Washington – Obstetrics – Elevated hCG Levels With Discovery Of Right Adnexal Mass Found On Ultrasound

In October 2008, a patient was referred by her primary care provider to an obstetrician to rule out an ectopic pregnancy.  Initially, the patient was followed by two of the obstetrician’s partners, who ordered serial pelvic ultrasounds on 10/6/2008, 10/10/2008, and 10/17/2008.  The findings indicated that the pregnancy was abnormal and there was a right adnexal mass.  A follow-up ultrasound was ordered on 10/20/2008 to confirm the abnormal pregnancy.

On 10/20/2008, the obstetrician saw the patient for the first time to follow up on her problem, which resulted in a pre-operative visit.  The obstetrician noted that the patient was 7 weeks and 2 days pregnant.  The obstetrician noted serial hCGs to be 32000, 51000, and 53000, respectively, and noted “several ultrasounds” including the “one done today” as showing “nothing in her uterus”, “yolk sac is not visible and no embryonic pole is visible, and they should be at this point.”  The obstetrician noted additional findings including a cystic structure in the uterus, a large anterior fibroid, a complex cystic mass in the right ovary, and a simple cyst in the left adnexa.  The obstetrician concluded that the most likely diagnosis was ectopic pregnancy.  The obstetrician also noted that the patient did not have any pain at this time and was completely stable.  The patient signed a consent for a D&C and possible laparoscopic salpingectomy or salpingostomy for probable ectopic pregnancy.

On 10/21/2008, the obstetrician performed a D&C on the patient.  The obstetrician determined no evidence of an intrauterine pregnancy and proceeded with laparoscopy.  During laparoscopy, the obstetrician observed a large right ovarian mass, determined to be a teratoma, which he attempted to remove, leaving the ovary intact.  Because of ovarian bleeding, the obstetrician had to remove the entire right ovary.

Sometime after the surgery, the obstetrician received the 10/20/2008 ultrasound report which indicated a uterine pregnancy with a visible yolk sac.

The obstetrician’s failure to review the 10/20/2008 ultrasound report before taking the patient to surgery on 10/21/2008 was below the standard of care.  The obstetrician’s failure to review the ultrasound and convey the contents of the report to the patient caused the patient to undergo surgery earlier than necessary and denied the patient the choice of continuing the pregnancy, abnormal or not.

The Commission stipulated the obstetrician reimburse costs to the Commission, have his license be placed on probation for a period of 2 years, complete 2 hours of continuing education addressing how to diagnose ectopic pregnancy and when to operate with an ectopic pregnancy diagnosis, write and submit a paper of at least 1000 words on what he learned from the continuing education course and how he will incorporate what he learned into his practice, and allow a representative to conduct annual visits to his practice and review patient charts and interview staff as needed.

State: Washington

Date: August 2012

Specialty: Obstetrics

Symptom: N/A

Diagnosis: Obstetrical Complication

Medical Error: Diagnostic error, Failure to follow up

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

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