Florida – Gynecology – Bilateral Tubal Ligation Error Results In Complications Of Tachycardia, Hypotension, Respiratory Failure, And Hypotension

On 4/21/2014, a gynecologist performed a Cesarean section and bilateral tubal ligation on a 29-year-old female at 36 weeks gestation.

The patient suffered from gestational hypertension associated with right upper quadrant abdominal pain and elevated liver function tests consistent with HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelet Count) Syndrome.

At 5:00 p.m. on 4/21/2014, the patient became hypotensive and tachycardic and was pale and lethargic.

Between 5:00 p.m. and 6:30 p.m. on 4/21/2014, a critical care consultant diagnosed the patient with acute hemorrhagic shock, possibly due to an intraabdominal bleed, transferred the patient to the ICU, ordered a transfusion of 4 L of blood, and called the gynecologist for a possible exploratory laparotomy to control the bleeding.

At 7:11 p.m., the patient was intubated and placed on ventilation due to respiratory failure.

At 9:10 p.m., an ultrasound examination was performed on the patient’s abdomen and pelvis that revealed moderate fluid in the right and left upper quadrants of the patient’s abdomen.

Immediately following the ultrasound examination, the gynecologist diagnosed the patient with a liver rupture.  The patient’s lab testing results did not support or corroborate the gynecologist’s diagnosed.

The gynecologist called the on-call general surgeon and discussed the patient’s case.  After the conversation, at 9:23 p.m., the gynecologist initiated the transfer of the patient to a medical center.

At 1:45 a.m. on 4/22/2014, the patient was transferred to the medical center with a tachycardic heart rate of 140 beats per minute and a hypotensive blood pressure of 89/44.  The gynecologist and a surgeon performed an exploratory laparotomy on the patient, which revealed that the patient had an arterial bleed from the tubal ligation procedure.

The Medical Board of Florida judged that the gynecologist did not appropriately assess, or did not create or maintain adequate documentation of assessing, the patient’s symptoms and condition. He did not timely diagnose, or did not create or maintain adequate documentation of timely diagnosing, the patient with an intraabdominal bleed and hemorrhagic shock.  The gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s deteriorating vital signs.  He did not timely order an ultrasound examination of the patient’s abdomen and pelvis on the patient’s deteriorating vital signs.  Also, the gynecologist did not timely perform or order an exploratory laparotomy based on the patient’s respiratory failure.  He did not recognize, or did not create or maintain adequate documentation of recognizing, that the fluid in the right and left upper quadrants of the patient’s abdomen, in conjunction with the patient’s other symptoms, indicated an intraabdominal bleed.  He did not perform or order an exploratory laparotomy based on the fluid in the right and left upper quadrants of the patient’s abdomen.  The gynecologist inappropriately diagnosed the patient with a liver rupture when the patient’s lab testing results did not support or corroborate the diagnosis.  He also did not order, or did not create or maintain adequate documentation of ordering, a surgery consultation for a surgeon to physically examine the patient upon diagnosing the patient with liver rupture.  He did not consult, or did not create or maintain adequate documentation of consulting, with one or more other OB/GYNs who might have had experience dealing with a patient with a liver rupture or a patient with similar complications and symptoms as the patient had.  The gynecologist did not timely perform or order an exploratory laparotomy after diagnosing the patient with liver rupture.  He also inappropriately transferred the patient to a medical center when the patient was unstable due to being tachycardic and hypotensive.  The gynecologist did not create or maintain adequate documentation related to his diagnosis and treatment of the patient.

The Medical Board of Florida issued a reprimand against the gynecologist’s license.  The Medical Board of Florida ordered that the gynecologist pay a fine of $22,500 against his license and pay reimbursement costs for the case at a minimum of $4,335.85 and not to exceed $6,335,85.  The Medical Board of Florida also ordered that the gynecologist complete ten hours of continuing medical education in diagnosis management of complications relating to cesarean sections, complete five hours in emergency obstetric care, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: May 2017


Specialty: Gynecology, Critical Care Medicine, General Surgery


Symptom: Abdominal Pain


Diagnosis: Post-operative/Operative Complication, Acute Abdomen, Hemorrhage


Medical Error: Diagnostic error, Delay in proper treatment, Failure to order appropriate diagnostic test, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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