Clinical Review
Does screening mammography save lives?
A Canadian study has left some clinicians uncertain about when to recommend mammography—and to whom. Here, four experts in breast cancer screening...
PARENTS’ CLAIM Testing failed to identify the condition; the couple had decided to terminate the pregnancy if the child was affected. Due to budget cuts in the maternal-fetal medicine clinic, the medical center borrowed a genetic counselor from another hospital one day a week. The parents told the genetic counselor of the family’s history of the defect and explained that the laboratory’s procedures require the referring center to obtain and share the necessary detailed information with the lab. The lab was apparently notified that the couple had a family history of the defect, but the genetic counselor did not transmit specific information to the lab, and lab personnel did not appropriately follow-up.
DEFENDANTS’ DEFENSE The medical center blamed the laboratory: the lab’s standard procedures state that the lab should call the referring center to obtain the necessary detailed information if it was not provided; the lab employee who handled the specimen did not do so. The lab claimed that the genetic counselor did not transmit the specific information to the lab.
The laboratory disputed the child’s need for 24/7 care, maintaining that he could live in a group home with only occasional nursing care.
VERDICT A $50 million Washington verdict was returned against the medical center and laboratory; each defendant will pay $25 million.
Related article: Noninvasive prenatal testing: Where we are and where we’re going. Lee P. Shulman, MD (Commentary; May 2014)
NECROTIZING FASCIITIS AFTER SURGERY
A 57-year-old woman underwent surgery to repair vaginal vault prolapse, rectocele, and enterocele, performed by her gynecologist. Several days after discharge, the patient returned to the hospital with an infection in her leg that had evolved into necrotizing fasciitis. She underwent five fasciotomies and was hospitalized for 3 weeks.
PATIENT’S CLAIM The gynecologist should have administered prophylactic antibiotics before, during, and after surgery. The patient has massive scarring of her leg.
PHYSICIAN’S DEFENSE The infection was not a result of failing to administer antibiotics. The patient failed to seek timely treatment of symptoms that developed after surgery.
VERDICT A $400,000 New York verdict was returned but reduced because the jury found the patient 49% at fault.
OXYTOCIN BLAMED FOR CHILD’S CP
A mother had bariatric surgery 12 months before becoming pregnant, and she smoked during pregnancy. She developed placental insufficiency and labor was induced shortly after she reached 37 weeks’ gestation.
During delivery, the mother was given oxytocin to increase the frequency and strength of contractions. Nurses repeatedly stopped the oxytocin in response to decelerations in the fetal heart rate, but physicians ordered the oxytocin resumed, even after fetal heart-rate monitoring showed fetal distress.
Three days after birth, the child was transferred to another hospital, and was found to have cerebral palsy and other injuries. At age 5, the child is nonverbal, cannot walk, and requires a feeding tube.
PARENTS’ CLAIM Oxytocin should have been stopped and a cesarean delivery performed when fetal distress was first noted.
DEFENDANTS’ DEFENSE There was no need for cesarean delivery. Apgar scores, blood gases, and fetal presentation indicated that the injury occurred prior to labor.
VERDICT A $6 million Texas settlement was reached during the trial.
Related article: Q: Following cesarean delivery, what is the optimal oxytocin infusion duration to prevent postpartum bleeding? Robert L. Barbieri, MD (Editorial; April 2014)
MOTHER DISCHARGED DESPITE SEVERE ABDOMINAL PAIN
A woman had prenatal care at different locations. Her history included two cesarean deliveries.
Reporting severe abdominal pain, she was taken from a homeless shelter to an ED by ambulance. The mother was uncertain of the fetus’ gestational age; a 4th-year obstetric resident determined by physical examination that the pregnancy was at 36.5 weeks. The resident discussed the case with the attending ObGyn, who said to discharge the mother if her pain was gone. After 11 hours, the mother was returned to the shelter.
The mother returned to the ED 12 hours later. Thirty-five minutes after fetal distress was identified, an emergency cesarean delivery was performed. At birth, the child was found to be at 38 to 39 weeks’ gestation. He received a diagnosis of severe hypoxic ischemic encephalopathy and was transferred to a children’s hospital for brain cooling.
The child lives in a long-term care facility and is dependent on a ventilator and gastronomy tube.
PARENT’S CLAIM The mother should not have been discharged after the first visit. A cesarean delivery should have been performed at that time. The attending ObGyn never saw the mother.
DEFENDANTS’ DEFENSE The mother should have given her correct due date, which was in her prenatal records based on previous ultrasonograpy. The first discharge was proper, as the pain had improved. The homeless shelter should have called an ambulance earlier for the second admission.
