Found 109 Results Sorted by Case Date
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Florida – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications



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 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, 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, who was born with spina bifida/myelomeningocele.

The obstetrician failed to diagnose neural tube defect on imaging studies.

The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.

The obstetrician failed to order an anatomical survey sonogram.

The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18.  The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he  complete five hours of continuing medical education on “Risk Management.”

State: Florida


Date: December 2017


Specialty: Obstetrics


Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain


Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Obstetrics – Obstetrician Unavailable During Labor With Fetal Heart Decelerations



On 1/24/2014 a 21-year-old female presented to a hospital with spontaneous rupture of membranes and meconium-stained amniotic fluid at about thirty-nine weeks of pregnancy.

Upon admission, the patient was placed on a fetal monitor, which documented variable decelerations of the fetal heart rate.  In response to the monitor tracings, an obstetrician ordered the administration of intravenous fluids.  Shortly thereafter, the obstetrician ordered the performance of an amnioinfusion.

Over the next couple of hours, the fetal monitor began documenting recurrent late fetal heart rate decelerations and loss of fetal heart rate variability, indicative of probable insufficient fetal oxygenation.  The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability.

In response to the monitor tracings, the obstetrician ordered the rate of IV fluid administration increased.  Despite the monitor tracings indicating probable fetal distress, the obstetrician did not diagnose, or did not document diagnosing, fetal intolerance to labor and allowed the trial of labor to continue.

At some point in time between 6:15 p.m. and 7:30 p.m., the obstetrician decided to manage the trial of labor from outside of the hospital.  Based on the patient’s presentation, the obstetrician should have continued to manage the trial of labor, in person, at the hospital. The fetal monitor continued to document recurrent late fetal heart rate decelerations and a loss of fetal heart rate variability over the next several hours.  The obstetrician was notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability on multiple occasions during that time span.  Despite the monitor tracings indicating probably continued fetal distress, the obstetrician did not promptly return to the hospital to deliver the baby.

Shortly after midnight on 12/25/2014, the obstetrician was again notified of the recurrent late fetal heart rate decelerations and loss of fetal heart rate variability.  At 1:28 a.m., the obstetrician returned to the hospital, presented to the delivery room, and shortly thereafter delivered the baby.

The baby was in full cardiac arrest at the time of delivery.  Efforts to resuscitate the baby were abandoned after about 20 minutes.  The final diagnosis was stillborn.

The obstetrician did not dictate or write any progress notes during the trial of labor.

The Board judged the obstetrician’s conduct to be below the minimum standard of competence given that she failed to diagnose fetal intolerance to labor, manage the trial of labor, in person, at the hospital, and promptly return to the hospital and deliver the baby upon receiving continued reports of probably fetal distress.

The Board ordered that the obstetrician pay a fine of $5,000 against her license and pay reimbursement costs for the case at a minimum of $3,949.77 and not to exceed $5,949.77.  The Board also ordered that the obstetrician complete five hours continuing medical education in the area of obstetric medicine and five hours of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Diagnostic error, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Induction For A Patient With A Bishop Score Of 4 And Continued Pitocin Use Despite Fetal Heart Tracing Abnormalities



A 24-year-old female was transferred from a physician to an obstetrician.  The patient first saw the obstetrician on 6/24/2009, and she was due with her first child in July 2009.  Her patient chart listed her at 120 lbs and 4’0” tall, but when she came to see the obstetrician, she weighed 170 lbs.

The patient was seen by the obstetrician twice in June and every week in July until 7/27/2009.  The patient was scheduled to be induced 7/29/2009. There was nothing in the records about her bony pelvic exam or pelvic adequacy for vaginal delivery.  The obstetrician did not do an ultrasound. The patient was admitted to the hospital on 7/29/2009. There was no risk assessment, no estimate fetal size, no ultrasound ordered, and a Bishop score of 4.

The patient was started on Pitocin at 9:30 a.m. and had made no progress by 6:00 p.m. that evening.  The patient was allowed to rest, and the next morning, on 7/30/2009 at 7:30 a.m., Pitocin was started again.  During this time, it was noted that she had “reactive” fetal heart tracings. The nurses did not place an order for an internal fetal monitor.  When the fetal heart tones were low, the Pitocin should be turned off. If the mother keeps having contractions, the baby gets no rest, which is what likely occurred in this case.

At 8:18 p.m., she was only dilated 4-5 cm.  The patient had spontaneous rupture of the membranes with thick meconium noticed.  At 8:50 p.m., the patient was dilated to 8 cm, 0 station. There was no mention of a possible Cesarean section in the notes.  On 7/31/2009, a female infant weighing 9 lbs 5 oz was delivered using a vacuum because a shoulder dystocia was encountered. Unfortunately, the baby was deceased.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because he failed to estimate the fetal size, fetal lie, and pelvic adequacy.  The obstetrician also did not mention the application of a fetal electrode. This is important because the obstetrician did not know if the heart rate was coming from the mother or the baby; thus, an internal electrode would have been an accurate way to measure the baby’s heart rate.  Review of the fetal monitor strips showed back to back contractions and inadequate recordings. During labor and delivery, Pitocin should have been stopped in the contractions showed a low fetal heart rate and tachysystole (no rest between contractions). This patient was also a poor candidate for induction because she had a Bishop score of 4.  When the membranes were ruptured with 3+ meconium, this should have alerted the obstetrician that the baby was somehow compromised and action by the obstetrician was required. Also, the patient was a transfer patient, but the obstetrician did not order lab studies or an ultrasound. There were many errors which lead to the untimely demise of this baby.  Had there been an estimate of fetal weight, or an ultrasound performed within 6 weeks of induction of labor, the obstetrician would have known the patient was having a big baby, and the obstetrician might have performed a Cesarean section.

The Medical Board of California issued a public reprimand and ordered the obstetrician to complete a clinical competence assessment program.

State: California


Date: November 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Failure to properly monitor patient, Improper treatment, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Obstetrics – Disregarding Patient’s Desire For Cesarean Section And Concerning Fetal Heart Rate Tracings



On 8/27/2010, a patient came under an obstetrician’s care and treatment for prenatal and obstetric care.  The patient, a 41-year-old Spanish-speaking primigravida in the third trimester of pregnancy, had not been receiving prenatal care prior to August 2010.

Previously, on 8/10/2010, she had been seen at the hospital for complaints of decreased fetal movement and was discharged after being reassured of fetal well-being by an ultrasound examination.  She had also returned to the hospital on 8/24/2010 and was discharged with a diagnosis of early latent labor and instructions to establish care with an obstetrician.  At her initial visit with the obstetrician, an estimated delivery date of 9/21/2010 was established by a third trimester ultrasound.  The patient was examined and given instructions on counting fetal kicks and labor precautions and was given an order for laboratory tests.

On 8/30/2010, the patient returned with complaints of pelvic pressure.  Her cervix was closed but 50% effaced and the fetal head had descended from -3 position to -1.  Although it is not documented in the obstetrician’s chart, the patient and her partner reported that they had advised the obstetrician of the patient’s desire for delivery by Cesarean section when the time came.  The patient was told to return in one week.

On 9/4/2010, the patient presented to the hospital in spontaneous labor.  She stated that contractions had started at approximately 4:00 a.m.  At 11:30 a.m., the cervix was approximately 6 cm dilated, 100% effaced, with the vertex at -2 station.  The patient was admitted by another physician, who contacted the obstetrician to take over intrapartum management.

The obstetrician arrived and assumed responsibility for the care and labor management of the patient.  In the obstetrician’s note timed 2:00 p.m., she recorded a fetal heart rate (“FHR”) of 145 beats per minute (“bpm”), with moderate variability and no decelerations.  The obstetrician noted that excellent progress in labor had been made and she anticipated a spontaneous delivery.

The obstetrician’s next note is timed at 4:30 p.m. and states that the patient had an epidural placed and was comfortable.  The FHR was reported as 145 bpm with moderate variability and accelerations and the fetal tracings were, overall, consistent with a classification of Category I, i.e., with no specific action required.  Contractions were 2-3 minutes apart.  The cervical exam was anterior lip, 100% effaced, zero station.  In her progress note timed 4:30 p.m. – albeit the obstetrician indicated that the labor was progressing well – the obstetrician documented her plan for oxytocin augmentation of labor.

The patient began pushing at approximately 5:00 p.m., with contractions coming every 1-2 minutes, at which time the obstetrician found the cervix to be complete with the head at zero to +1 station.  At this point, the tracing showed moderate variability, but recurrent variable decelerations with contractions and pushing effort.  This was consistent with Category II, i.e., requiring evaluation, continued surveillance, reevaluation and possibly ancillary tests to assure fetal well-being.  Oxytocin was increased to 6 mU/min.  During the approximate period of 5:00 p.m. to 5:40 p.m., the patient was pushing while the obstetrician coached her in Spanish.  By approximately 5:30 p.m., the fetal heart rate baseline became tachycardic and the variable decelerations more deep and prolonged.  A nurse who was present at the time noted that there were multiple late and variable decelerations and she advised the obstetrician of this.  Although it is not charted, the nurse recalled that the patient repeatedly stated that she wanted a Cesarean section, but that the obstetrician urged her to continue pushing.

At approximately 5:40 p.m., the obstetrician was called away to attend a delivery for another patient whose obstetrician was still en route to the hospital.  According to her notes, she returned at approximately 6:20 p.m.  The fetal heart tracing progressively worsened, with continued tachycardia and gradual loss of variability until, at approximately 6:40 p.m., variability is absent from the tracing.  At this point in time, the fetal heart tracing was consistent with Category III, i.e., associated with abnormal fetal acid-base status, requiring immediate evaluation, expeditious efforts to resolve the abnormal FHR pattern and, failing resolution, expedited delivery.

At 7:00 p.m., the obstetrician noted that the FHR decreased “to 60’s” for 5-6 minutes.  At that time, the obstetrician reported that she was advised there was not an available operating room, so she instructed the patient to stop pushing and had the patient change positions.  The obstetrician discontinued the oxytocin at 7:02 p.m. and terbutaline was administered at approximately 7:12 p.m.  Despite these efforts to improve the fetal status, the FHR did not improve to the point that it could be considered reassuring.

The patient was moved to the operating room at about 7:22 p.m. and arrived at 7:25 p.m.  She consented in Spanish to a vacuum-assisted delivery, with the possibility of Cesarean section.  Two attempts with the Mityvac, each approximately 20 seconds, were made at 7:34 p.m. and 7:35 p.m. without fetal descent.  The anesthesiologist arrived at about the time of the second attempt.  A Cesarean section was called by the obstetrician at 7:37 p.m.  The incision was made at 7:45 p.m. and the infant delivered at 7:47 p.m.  The obstetrician described the infant as having poor tone and pale color after delivery.  The anesthesiology note states that the infant was not crying and was not breathing.  An emergency intubation was performed, and the infant was taken to the newborn intensive care unit (“NICU”).  Apgar scores were 2, 3, and 5.

The Board judged the obstetrician’s conduct as having fallen below the standard of care for the following reasons:

1) The obstetrician failed to recognize non-reassuring fetal heart tracings consistent with abnormal fetal acid-base status.

2) The obstetrician failed to undertake appropriate steps to expedite delivery in the circumstance of Category III fetal heart tracing that had not resolved despite steps to improve fetal status.

3) The obstetrician prescribed oxytocin when the labor pattern was adequate and continued administration after the fetal heart tracing had developed to a Category III.

4) The obstetrician failed to perform a Cesarean section in response to the patient’s request and the non-reassuring fetal testing in the second stage of labor.

The Board issued a public reprimand against the obstetrician with stipulations to complete a clinical competence assessment program.

State: California


Date: June 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Procedural error, Diagnostic error, Improper medication management


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Pregnant Patient With Abdominal Pain And Green Pelvic Discharge Diagnosed With Cervicitis And Urinary Tract Infection



On 3/24/2015, a 22-year-old female presented to an ED physician in the emergency department with complaints of abdominal pain.

The ED physician ordered the patient to undergo a urine pregnancy test and, based on the results, diagnosed her with pregnancy.

The ED physician ordered that the patient undergo a pelvic ultrasound, after performance of which the technician advised the ED physician the fetus estimated gestational age was thirty-five weeks and six days.  The ED physician performed a pelvic examination of the patient which revealed abnormal green discharge.

The ED physician ordered the patient undergo further urinalysis and based on the results, diagnosed her with cervicitis and urinary tract infection.

The ED  physician failed to consider possible premature rupture of membranes.  He also failed to consider possible premature labor.

The ED physician prescribed parenteral and oral antibiotics to the patient and discharged her home.

The patient’s medical condition required further emergent evaluation by an obstetrician.  The ED physician failed to arrange or failed to document arranging for transfer of the patient to an obstetrician for further evaluation.

On 3/25/2015, the ultrasound report was read by the radiologist whose impressions included: single live intrauterine pregnancy, a large disparity in estimated age based on measurements, and potential premature rupture of membranes.

Following an examination, the patient was emergently transferred to the labor and delivery department where the baby was delivered stillborn.

The Medical Board of Florida issued a letter of concern against the ED physician’s license.  The Medical Board of Florida ordered that the ED physician pay a fine of $10,000 against his license and pay reimbursement costs for the case at a minimum of $4,445.91 and not to exceed $6,445.91.  The Medical Board of Florida also ordered that the ED physician complete five hours of continuing medical education in the area of high-risk emergency medicine, complete a medical records course, and complete five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Emergency Medicine, Obstetrics


Symptom: Abdominal Pain, Abnormal Vaginal Discharge


Diagnosis: Obstetrical Complication


Medical Error: Diagnostic error, Referral failure to hospital or specialist, Lack of proper documentation


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Obstetrics – Pitocin Dosing Of 18 milliunits/hour To 30 milliunits/hour Prescribed For Labor



On 1/7/2012, a patient was admitted to a medical center for the birth of her child.

At 4:30 p.m., an obstetrician ordered the patient to receive intravenous Pitocin 20 m units/1000 ml, starting at 2 m units/minute (6ml/hour).  From 4:30 p.m. to 7:00 p.m., Pitocin was increased in increment of 2 m units/minute, as per the obstetrician’s order.  By 7:00 p.m., the patient was administered 10 m units/minute (30ml/hour) of Pitocin.

Over the next nine hours, the dosage of Pitocin was intermittently increased and decreased, vacillating between 6 m units/minute (18ml/hour) and 10 m units/minute (30 ml/hour).

The increases and decreases in Pitocin administered were not substantially justified by the frequency of the patient’s contractions.

During the patient’s labor, she displayed a pattern of uterine hyperstimulation.

The Medical Board of Florida judged the obstetrician’s conduct to be below the minimal standard of competence given that she failed to adequately treat the patient for uterine hyperstimulation, to include the discontinuation of Pitocin.  The obstetrician failed to adequately assess and/or appropriately respond to the child’s level of distress, indicated by the fetal monitoring strip, by failing to utilize internal monitoring of uterine activity and/or fetal heart tracing.  The obstetrician failed to undertake intrauterine resuscitation, and/or failed to expeditiously deliver the child via Cesarean section or operative vaginal delivery.

The Medical Board of Florida issued a letter of concern against the patient’s license.  The Medical Board of Florida ordered that the obstetrician pay a fine of $8,000 against her license and pay reimbursement costs for the case at a minimum of $6,859.96 and not to exceed $8,859.96.  Also, the Medical Board of Florida ordered the obstetrician to complete five hours of continuing medical education in labor induction and five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Improper medication management, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Postpartum Hemorrhage Diagnosed As Uterine Atony



On 1/15/2014, an obstetrician performed a Cesarean section on a patient.  The obstetrician documented no complications and a 600 ml blood loss.  Shortly after reaching the recovery room, the patient began vaginally hemorrhaging postpartum from what was diagnosed as uterine atony.  The obstetrician determined the patient was unstable and would need to return to the operating room (OR) after administering fluids and blood products and conducting a uterine massage.  Once in the OR, the patient was stabilized, yet continued persistent vaginal bleeding.  The decision was made by the obstetrician to reopen the abdomen and explore the prior Cesarean section.  After inspecting the uterus, the obstetrician made the determination that a supracervical hysterectomy was necessary.

A supracervical hysterectomy was performed by the obstetrician and another physician.  Once completed, a bimanual exam showed ongoing bleeding from the cervix.  An unsuccessful attempt was made to control the bleeding.  At this point, the determination was made to remove the cervix through the abdominal incision and a full hysterectomy was performed by the obstetrician and another physician. After the second surgery, the patient was taken to recovery in stable condition.

A discharge summary of the patient showed both placenta accreta and placenta increta in the endometrium and upper myometrium.

When the patient began hemorrhaging postpartum, the obstetrician appropriately returned to the patient’s bedside and examined her and ordered fluids and blood products as she alerted staff that the patient would need to return to the OR.

Once in the OR, however, the obstetrician failed to attempt more conservative therapies, including B-lynch suture, intrauterine balloon, uterine artery ligation, hypogastric artery ligation, and dilation and curettage.  There is no documentation that the obstetrician considered these options or ruled them out as potential actions prior to performing a hysterectomy on the patient.

On 6/7/2016, the obstetrician underwent an evaluation by a Board appointed psychiatrist.  The psychiatrist concluded that the obstetrician suffers from Major Depressive Disorder, Recurrent, and an Unspecified Anxiety Disorder, conditions that impair her ability to safely practice medicine.

The obstetrician was placed on probation for three years with stipulations to complete 40 hours annually for each year of probation of continuing medical education, complete a medical record keeping course, and undergo psychotherapy.

State: California


Date: March 2017


Specialty: Obstetrics


Symptom: Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Improper treatment, Lack of proper documentation, Practicing while not being sound physically or mentally


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Obstetrics – Postpartum Bleeding Following Early Labor In A Patient With A History Of Anemia



On 9/7/2012 at 8:00 p.m., a 27-year-old female presented to a medical center with a complaint of early labor.  The patient had a history of anemia.

At 8:50 p.m., a biophysical profile was ordered for the patient due to heart tracing concerns for the fetus.

By the time the patient arrived back from her biophysical profile, she was found to have made cervical changes from 1-½ cm to 4 cm, and she then very rapidly went from 4 cm to 9 cm.

At 11:15 p.m., the patient’s membranes were artificially ruptured and meconium stained fluid was obtained.  At this time, the cervix was now completely dilated.

At 11:55 p.m., an obstetrician applied a fetal scalp lead to better evaluate the monitor tracing.

At 12:15 a.m., the obstetrician then called in additional medical personnel and proceeded to apply a Kiwi vacuum extractor.

At 12:17 a.m., a second vacuum was applied and at 12:27 a.m. a third vacuum was applied.

At 12:27 a.m., the fetus was delivered with the baby weight 9 pounds and 8 ounces

The patient then experienced a severe postpartum hemorrhage, and the obstetrician inspected the cervix and found there to be no lacerations.  The obstetrician used appropriate medications to cause the uterus to clamp down.

At 12:45 a.m., the obstetrician repaired episiotomy and third-degree perineal laceration, and the uterus was still boggy in spite of the medications. The bleeding continued.

At 1:00 a.m., the uterus was described as firm, the bleeding had decreased and the patient was sleepy but responsive.

At 1:15 a.m., the patient had a steady trickle of lochia resulting in the obstetrician being called back into the room.

At 1:20 a.m., the obstetrician performed a repair of laceration.

At 1:25 a.m., the patient was administered a Foley catheter per the obstetrician’s instructions.

At 1:35 a.m., following repair of the laceration, the patient was bleeding dark blood vaginally.  Additionally, the patient was hypotensive and lethargic.

Sometime after 1:35 a.m. but before 2:10 a.m., the obstetrician left the hospital.

At 2:00 a.m., the patient continued to bleed vaginally, small to moderately.

At 2:10 a.m., the patient’s family called medical staff to the room due to the patient “acting funny” as the patient was lying on her stomach and moving her legs and moaning that she was hurting but would not say where.

At 2:10 a.m., the patient was noted to have bloody fluid in the Foley catheter.

The obstetrician was not present in the hospital at the time.  The obstetrician was informed of the patient’s behavior and the continuation of her steady trickle of blood.

At 2:25 a.m., a registered nurse stayed in the room with the patient as the patient became more combative and a large amount of blood poured from the patient’s vagina.

At 2:25 a.m., the obstetrician was called to return to the hospital.

At an unidentified time, the obstetrician was called again to ensure she was on her way back to the hospital.

At 2:55 a.m., the obstetrician arrived back in the hospital room with the patient.

At 3:14 a.m., the patient became unresponsive and a code blue was called.  The patient experienced cardiac arrest and cardiopulmonary resuscitation was started.

At 6:03 a.m., the patient was pronounced dead.

The Medical Board of Florida judged the obstetricians conduct to be below the minimal standard of competence given that she failed to determine the source of the bleeding for the patient who had been bleeding heavily after a vaginal delivery.  The obstetrician failed to transfer the patient to the operating room for evaluation. She also failed to remain at the physical location of the hospital to monitor the patient who had been bleeding continuously.

It was requested that the Medical Board of Florida order one or more of the following penalties for the obstetrician: permanent revocation or suspension of her 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 Medical Board of Florida deemed appropriate.

State: Florida


Date: February 2017


Specialty: Obstetrics


Symptom: Abnormal Vaginal Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Underestimation of likelihood or severity, Failure to examine or evaluate patient properly, Failure to properly monitor patient


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Obstetrics – Pregnancy With Elevated Blood Pressure And Proteinuria



On 02/02/2015, a 37-year old-woman was evaluated for vaginal bleeding in the emergency department.

On 02/04/2015, she established care with an obstetrician.  She had received prenatal care on two prior occasions from other providers.  An ultrasound was performed and a sub-chorionic hemorrhage was identified along with fibroids.  Blood pressure was noted to be 139/79.

On 03/18/2015, she was noted to have elevated blood pressure at an appointment with the obstetrician.

On 04/14/2015, the blood pressure was elevated and 2+ protein was present.  The obstetrician sent the patient to her family practitioner for evaluation, and the family practitioner then sent the patient to the hospital, where she was treated with labetalol and discharged with no further evaluation.

On 04/16/2015, the patient was seen at the obstetrician’s office with continued significantly high blood pressure.  The obstetrician ordered a 24-hour urine and pregnancy induced hypertension labs.  The patient then went home.

On 04/17/2015, the lab studies showed significant abnormalities consistent with severe pregnancy induced hypertension.  The patient went to the hospital.  She subsequently had an intrauterine fetal death at approximately 22 weeks gestation with delivery.

The Board judged obstetrician’s conduct to be below the minimum standard of competence given failure to evaluate the patient for preeclampsia with a history and physical, serial blood pressure evaluations, and laboratory studies.  He failed to admit the patient to a hospital for treatment.

The Board ordered the obstetrician be reprimanded, be placed on probation for a period of 6 months, and take 5 hours of CME in hypertensive disorders in pregnancy.

State: Arizona


Date: February 2017


Specialty: Obstetrics


Symptom: Gynecological Symptoms


Diagnosis: Preeclampsia


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Massachusetts – Obstetrics – Postpartum Bleed With Difficulty Identifying The Source Of Bleed



At 12:35 a.m. on 4/2/2009, an obstetrician performed an unscheduled Cesarean section on a patient who began to bleed heavily after birth.  The obstetrician incorrectly identified the major source of bleeding as a uterine tear.  The obstetrician failed to properly administer medications to stop the bleeding pursuant to a uterine hemorrhage protocol.  The obstetrician failed to obtain assistance until between 2:00 and 2:15 a.m.  A trauma resident arrived at 2:30 a.m. and another physician from the obstetrician’s practice arrived at 2:45 a.m., who repaired a laceration of the uterine artery.

Ultimately, the Board revoked the obstetrician’s license.

State: Massachusetts


Date: January 2017


Specialty: Obstetrics


Symptom: Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Procedural error, Delay in proper treatment, Diagnostic error, Improper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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