headache.  The family physician instructed the patient to go to the emergency room.  The patient was subsequently admitted with a diagnosis of a potential placental abruption.  An ultrasound revealed oligohydramnios (decreased amniotic fluid for gestational age), intrauterine growth restriction, and a Grade II placenta (some placental calcification/hyperechoic areas).  During the patients admission she experienced repeated high blood pressures, headaches, variable, and late decelerations, an abnormal D-Dimer reading, and a drop in her platelet count.  Five days later, the patient was discharged from the hospital and advised to go to M. Valley Hospital to obtain an ultrasound.  That same evening, the patient called the family physician, and reported vomiting, abdominal pain, and headaches.  The family physician reportedly instructed the patient to call her back in one hour which she did, and was told to go to the hospital.  Upon arrival to the hospital the patients’ blood pressure was 128/103, and 155/100.  The patient was allegedly grimacing, complaining of a headache, was vomiting and had facial edema.  The family physician ordered the patient to be admitted for observation. Approximately six hours following the patients arrival to the hospital, she was found with her head hanging over the bed, having vomited, and in an obtunded state.  The emergency response team was called, and an obstetrician who was physically on the unit was called to evaluate the patient.  The obstetrician ordered magnesium sulfate, and hydralazine.  The obstetrician diagnosed the patient with eclampsia, and immediately transported her to the operating room for delivery of her baby boy by cesarean section.  The patient remained unresponsive.  A CT scan confirmed a massive intracranial hemorrhage.  A brain scan was subsequently performed which showed lack of brain flow, and the patient was pronounced dead. 

Plaintiff’s Allegations: The plaintiffs’ counsel contended that the family physician egregiously deviated from the accepted standards of medical care.  The lawsuit further claimed that the family physician materially misrepresented to the patient that she was experienced and trained in the treatment of all her obstetrical conditions, and fraudulently concealed from her that her ability to practice obstetrics was restricted to minor obstetrics in accordance with the Samaritan North Hospital policy.  The lawsuit also claimed that the family physician was guilty of constructive fraud, was inadequately trained and inexperienced to treat the patient, and abandoned her patient by failing to adequately diagnose, and treat her condition or refer her to an obstetrician who could provide treatment to her. 

Defendant’s Allegations: The defense argued that the family physician met the standard of care applicable in this case.  The defense pointed to the fact that the family physician was credentialed to practice obstetrics at Samaritan Hospital.  Also, the defense contended that the patient’s blood pressures were never sustained, and never reached a level that would require a consult with an obstetrician before the event occurred.  The defense maintained that the family physician did consult with a board-certified obstetrician, and maternal fetal medicine specialist who ordered continuous antepartum testing, and induction at 39 weeks, and that the family physician appropriately instructed the patient to return to the hospital for monitoring.  The defense argued that the patients complications, and death were unforeseeable.  The defense argued that the patient never had an eclamptic seizure, and that she never met criteria for preeclampsia.  Additionally, the defense argued that the evidence demonstrated that, more likely than not, this was a ruptured aneurysm in a patient with a family history of stroke.    

Physical Injuries Claimed by Plaintiff: The patient allegedly died from complications of preeclampsia that caused a major intracranial hemorrhage. 

Gross Verdict (Award): The jury found that the negligence of the family physician, and the private practice was a direct, and proximate cause of the patients death.  The jury awarded compensatory damages of $6,067,830.10, which included loss of support from earning capacity of the patient; loss of services; loss of society including companionship, consortium, care, assistance, attention, protection, advise, guidance, counsel, instruction, training, and education suffered by the surviving spouse, children, parents, and next of kin; mental anguish; and reasonable funeral and burial expenses.  The award was reduced to $900,000 pursuant to a high/low agreement. 

Standard of Care Takeaways:

• Early Recognition and Management: Health care systems responsible for rendering care to pregnant and postpartum persons should develop procedures for (re)measuring blood pressure, and integrate standardized criteria for the diagnosis, and management of preeclampsia, and severe hypertension.
• Education: Role specific multidisciplinary education, simulation training, and team de-briefing should be required for all members responsible for caring for obstetrical, and postpartum patients.  Care areas should include labor and delivery, anesthesia, emergency department, and intensive care unit. 
• Quality Improvement: Organizational review of severe hypertension/preeclampsia cases should occur as part of a quality improvement process.  Additionally, printed patient and family education should be disseminated focusing on risk factors for severe hypertension/preeclampsia, as well as signs and symptoms to report.
• Maternal Safety Bundles: Multiple organizations (i.e., ACOG, AWHONN, CDC, CMQCC, NIH) have maternal safety bundles that focus on prevention, early identification, and early treatment of preeclampsia in an effort to reduce maternal mortality. Organizations are encouraged to integrate such safety bundles into their policies and procedures.

Resources:

American College of Obstetricians and Gynecologists, (2020). Gestational hypertension & preeclampsia. Practice Bulletin #222.

American College of Obstetricians and Gynecologists. (n.d.). Safe motherhood initiative. Retrieved March 8, 2023, from https://www.acog.org/community/districts-and-sections/district-ii/programs-and-resources/safe-motherhood-initiative

California Maternal Quality Care Collaborative. Retrieved December 17, 2023, from https://www.cmqcc.org/

Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System. Retrieved December 27, 2023, from  https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm

Collier A.Y., Molina R.L. (2019).  Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions

P.S. COMMENT AND SHARE:  Have you had a case theme centered around diagnosis, and/or management of preeclampsia?   What were some of the case facts?  How did the case facts impact the case outcome?

In this blog, I’ll be reviewing a maternal wrongful death case involving obstetrical hemorrhage.  I’ll identify how to diagnose obstetrical hemorrhage, and review the incidence of obstetrical hemorrhage within the United States.  Following a review of case facts, I’ll highlight key standard of care takeaways that support obstetrical hemorrhage prevention, early identification, and intervention.  The provided takeaways are evidence based practices which serve to reduce the incidence of maternal morbidity, and mortality associated with obstetrical hemorrhage.     

Definition: Obstetrical hemorrhage is defined as a cumulative blood loss of greater than or equal to 1,000 ml. of blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after childbirth, regardless of the mode of delivery (AGOG, 2021). 

Incidence: Obstetrical hemorrhage remains one of the leading causes of pregnancy-related deaths worldwide. In the U.S., during 2017 – 2019, obstetrical hemorrhage accounted for 12.1% of the total pregnancy-related deaths (CDC, 2023).

Case Facts:  A 36-year-old mother experienced profound uterine bleeding immediately after cesarean section for a twin delivery.  The patient was transferred to the post anesthesia care unit (PACU) where she continued to have severe bleeding, vital sign instability, and experienced hemorrhagic shock.  The patient received fluid resuscitation with blood products, and intravenous fluids.  Blood products were not promptly available.  The patient was transferred to the intensive care unit (ICU) where her vital signs continued to worsen.  The Obstetrician urged for an immediate hysterectomy.  After the patient was transferred to the ICU, the anesthesiologist left the hospital for another case at a different hospital, and there was no anesthesiologist available.  A hysterectomy was eventually performed. Due to the postpartum bleeding, and insufficient fluid resuscitation with blood products, the patient developed disseminated intravascular coagulation (DIC).  The patient was pronounced dead shortly after the DIC diagnosis was made. The anesthesiologist settled out.  The case continued to trial against the hospital and Obstetrician.

Plaintiff’s Allegations: The plaintiffs’ counsel contended the patient needed operative intervention much sooner to stop the uterine bleeding.  Plaintiffs’ counsel also contended the hospital blood bank did not promptly deliver the needed blood products. Lastly, the hospital failed to perform lab tests to assess the extent of the patients bleeding.

Defendant’s Allegations: The hospital contended the death was due to the negligence of the other physicians, including the anesthesiologist, for failing to promptly respond to, and manage the evolving shock. 

Physical Injuries Claimed by Plaintiff: Death; loss of love, companionship, comfort, care, assistance, protection, affection, society, moral support; loss of training and guidance; loss of financial support; the reasonable value of household services.

Gross Verdict (Award): $10,850,000 (100% against the hospital.  The obstetrician received a 12-0 defense verdict)

Standard of Care Takeaways:

• Hospital systems should require the performance of antepartum (prenatal), intrapartum (during labor), and postpartum (after delivery of the placenta) hemorrhage risk (re)assessments.
  • These standardized risk assessments are performed in an effort to identify patients at medium or high risk for obstetrical hemorrhage, and guides necessary interventions.
• Use of a stage-based management plan should be adopted that requires the performance of quantitative blood loss (QBL) measurements for every delivery.
  • With the use of a standardized stage-based management plan, best practice interventions are prompted, and are specific to the hemorrhage stage (stage 1-3).
• Standardized hemorrhage medication kits, and supply carts should be readily accessible on every unit caring for obstetrical patients.
  • Care units include labor and delivery, emergency departments, intensive care units, and operating rooms.
• Multi-disciplinary, role-specific obstetrical hemorrhage education, and simulation drills (including all members that care for obstetrical patients) should occur at the time of new hire orientation, whenever there are changes to the policy or procedure, or every one to two years.
• Every organization should have established criteria for identifying obstetrical hemorrhage cases requiring quality review. The quality review process serves as a quality improvement effort, and guides future continuing education.
• Patient education should be provided specific to hemorrhage risk factors, as well as signs, and symptoms of hemorrhage that must be reported.

Closing Remarks: Professional organizational standards exist specific to prevention, early recognition, and timely treatment of obstetrical hemorrhage.  Obstetrical risk reduction strategies should involve adoption of obstetrical hemorrhage safety bundles, perinatal quality review processes, as well as multidisciplinary data review by means of  audit and feedback methodologies.  

Resources:

AGOC, 2021. Postpartum Hemorrhage

Centers for Disease Control and Prevention, (2023). Healthy People 2020. https://www.cdc.gov/nchs/healthy_people/hp2020.htm

Centers for Disease Control and Prevention, (2023).Pregnancy Mortality Surveillance System. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm

The Joint Commission, 2023). R3 Report Issue 24: PC Standards for Maternal Safety.  https://www.jointcommission.org/standards/r3-report/r3-report-issue-24-pc-standards-for-maternal-safety/#.ZAdWsB_MJPY

P.S. COMMENT AND SHARE: Have you been involved in a maternal wrongful death case involving obstetrical hemorrhage?  What was the case theme?  What were strengths, and weaknesses of the case?

Barber Medical legal Nurse Consulting, LLC is available to support medical record review of obstetrical care involving a hemorrhage, perinatal quality consults, and obstetrical hemorrhage education.  Email: Contact@barbermedicallegalnurse.com.