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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



California – Obstetrics – Preeclampsia Pregnancy Complicated By Postpartum Abdominal Pain And Vaginal Discharge



An obstetrician was a physician supervisor for a nurse midwife who was following a patient’s prenatal course through spring and summer 2013.  At the 39 weeks gestation visit, the midwife recorded the patient’s blood pressure as 131/90.  At the next week’s visit, the patient’s blood pressure was measured at 186/101 and her proteinuria was 3+.  The midwife was apparently monitoring the patient for preeclampsia.

There was no indication that the obstetrician was actively supervising the high-risk patient.  The midwife elected to induce labor to address the evolving preeclampsia.  The consequent labor resulted in a vaginal delivery of the patient’s healthy baby in hospital on 8/15/2013.

The obstetrician was called in after the delivery and performed a manual removal of the placenta and a postpartum curettage under general anesthesia.  Over the course of the delivery and postpartum surgery, the patient lost 2-3 liters of blood and her hematocrit level dropped from 41 to 27.  The patient was discharged from the hospital two days after the birth.

Fourteen days later the patient presented with complaints of abdominal pain and vaginal discharge.  The obstetrician treated the patient on an outpatient basis, prescribing oral antibiotics.  The patient’s symptoms did not improve and she was seen in the emergency department, where she was given the first intravenous dose of a long-acting antibiotic.  The patient underwent a diagnostic ultrasound the following day, which was read as revealing “retained products of conception.“

The obstetrician immediately performed another dilation and curettage; the pathology report found “inflamed decidua” but no placental tissue.  The patient was prescribed additional oral antibiotics and discharged from the hospital.  She returned four days later with continuing abdominal pain; physical examination found peritoneal irritation.  She was admitted to the hospital with a diagnosis of peritonitis.  The patient was treated with intravenous antibiotics and improved quickly.  She was released symptom-free from the hospital three days after admission.

The Board judged the obstetrician’s conduct as having fallen below the minimum level of competence given his failure to adequately supervise the midwife’s prenatal monitoring of the patient’s severe preeclampsia and his failure to have a plan of hospital admission if the antibiotics used to treat the patient’s abdominal pain and vaginal discharge two weeks postpartum were unavailing.

For this allegation and others, the Board ordered the obstetrician be placed on probation for a period of three years, complete 40 hours of continuing education per year of probation, enroll in a clinical or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE), be prohibited from supervising any physician assistants, and have a practice monitor assigned to him.

State: California


Date: November 2016


Specialty: Obstetrics


Symptom: Bleeding, Abdominal Pain


Diagnosis: Preeclampsia, Acute Abdomen


Medical Error: Failure to properly monitor patient, Referral failure to hospital or specialist


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Obstetrics – Failure To Recognize Preeclampsia In Early Preterm



The Board was notified of a professional liability payment made on 05/06/2015.

The Board expressed concern that an obstetrician was insufficiently aware of preeclampsia in a patient.  The Board expressed concern that the obstetrician’s conduct was below the minimum standard of competence given failure to manage a Category II (indeterminate) fetal heart tracing on the patient by continued observation.  The obstetrician obtained a biophysical profile on the patient in response to the Category II fetal heart tracing, but the study was insufficient to assure fetal well-being.  The Board acknowledged that the patient’s pregnancy was early preterm making the diagnosis of pre-eclampsia difficult, but remained concerned that the management of the patient fell below the standard of care.

The Board ordered the obstetrician to complete the ACOG course on Fetal Heart Rate Monitoring and complete the ACOG Task Force Publication on Hypertensive Disorders in Pregnancy Status.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It may not have been reported to the National Practitioner Data Bank.

State: North Carolina


Date: April 2016


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Preeclampsia


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Kansas – Obstetrics – History Of Hypertension And Presentation With Vaginal Bleeding And Cramping



On 2/25/2013, a 26-year-old pregnant female with a history of four prior pregnancies, resulting in four prior premature births, presented to the emergency department with complaints of vaginal bleeding and cramping.  The patient was documented to have a history of hypertension and an ultrasound confirmed an intrauterine pregnancy.

The patient was scheduled to see an obstetrician for follow-up care the following morning but failed to keep the appointment.

On 5/30/2013, the obstetrician saw the patient for an appointment.  He designated the appointment as the patient’s first prenatal visit. At the time of the appointment, the patient’s blood pressure was documented as 198/154.

That same day, the obstetrician sent the patient for a sonogram and lab tests with a follow-up appointment to be scheduled in two weeks.  Lab results showed that the patient had a urinalysis protein of 100, but there was no documentation showing the obstetrician reviewed the results or that the patient was contacted with the results.

On 6/4/2013, the patient returned to the obstetrician’s office.  The patient’s blood pressure was documented as 202/136.

The patient was subsequently admitted to a clinic that same day at approximately 5:00 p.m. with hypertension and severe headache.  The obstetrician’s admission diagnosis was documented as severe chronic hypertension, single intrauterine pregnancy at twenty-nine weeks.

The nursing notes for the patient’s admission to the clinic document that the patient arrived from the obstetrician’s office for a non-stress test and labs.  The nursing staff further documented that the patient was experiencing a severe headache with the right side of her head feeling numb.  Her blood pressure was documented at 208/129.

The obstetrician initially ordered pregnancy-induced hypertension lab testing but canceled the ordered labs.  The patient was given labetalol 400 mg by mouth twice daily with the first dose administered at approximately 5:37 p.m.  Two non-stress tests were also completed.

After the administration of Labetalol, the patient’s blood pressure slowly dropped with systolic measurements in the 160’s and diastolic measurements in the 90-100’s.

At 7:20 p.m., the clinic staff informed the obstetrician of the patient’s high blood pressure and requested medication and parameters.  The obstetrician instructed the staff that the patient was to be left alone and do nothing different.

At 8:00 p.m., orders were obtained by the staff to administer Tylenol for the patient’s continued headache.  However, the Tylenol was not effective as the patient continued to complain of a severe headache.

No new orders were issued for the remainder of 6/4/2013, but staff continued to document the patient’s blood pressure and fetal heart tones. The patient’s systolic measurements remained between 170-220’s and diastolic measurements remained in the 100’s.

At 4:47 a.m. on 6/5/2013,  the patient’s fetal heart tones were documented to have decreased to 125 for approximately 140 seconds, and then returned to baseline.  At 5:38 a.m., the patient was given labetalol 400 mg by mouth.

At 8:55 .m., the patient was documented as resting and denied having a headache or pain.

At 10:13 a.m., the obstetrician saw the patient and ordered a twenty-four hour urine protein.

At 3:25 p.m., the patient again complained of a constant, dull headache.  The patient was given Tylenol 1000 mg orally and later complained that she was feeling “shaky all over.”

At or around 4:03 p.m., the staff notified the obstetrician of the patient’s status, including the fact that the patient had an elevated blood pressure in spite of labetalol.  They asked whether the patient should be on bed rest.  The notified the obstetrician of the patient’s complaint of headache, shakiness, and limited voiding.  They asked if these issues could be related to preeclampsia.  The obstetrician gave no new order or diagnosis and stated that he would be on the OB floor in approximately an hour.

At 4:59 p.m., the patient was documented with a continued complaint of a headache when she moved her eyes.

At 5:20 p.m., the obstetrician was in to see the patient and again wrote orders reiterating the patient’s diagnosis of severe chronic hypertension, and ordered an EKG, echocardiogram, ophthalmology consult, continued twenty-four hour urine protein, and labetalol 20 mg IV bolus with a repeat dose of 40 mg IV if the patient’s blood pressure were to be greater than 160/110 after ten minutes, and to continue Labetalol 400 mg by mouth twice daily.

At 5:40 p.m., the obstetrician dictated the patient’s history and physical for her admission.  The obstetrician documented the patient had severe hypertension; had 100 mg/dl of proteinuria; had no headaches, and had “[n]o sign of preeclampsia at this time.”

The patient received an additional 80 mg of labetalol IV at 8:57 p.m. and her blood pressure remained in the severe level above 160/110, only dropping briefly to 185/115 before returning to the 200’s systolic and 120’s to 130’s diastolic.

On or about 6/6/2013, the patient’s blood pressure remained elevated despite receiving labetalol 40 mg IV at 12:57 a.m., 20 mg IV at 2:00 a.m., and 40 mg IV at 4:12 a.m.

The obstetrician was updated on the patient’s blood pressure status, but was not in to see the patient until 10:35 a.m.  At that time, the obstetrician ordered labetalol 400 mg by mouth every eight hours.

The patient’s previously ordered twenty-four urine protein results was 1953 mg/dl.  The obstetrician was notified by staff of the patient’s results and was documented as saying the patient’s protein was good.

The patient’s blood pressure continued to run in the 210-220’s systolic and 120’s-130’s diastolic

At 6:37 p.m., the obstetrician dictated a progress note for the patient documenting the patient as having severe chronic hypertension.  The obstetrician also noted the patient was on labetalol 400 mg three times daily and that the patient’s blood pressure remained high.  The obstetrician planned to continue the patient’s labetalol.

The patient’s blood pressure remained elevated and at 9:58 p.m. the obstetrician was notified of the situation and the patient’s complaint of a headache.  No new orders were given.

At 10:22 p.m., the obstetrician called to check on the patient’s condition.  The patient continued to complain of a headache and had a documented blood pressure of 221/129.

At 10:25 p.m., the obstetrician ordered “hydralazine 10 mg SIVP over 2 min x 1 Now” for the patient’s symptoms.

At 1:08 a.m. on 6/7/2013, the staff again contacted the obstetrician with the patient’s high blood pressure and headache.  The obstetrician gave orders for repeat a hydralazine 10 mg SIVP and for the patient to be started on magnesium sulfate.  Twenty minutes later the obstetrician ordered the magnesium sulfate to be held.

The patient continued to have a headache and at 1:42 a.m. was documented to complain of blurry vision.  The staff notified the obstetrician of the patient’s symptoms and continued headache.

At 5:34 p.m., the fetal heart rate dropped to sixty for two and a half minutes with recovery to the 120’s.

The patient continued to complain of a headache and at 5:49 p.m. the staff documented the patient as stating, “I feel like there is something wrong with me…I just don’t feel myself…headache is not going away and I feel weird.”

At 6:10 p.m., the obstetrician was in to see the patient who was complaining of upper abdominal pain, increasing headache pain and decreased urine output.  The obstetrician ordered the staff to give the patient hydralazine 10 mg SIVP, and magnesium sulfate 4 gm bolus followed by magnesium sulfate 2 gm/hr and betamethasaone intramuscularly.

The obstetrician also decided to transfer the patient to a different medical center for further care.

At 7:58 p.m., the patient was discharged to EMS care for transfer to a medical center.

In the obstetrician’s discharge summary for the patient, he documented that the patient was admitted with a diagnosis of “severe chronic hypertension with superimposed preeclampsia.”  In addition, he noted that he had given the patient three doses of labetalol, but failed to mention the three previous doses given during the early morning hours on 6/6/2013.

The board judged that the obstetrician failed to adhere to applicable stand of care to a degree constituting ordinary and/or gross negligence due to the following omission: the obstetrician delayed involving other specialists to assist the patient’s care and treatment, failed to acknowledge the patient’s proteinuria and high blood pressure, failed to diagnose and treat the patient’s severe preeclampsia, placed the patient at an increased risk for placental abruption, seizures, and renal damage, and stroke, and the obstetrician delayed to transfer the patient to a facility that could care for the patient and her premature infant.

The Board revoked the obstetrician’s license.

State: Kansas


Date: March 2016


Specialty: Obstetrics


Symptom: Bleeding, Headache, Numbness, Abdominal Pain, Vision Problems


Diagnosis: Preeclampsia


Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Obstetrics – High-Risk Pregnancy Complicated By Diabetes, Previous Cesarean Sections, Obesity, High Blood Pressure, Proteinuria, Abdominal Pain, And Abnormal Discharge



On 5/12/2011, a patient presented to an obstetrician for prenatal care as a new obstetric patient.  The patient’s last menstrual period was on 3/17/2011, and her expected delivery date was confirmed by ultrasound to be 12/22/2011.  Although this was a new pregnancy, the patient had been known to the obstetrician since the age of 15 because the obstetrician had treated the patient for at least two other prior pregnancies, and the obstetrician had known about the patient’s medical history and prior Cesarean sections.

Since the patient’s first delivery, the patient has had two additional Cesarean sections as well as an early miscarriage.  Despite knowing the patient’s medical history, the obstetrician reported no significant past medical history, but elevated blood pressures were documented outside of pregnancy, and the obstetrician documented that the patient was obese.  The history of a prior classical Cesarean delivery was not recorded on the ACOG flow sheets in this pregnancy or in the 2010 pregnancy for which the obstetrician also provide care.  The diagnosis of insulin-requiring gestational diabetes and preeclampsia in the patient’s 2010 pregnancy was also not documented.

On 5/12/2011, the patient’s first prenatal care, 2+ proteinuria was documented.  Although the patient’s protein levels fluctuated and rose throughout her pregnancy, records show that the obstetrician merely instructed the patient to drink more water, but did not show that the obstetrician referred the patient to a specialist to treat the proteinuria.  The patient failed her one-hour glucose tolerance test, which was elevated at 213.  There was no record that a diagnostic three-hour test was performed.  On 9/15/2011 (25 weeks) and 9/26/2011 (27 weeks), the patient complained of pressure and spotting.  Progress notes did not document a speculum exam, digital cervical exam, or ultrasound.  No record was found of any ultrasound besides the ultrasound performed on the initial visit.

On 7/15/2011, an elevated blood pressure was first detected at 17+ weeks of gestation.   Blood pressure was again increased on 10/26/2011 at 142/82 (at 31 5/7 weeks of gestation).  No note was made of this in the visit summary, and the patient was scheduled to return in two weeks.

On 11/10/2011 (34 weeks pregnant), the patient complained of pain/cramping, and the patient’s proteinuria was 4+. The abdominal exam was listed as “normal.”  No fetal heart rate was documented.  The patient was given a prescription for a narcotic pain reliever and terbutaline.  The obstetrician continued to follow the expected delivery date, which was scheduled for 12/15/2011.

On 11/17/2011, the patient presented to the hospital complaining of abdominal pain, vaginal bleeding, and having passed a large blood clot.  The patient was noted to be contracting irregularly.  Her blood pressure was elevated and proteinuria was again present.  After nursing staff communicated these findings to the obstetrician, he treated the patient by phone and ordered one liter IV hydration, a one-time dose of methyldopa (Aldomet), and IV butorphanol (Stadol).  A verbal order was also given to discharge the patient if the pain resolved.  The obstetrician did not examine the patient in person.

The obstetrician did not see the patient again until 11/29/2011, 19 days after her prior office visit.  The patient’s blood pressure was 152/85 and 4+ proteinuria was noted. The patient’s weight also increased 8 pounds in two weeks to 210 pounds.  No fetal heart rate was documented.  The patient complained of increased swelling, off and on headaches, and a pink vaginal discharge.  The patient was given a prescription for Aldomet and instructed to rest.  The visit summary documented a plan for a follow-up appointment in one week.

At 3:50 p.m. on 11/29/2011, the patient presented to the labor and delivery department of the hospital complaining of severe abdominal pain and no fetal activity for one-hour.  The nurses placed the patient in her bed but could not document a fetal heart rate.  The obstetrician was called at 3:56 p.m. and arrived at 4:02 p.m.  The obstetrician documented a very slow fetal heart rate by ultrasound.  An emergency Cesarean section was performed.  A uterine rupture and complete abruption of the placenta occurred, and the fetus was not alive when evacuated from the uterus.

Proteinuria on a subsequent formal UA was 2+.  The obstetrician did not mention a diagnosis of preeclampsia in his notes, nor did he order magnesium sulfate for seizure prophylaxis.  The blood pressure was noted to be 147/85 on post-operative day one.  The patient was discharged on post-operative day two.  The patient was seen for a post-operative visit for staple removal on 12/5/2011.  The patient had lost 25 pounds in five days, and her blood pressure was 169/94 at that time.  This was not mentioned in the visit summary.  There was no documentation that the patient was questioned about symptoms of preeclampsia or that any additional evaluation was ordered.  The patient was scheduled to return in five weeks.

The Medical Board of California judged that the obstetrician committed gross negligence in his care and treatment of the patient given that he failed to properly manage a high-risk pregnancy with a prior classical Cesarean section, diagnose and manage a pregnant woman with chronic hypertension, chronic proteinuria, and suspected preeclampsia and gestational diabetes, maintain and/or document the patient’s medical/surgical history as well as the care and procedures provided during patient visits, and deliver the baby earlier despite signs of fetal distress, which were evident before 11/29/2011 and the previously scheduled expected delivery date of 12/15/2011. The obstetrician also allowed a 19-day interval between the last two patient visits in a high-risk patient as well as failed to follow up on an elevated one-hour glucose, document any laboratory evaluation of proteinuria, document any sonograms, non-stress test, or biophysical profiles, and evaluate vaginal bleeding notes at 25 and 27 weeks gestation.

The Medical Board of California ordered that the obstetrician complete an education course, medical record keeping course, and clinical training program equivalent to the courses offered at the University of California San Diego School of Medicine (Program).

State: California


Date: October 2015


Specialty: Obstetrics


Symptom: Abnormal Vaginal Bleeding, Abnormal Vaginal Discharge, Headache, Abdominal Pain


Diagnosis: Preeclampsia, Diabetes


Medical Error: Failure to examine or evaluate patient properly, Underestimation of likelihood or severity, Failure to follow up, Improper treatment, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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



California – Obstetrics – Ampicillin Use During Induction Of Labor In GBS Negative Patient



A 24-year-old female at 39 weeks 2 days gestation was admitted to the hospital by an obstetrician on 2/2/2012 for induction of labor due to mild preeclampsia.  Induction of the patient’s labor was started on the evening of 2/2/2012. At 2:08 p.m. on 2/3/2012, the obstetrician examined the patient and performed artificial rupture of the membranes.  The obstetrician then gave an order to administer ampicillin 2 g IV bolus dose followed by 1 g IV every 4 hours until delivery, which ultimately occurred at 5:45 a.m. on 2/3/2012.

The patient was known to be negative for GBS (group B streptococcus), the most common reason for giving ampicillin to patients in labor.  The obstetrician did not document any indication for this order, and no indication was apparent from the patient’s medical record.

The Medical Board of California judged that the obstetrician’s conduct departed from the standard of care because she ordered ampicillin in circumstances in which it was not indicated.

For this case and others, the Medical Board of California placed the obstetrician on probation for 7 years and ordered the obstetrician to complete a medical record keeping course, a professionalism program (ethics course), an education course (at least 40 hours per year for each year of probation), and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.  The obstetrician was also ordered to have a psychiatric evaluation and receive psychotherapy. The obstetrician was required to have a practice monitor.2

State: California


Date: September 2015


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Preeclampsia


Medical Error: Improper medication management, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Virginia – Obstetrics – 29 Weeks Pregnant With Persistent Hypertension And Proteinuria



On 2/25/2013, a 26-year-old pregnant female with a history of four prior pregnancies resulting in four prior premature births presented to the emergency department with complaints of vaginal bleeding and cramping.  The patient had a history of hypertension and a prior ultrasound confirming intrauterine pregnancy.

The patient was referred and scheduled to see an obstetrician for follow-up care the following morning but failed to keep the appointment.

On 5/30/2013, the obstetrician saw the patient for an appointment.  The obstetrician designated the appointment as the patient’s first prenatal visit.  At the time of the appointment, the patient’s blood pressure was documented at 198/154.

The same day, the obstetrician sent the patient for a sonogram and lab tests with a follow-up appointment to be scheduled in two weeks.  The urinalysis revealed a protein of 100 but there was no documentation showing that the obstetrician reviewed the results.

On 6/4/2013, the patient returned to the office with a blood pressure of 202/136.

On the same day, the patient was admitted with hypertension and a severe headache.  She was diagnosed with severe chronic hypertension and single intrauterine pregnancy at twenty-nine weeks.

Nursing notes for the patient’s admission documented that the patient arrived from the obstetrician’s office for a non-stress test and labs.  The nursing staff further documented that the patient was experiencing a severe headache with the right side of her head feeling numb and her blood pressure was documented at 208/129.

The obstetrician initially ordered pregnancy-induced hypertension lab testing but canceled the ordered labs.  The patient was given “400 mg po bid” of labetalol with the first dose administered at approximately 5:37 p.m.  Two non-stress tests were also completed.

After the administration of labetalol, the patient’s blood pressure slowly dropped with systolic blood pressure in the 160’s and diastolic blood pressure in the 90-100’s.

At 7:20 p.m., the hospital staff informed the obstetrician of the patient’s high blood pressure and requested medications and parameters.  The obstetrician staff had no further recommendations.

At 8:00 p.m., the orders were obtained by staff to administer acetaminophen for the patient’s continued headache.  However, the acetaminophen was not effective as the patient continued to complain of a severe headache.

For the rest of the night, the obstetrician wrote no further orders.  The staff continued to document the patient’s blood pressure and fetal heart tones.  The patient’s systolic blood pressures remained between 170-220’s and diastolic measurements remained in the 100’s.

On 6/5/2013 at 4:47 a.m., the patient’s fetal heart tones decreased to 125 for 140 seconds and then returned to baseline.  At 5:38 a.m., the patient was given 400 mg p.o. of labetalol.

At 8:55 a.m., it was documented that the patient was resting and she denied having a headache or pain.

At 10:13 a.m., the obstetrician saw the patient and ordered a twenty-four hour urine protein.

At 3:25 p.m., the patient again complained of a constant, dull headache.  The patient was given 1000 mg of acetaminophen orally and later complained that she was feeling “shaky all over.”

At 4:05 p.m., the staff notified the obstetrician of the patient’s status including the fact that the patient had an elevated blood pressure in spite of labetalol.  Staff also asked whether the patient should be on bed rest.  The patient complained of having a headache and shakiness.  Her urine output was decreased.  Staff was concerned whether these issues could be due to preeclampsia.  The obstetrician gave no new orders or diagnoses and stated that he would be on the floor in an hour.

At 4:59 p.m., the patient was documented with the complaint of a headache when she moved her eyes.

At 5:20 p.m., the obstetrician was in to see the patient and reiterated the patient’s diagnosis of severe chronic hypertension.  He wrote for an EKG, an echocardiogram, an ophthalmology consult, a 20 mg labetalol IV bolus, and a repeat dose of 40 mg labetalol IV if the patient’s blood pressure was greater than 160/110 after ten minutes.  He wrote for a continuation of 400 mg labetalol orally twice a day.

At 5:40 p.m., the obstetrician dictated the patient’s history and physical for her admission.  The obstetrician documented that the patient had severe hypertension, had 100 mg/dl of protein in her urine, had no headaches, and had “[n]o sign of preeclampsia at this time.”

The patient received an additional 80 mg of labetalol IV at 8:57 p.m. and her blood pressure remained in the severe level above 160/110, only dropping briefly to 185/115 before returning to the 200’s systolic and 120’s to 130’s diastolic.

On 6/6/2013, the patient’s blood pressure remained elevated despite receiving labetalol 40 mg IV at 12:57 a.m., 20 mg IV at 2 a.m., and 40 mg IV at 4:12 a.m.

The obstetrician was updated on the patient’s blood pressure status but was not in to see the patient until 10:35 a.m.  At that time, the obstetrician ordered labetalol 400 mg by mouth every eight hours.

The patient’s previously ordered twenty-four urine protein result was 1953 mg/dl.  The obstetrician was notified by staff of the patient’s result and is documented as saying the patient’s urine protein was “good.”

The patient’s systolic blood pressure continued to run in the 210’s-220’s and diastolic blood pressure in the 120’s-130’s.

At 6:37 p.m., the obstetrician dictated a progress note for the patient documenting that the patient as having severe chronic hypertension.  The obstetrician also noted that the patient was on labetalol 400 mg three times a day and that the patient’s blood pressure remained high.  The obstetrician planned to continue the patient’s labetalol.

The patient’s blood pressure remained elevated and at 9:58 p.m., the obstetrician was notified of the blood pressure and the patient’s complaint of a headache.  No new orders were given.

At 10:22 p.m., the obstetrician called to check on the patient’s condition.  The patient continued to complain of a headache and had a documented blood pressure of 221/129.

At 10:25 p.m., the obstetrician ordered “Hydralazine 10 mg SIVP over 2min x 1 Now” for the patient’s symptoms.

On 6/7/2013 at 1:08 a.m., the staff again contacted the obstetrician with the patient’s hypertension and headache.  The obstetrician gave orders for repeat hydralazine 10 mg SIVP (“slow IV push”) and for the patient to be started on magnesium sulfate.  Twenty minutes later the obstetrician ordered the magnesium sulfate to be held.

The patient continued to have a headache and at 1:42 a.m. was documented to complain of blurry vision.  Staff notified the obstetrician of the patient’s symptoms and continued headache.

At 5:34 p.m., the fetal heart rate dropped to sixty for two and a half minutes with recovery to the 120’s.

The patient continued to complain of a headache.  At 5:49 p.m., the staff documented the patient as stating, “I feel like there is something wrong with me…I just don’t feel myself…headache is not going away and I feel weird.”

At 6:10 p.m., the obstetrician was in to see the patient, who was complaining of upper abdominal pain, worsening headache, and decreased urine output.  The obstetrician ordered staff to give the patient hydralazine 10 mg SIVP and magnesium sulfate 4 gm bolus followed by magnesium sulfate 2 gm/hr and betamethasone intramuscularly.

The obstetrician also decided to transfer the patient to a different medical center for further care.

At 7:58 p.m., the patient was taken by ambulance to a different medical center.

In the obstetrician’s discharge summary, he documented the patient was admitted with a diagnosis of “severe chronic hypertension with superimposed preeclampsia.”  In addition, he noted that he had given the patient three doses of labetalol but failed to mention the three prior doses given during the early morning hours on 6/6/2013.

On 6/4/2014, the obstetrician’s clinical privileges at the hospital were revoked.

The Board raised concern that the obstetrician failed to achieve the standard of care in the following ways:

  1. The obstetrician delayed in consulting other specialists.
  2. The obstetrician failed to promptly address the patient’s proteinuria and hypertension.
  3. The obstetrician failed to diagnose and treat the patient’s severe preeclampsia.
  4. The obstetrician placed patient at an increased risk for placental abruption, seizures, renal failure, and stroke.
  5. The obstetrician delayed in transferring the patient to a facility capable of caring for her.

The obstetrician’s license was revoked by the State of Kansas and suspended by the Board of Virginia.

State: Virginia


Date: July 2015


Specialty: Obstetrics


Symptom: Headache, Bleeding, Gynecological Symptoms, Numbness, Abdominal Pain, Vision Problems


Diagnosis: Preeclampsia


Medical Error: Underestimation of likelihood or severity, Delay in proper treatment, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Obstetrics – Increasing Blood Pressure After Suspected Fetal Macrosomia And Cesarean Section



A 31-year-old gravida-1, para-0 patient started seeing an obstetrician for her prenatal care on 5/12/2006.  Her initial estimated date of delivery (EDD) was calculated as 12/3/2006; however, based on an ultrasound taken at 7.4 weeks of pregnancy, the EDD was changed to 12/26/2006.  The patient was a hepatitis B carrier. An AFP test done during her pregnancy was normal. On 12/28/2006, the patient was at 40.2 weeks of pregnancy. Her blood pressure was 117/75, and she had gained 48 pounds to date.  Fundal height was 40, and the fetal heart rate was 145.

On 1/1/2007, the patient was admitted to labor and delivery (L&D) at a medical center for induction of labor.  She was admitted by another obstetrician, who started her on intravaginal misoprostol. On 1/3/2007, two days later, she was diagnosed as failed induction and suspected fetal macrosomia.  She underwent a Cesarean section and delivered a live baby girl weighing 9 pounds and 8 ounces. The patient’s post-operative course was uneventful, and on 1/6/2007 she was discharged home.  Her last recorded blood pressure at the time of discharge was 149/71.

On 1/10/2007, the patient was seen by the obstetrician in his office for a follow-up.  Her blood pressure was measured at 163/96. A second blood pressure was not taken to verify the elevated reading, nor was the elevated blood pressure evaluated or acted upon.  The patient asked the obstetrician for a prescription for her high blood pressure; however, the obstetrician advised her to seek care from her primary care physician. During this office visit, the patient’s skin staples were removed.

On 1/14/2007, the patient presented to the medical center emergency department complaining of severe headache and vomiting.  She was given pain medications, and a CT scan of her head was ordered. A urinalysis was obtained with the final computer printout of the results showing 30 ml/Dl protein or the presence of +1 protein.  The patient’s first recorded blood pressure was 153/84. Another blood pressure during the triage was recorded at 192/119.

At 2:00 a.m. on 1/15/2007, the patient underwent an epidural blood patch by an anesthesiologist.  The epidural blood patch was repeated at approximately 2:20 a.m. due to lack of relief from the presumed spinal headache after the first injection of blood.  Her blood pressure was recorded in the anesthesia history and physical as 140/80. The patient was discharged from the emergency department at 4:30 a.m. Her blood pressure in the emergency department ranged from 153/90 to 169/101.

Shortly after arriving home, the patient had a seizure.  She started shaking, and her eyes rolled up into her head.  A 911 call was made, and the patient was taken by ambulance back to the medical center emergency department, arriving approximately 1.5 hours after she had left.  Her blood pressure was 167/93, and one hour later it was 143/90. She was admitted by the obstetrician and placed on IV magnesium sulfate. A brain MRI came back normal.  The postpartum severe pre-eclampsia order set was utilized, and the patient was placed under the care of a perinatologist. On 1/18/2007, the patient was well enough to be discharged home.

The obstetrician committed gross negligence in his care and treatment of the patient, which included: failure to document his awareness of the patient’s elevated blood pressure and failure to identify the patient’s elevated blood pressure as a possible postpartum complication.

For this allegation as well as others, the State Board of California ordered the obstetrician to be placed on probation for three years as well as to attend a medical record keeping course, a PACE program, be assigned a practice monitor during the probation period, and be prohibited from supervising physician assistants during the probation period.

State: California


Date: May 2014


Specialty: Obstetrics


Symptom: Headache, Nausea Or Vomiting, Seizure


Diagnosis: Preeclampsia


Medical Error: Diagnostic error, Failure to follow up, Lack of proper documentation, Procedural error


Significant Outcome: Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



California – Obstetrics – Untreated Pregnancy Induced Hypertension And Discordant Twins



On 8/18/2009, a 24-year-old patient, gravida 1, para 0, and at 23-24-weeks twin gestation presented to an obstetrician’s medical office for prenatal care.  She previously had some prenatal care in Mexico. Her estimated date of delivery was 12/9/2009. According to the records, she saw the obstetrician on 8/24/2009, 9/7/2009, 9/22/2009, 10/6/2009, and 10/27/2009.  Clinically, her size was within range until 31 weeks of gestation. At 34 weeks, the patient measured 38 weeks.

On 10/27/2009, the patient exhibited a blood pressure of 118/80, was complaining of a headache, and had a 3+ protein reading.  The patient’s charts did not include records relating to hyperreflexia or edema. Subsequently, the obstetrician referred her to the hospital for admission and evaluation of pregnancy-induced hypertension (PIH).

The patient was admitted to the hospital on 10/28/2009 where a routine order set was given, plus toxemic panel.  No evaluation or magnesium sulfate was started. A total obstetric ultrasound was ordered as well as a urinary catheter.  The patient’s blood pressure upon admission was 145/95 and 3+ protein reading in the urine. According to the records, the patient’s blood chemistries were in the chart at 4:15 p.m. with serum glutamic oxaloacetic transaminase (AST) at 205, serum glutamic pyruvic transaminase (ALT) at 190, uric acid at 6.7, and cathed urine showed +2 albumin at 5:30 p.m.  The ultrasound revealed gross discordance of the twins 2545 grams to 1242 grams and an amniotic fluid index (AFI) of 21 and 0.

The obstetrician was notified of the results, and at 8:00 p.m., he ordered repeat labs.  At 11:00 p.m., ampicillin was ordered and consent was given for a Cesarean section the next morning.  Despite a low finding of 60,000 platelets, the obstetrician merely ordered a repeat platelet count for the next morning, which yielded a result of 56,000.  The obstetrician then ordered a unit of platelets for the Cesarean section. The obstetrician failed to order any magnesium sulfate or any other anti-hypertensive for the patient.  The obstetrician did not see the patient on the evening of 10/27/2007.

The obstetrician failed to order an ultrasound before 10/27/2007.  The patient’s medical charts did not contain ultrasounds. The discordance of one of the twins was not discovered before 10/27/2007.

On the morning of 10/28/2007, the obstetrician dictated the patient’s history and physical for the Cesarean section.  Additionally, he wrote and signed the post-operative routine orders before the surgery was performed. However, the obstetrician’s orders were canceled and the patient was transferred urgently to another hospital and admitted as an emergency case of PIH, discordant twins, and HELLP syndrome.  The patient delivered the infants at 2:56 p.m. Twin A was 850 g and twin B was 2240 g. The patient made a normal recovery, but twin A did not survive.

For this allegation and others, the Medical Board of California ordered that the obstetrician be placed on probation for one year, attend an education course, and be assigned a practice monitor.

State: California


Date: October 2013


Specialty: Obstetrics


Symptom: Headache


Diagnosis: Preeclampsia, Obstetrical Complication


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


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



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