Kansas – Obstetrics – Poor Control Of Diabetes And Hypertension Results In Obstetrical Complications

A female patient began to see an obstetrician for her prenatal care on 12/6/2010.  The patient had one previous pregnancy resulting in one live birth.  The obstetrician documented that the patient had a history of diabetes, hypertension, and preeclampsia.

The patient was treated between 12/11/2010 and 3/18/2011 by a physician at an OB/GYN health facility.  The OB/GYN records were faxed to the obstetrician on 4/5/2011 and were present in the obstetrician’s medical record for the patient.

On 3/15/2011 the patient’s gestational diabetes screen was elevated.

On 4/5/2011, the obstetrician observed the patient at a medical center for contractions and back pain.  The obstetrician documented a history and physical/discharge summary for the patient, incorrectly noting the patient was a primigravida and failing to mention the patient’s glucose or history of hypertension and diabetes.

The obstetrician saw the patient on 5/12/2011 and documented the patient’s sugar was 169.  The obstetrician documented a plan to perform nonstress tests at each visit and deliver the baby at 39 weeks.

The obstetrician saw the patient on 5/26/2011 and noted the patient had swollen feet and had not been taking her medications as prescribed. He scheduled an induction for 6/14/2011.

The obstetrician saw the patient on 6/2/2011 and noted the patient reported her feet were getting very swollen and she felt very tired.  The patient’s Hgb was 8.7.  The obstetrician failed to document a plan to address the patient’s anemia.

On 6/2/2011, the patient’s blood pressure was severely elevated at 161/88.  The obstetrician failed to recheck the patient’s blood pressure or otherwise address the hypertension as possible preeclampsia in his plan for the patient.

The patient’s blood sugar logs were scanned into the obstetrician’s medical record and showed poor control of her diabetes.  The obstetrician failed to make any adjustments to the patient’s medications.

Infants of a diabetic mother are known to be at risk of macrosomia and shoulder dystocia.  This is most elevated in the setting of poorly controlled diabetes.  There is no documentation in the obstetrician’s medical record that he discussed the possibility of these complications with the patient.

The obstetrician failed to make any effort to follow the growth of the infant with serial ultrasounds.  The obstetrician failed to document any discussion with the patient regarding the desirability of such testing and failed to document the patient’s refusal of such testing.

The patient was admitted to a medical center for induction of labor on 6/14/2014.

The obstetrician initiated Pitocin at approximately 6:00 a.m.  The Pitocin was increased at intervals to 16 milliunits/min until it was discontinued at 12:23 p.m.

The patient was documented as having severely elevated blood pressures, headache, and lower extremity edema during her induction.  The patient was also given magnesium sulfate during her induction, suggesting she was suffering from severe preeclampsia.

The patient was complete at 12:23 p.m., and the obstetrician arrived at 12:40 p.m.  The patient pushed for approximately 15 minutes before the obstetrician made a diagnosis of maternal exhaustion and documented “poor pushing effort.”  The obstetrician failed to document any extenuating circumstances to support his premature discontinuation of the patient’s second stage of labor.  There was no indication of fetal distress.

The obstetrician applied vacuum suction.  There is no indication in the record that the obstetrician discussed options with the patient prior to attempting vacuum extraction of the fetus.  There is no indication in the record that the patient was provided an explanation of risks and benefits regarding the use of vacuum extraction.  There is no indication in the record that the obstetrician offered the patient the option for a Cesarean section.

The baby’s head was delivered at 12:58 p.m.  The infant then sustained shoulder dystocia that the obstetrician was unable to resolve.

A labor and delivery emergency was then called, bringing several physicians and others to assist.

The 10 lb 5 oz infant was born six to seven minutes after the head was delivered.  The infant had Apgars of 1,4 and 6.  A neonatal consult was obtained, and the infant was diagnosed with multiple issues including bilateral brachial plexus injury.  The infant was then transferred to Children’s Mercy Hospital.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given his failure to attempt to adjust the patient’s medication despite the fact that she had a known history of diabetes and her blood sugar logs indicated she had poor control over it.  The obstetrician failed to document any attempt to educate the patient regarding the risks associated with a poorly controlled blood sugar, including but not limited to macrosomia and shoulder dystocia.  Also, the obstetrician failed to monitor the growth of the infant in utero.  He failed to perform appropriate weekly antenatal testing which would be indicated in a poorly controlled diabetic starting from 32 weeks.  The obstetrician failed to appropriately evaluate and treat for preeclampsia in the face of severely elevated blood pressure in a patient with a known history of preeclampsia.  The patient was administered Methergine, not as a last resort, but as the first medication after oxytocin and before cytotec, putting the patient at risk of a stroke in the postpartum period.

The Board ordered that the gynecologist change his licensure status from active to inactive and that he should not perform any type of surgical procedure including gynecological surgeries or provide obstetric care.

State: Kansas

Date: October 2015

Specialty: Obstetrics

Symptom: Headache, Swelling

Diagnosis: Preeclampsia, Diabetes

Medical Error: Improper medication management, Failure of communication with patient or patient relations, Failure to properly monitor patient, Lack of proper documentation, Procedural error

Significant Outcome: Permanent Loss Of Functional Status Or Organ

Case Rating: 4

Link to Original Case File: Download PDF

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