Florida – Obstetrics – Missed Indicators Of A Neural Tube Defect

On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son.  The child was born with a neural tube defect called spina bifida/myelomeningocele.

The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.

The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.

The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.

It was requested that the Board order one or more of the following penalties for the obstetrician: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: August 2017


Specialty: Obstetrics


Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain


Diagnosis: Neurological Disease


Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



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