Found 144 Results Sorted by Case Date
Page 10 of 15

California – Obstetrics – Prescribed Misoprostol For Suspected Miscarriage Yields Breathing Baby



A patient was seen by her primary care physician at a medical facility on 8/17/2009.  The physician chart entries from that visit stated that the patient reported that she had not had a menstrual period for 3 months and noted a positive serum pregnancy test result.  Her physician advised the patient to stop her medications and schedule an obstetric/gynecological consult the following week.

On 8/31/2009, an obstetrician first saw the patient.  The obstetrician’s chart entries for this initial visit reflected a brief history and stated that the patient was experiencing no pregnancy symptoms, that the patient believed her last menstrual period had been about 3 months prior and that she suffered from hypertension and cirrhosis.  The obstetrician performed a transvaginal ultrasound and documented her findings as “No sac in uterus, stripe normal. No masses seen.” The obstetrician did not perform a manual physical examination, believing that the patient’s body structure precluded a meaningful physical examination.  The obstetrician ordered a pregnancy hormone level test to be done that day and repeated two days later. The patient’s pregnancy hormone test results were 21914 mIU/ml on 8/31/2009 and the 9/2/2009 test result yielded a reading of 21795 mIU/ml.

The obstetrician had numerous conversations by telephone with the patient over the following 10 days, which included informing the patient that the laboratory results were consistent with miscarriage.  In their conversation, the obstetrician also described 3 alternatives she was recommending to the patient: await delivery of the residue of pregnancy tissue without medical intervention; undergo a dilation and curettage to surgically cleanse the uterus; or use misoprostol to chemically induce labor and thereby deliver the pregnancy tissue.  The obstetrician did not order a repeat hCG test nor did she perform a second ultrasound or a more encompassing transabdominal ultrasound to confirm her diagnosis of miscarriage. On 9/10/2009, the patient informed the obstetrician of her decision to use misoprostol.

The obstetrician prescribed analgesics and the requisite dose of misoprostol for the patient on  9/10/2009. The patient arrived at the medical facility that day to pick up the medications and the printed instructions for administering the misoprostol at home.  As the instructions directed, the patient self-administered the misoprostol about 4:00 p.m. that afternoon. At 2:00 a.m. the next morning, the patient suffered prolonged contraction-like pains and delivered a moving fetus.  The paramedics found fetal heart tones and attempted to maintain heartbeat and breathing, but declared the death of the fetus at 2:45 a.m.

The obstetrician’s care and treatment for the patient showed negligence, including: failure to conduct a more comprehensive initial antepartum evaluation, particularly in light of ultrasound findings inconsistent with the patient’s believed date of possible conception; and the obstetrician’s election to offer misoprostol to a patient in whom the obstetrician’s transvaginal ultrasound had revealed no pregnancy tissue.

For this allegation and others, the Medical Board of California issued that the obstetrician be placed on probation for five years, attend a PACE program, and be prohibited from solo practice.

State: California


Date: March 2013


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 follow up, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



California – Obstetrics – Team Of Medical Students And Residents And Non-Reassuring Fetal Heart Rates



On 9/23/2006 at 4:30 p.m., a patient presented to a medical center in early labor.  She was at 40.5 weeks gestation. Her membranes had ruptured prematurely at approximately 8:00 a.m.  The patient received her prenatal care at a high-risk obstetric clinic because she had complications of cervical incompetence.  She had a cervical cerclage procedure done at 19 weeks gestation.

The attending obstetrician for the patient was part of the treatment team along with a third-year obstetric resident, as well as various medical students.  The patient was initially evaluated in the Triage unit, beginning at 4:40 p.m. on 9/23/2006. Her fetal heart tone (FHT) baseline rate was in the 160s and had average variability and no decelerations but no accelerations.  The patient was examined by a first-year obstetric resident, who confirmed ruptured membranes. It was noted that the patient’s cervix was 1-2 cm dilated, 90% effaced, with vertex at -2 station, and her contractions to be regular every minute.

At 6:00 p.m., an admission history and physical were taken by a fourth-year medical student and cosigned by the third-year obstetric resident, as well as the obstetrician.  The history and physical noted the occurrence of 2 late decelerations. There were 2 decelerations occurring during the same time frame at 5:52 p.m and 5:55 p.m., with the lowest bpm of 100 and 90-130 bpm and durations over 120 seconds.  The third-year obstetric resident was notified of the decelerations; the response was to position changes and an IV fluid bolus.

At 7:00 p.m., the patient’s temperature had risen to 100 F, and the FHT baseline remained in the 160s.  At 8:07 p.m., the third-year obstetric resident saw the patient because of decelerations to the 90s bpm persisting for 6.5 minutes.  The third-year obstetric resident noted that the patient’s cervix was 2 cm dilated. At 9:50 p.m., she noted findings of 2/90/-2 and contractions occurring every 1-2 minutes.  She also noted that there had been severe variable decelerations to the 90s, lasting 2 minutes at 9:30 p.m. Her interpretation was that the strip was overall reassuring. The third-year obstetric resident noted in the chart at 11:10 p.m. her examination of the patient, which revealed 3-4/100/-2.  She again noted “at times” there were severe variable decelerations to the 80s, lasting 1-2 minutes. Again, she interpreted the fetal strip as reassuring. The obstetrician did not meet with the patient.

On 9/24/2006, at 12:40 a.m., the third-year obstetric resident noted that it was difficult to assess the patient’s contractions.  She also recorded the occurrence of decelerations to the 100s lasting 30-60 seconds. The third-year obstetric resident examined the patient and found her cervix was completely dilated.  She noted that the patient would be encouraged to start pushing and “see how the fetal tracing is.” The intrapartum flowsheet revealed the persistence of what the nurses interpreted as variable decelerations down to 80-110 bpm “following cessation of contractions, gradual rise to baseline” since approximately 10:00 p.m. on 9/23/2006.  The “USCD Retired Items” printout indicated that the fetal heart rate (FHR) baseline ranged from 130-136 bpm and was associated with minimal (<5 bpm amplitude) variability beginning at 1:00 a.m. The obstetrician did not meet with the patient.

At 2:15 a.m., the obstetrician, the third-year obstetric resident, and a first-year obstetric resident were notified of imminent delivery and were presented in the labor room at 2:20 a.m.  This was the first time the obstetrician had met with the patient or entered her room. At 2:28 a.m, the first-year obstetric resident delivered the baby’s head, which was followed by a thick meconium.  The third-year obstetric resident took over the delivery at that point, completing the delivery shortly thereafter. The baby showed no signs of life, and a pediatrician was summoned. The third-year obstetric resident handed the baby to the obstetrician, who transported her to the warmer in the delivery room, where she attempted to stimulate the baby.  Approximately 30 seconds later, the respiratory therapist and neonatal nurse arrived and took over resuscitation. The baby’s Apgar scores were 0, 3, and 3 at 1-, 5-, and 10-minute intervals. The arterial cord blood gas pH was 6.69, pCO2 was 107, pO2 was 11, base deficit was 26 mmol/L, and HCO3 was 12, which were consistent with a mixed metabolic and respiratory acidosis and the diagnosis of perinatal asphyxia.

The patient’s baby was ultimately resuscitated after 4 minutes; however, she immediately manifested signs of hypoxic-ischemic encephalopathy with seizures beginning in the first day of life.  She also had multiple organ system failure and irreversible brain damage. On 10/2/2006, the baby was taken off life support and passed away. Her final diagnosis included severe hypoxic-ischemic encephalopathy, seizures, acidosis, respiratory failure, acute tubular necrosis, acute renal failure, and coagulopathy.

The obstetrician did not make any progress notes documenting her participation in the management and care of the patient.  The obstetrician committed repeated acts of negligence in her care and treatment of the patient including: failing to provide adequate supervision to her resident physician and ultimately failing to provide adequate care for the patient; failing to document her participation in the management and care of the patient; failing to obtain informed consent from the patient to pursue expectant management of her pregnancy, rather than the option of intervention with a Cesarean section, when non-reassuring fetal heart rate changes suggested the likelihood of intrauterine asphyxia; and failing to recognize non-reassuring fetal heart rate patterns.

The Medical Board of California ordered that the obstetrician be placed on probation for one year, attend an education course, a medical record keeping course, and be prohibited from supervising physician assistants.

State: California


Date: February 2013


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Diagnostic error, Failure of communication with patient or patient relations, Improper supervision, Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Obstetrics – A Woman With Polycystic Ovarian Syndrome Offered Ovarian Drilling



On 08/16/2002, a 29-year-old woman gravida 2, para 2-0-0-2, presented to an obstetrician after her primary care physician could not locate her IUD at an annual examination.  The patient asked the obstetrician if the IUD was properly placed.  The patient also complained of hirsutism.  The obstetrician documented that the patient reported having polycystic ovarian syndrome with consequent metabolic abnormalities and hormonal imbalance and reported that she would be interested in potentially having another pregnancy. The obstetrician reviewed laboratory results from October 2005 and agreed with the diagnosis of PCOS. The obstetrician recommended ovarian drilling as the treatment plan.

On 01/13/2007, the patient contacted the obstetrician expressing interest in tubal ligation and the ovarian drilling procedure.  On 02/09/2007, the patient was admitted to the hospital for laparoscopy, bilateral tubal cautery, lysis of adhesions, ovarian drilling, cautery of endometrial implants, and removal of Mirena IUD.

The Board stated that “Ovarian drilling is not indicated for treatment of metabolic abnormalities in PCOS or hormone imbalance.  Respondent’s conduct in proceeding with an ovarian drilling procedure when not indicated as a treatment for hormone imbalance or metabolic disease evidences a lack of knowledge which creates the risk to the patient of an unnecessary surgery with all attendant risks, including the risks accompanying general anesthesia, up to and including death.”  The Board reprimanded the obstetrician.  In light of other instances of unprofessional conduct, limitations were placed on her license to practice.

State: Wisconsin


Date: February 2013


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Gynecological Disease


Medical Error: Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Wisconsin – Obstetrics – Persistent Headaches With Menometrorrhagia



From 04/13/2004 to 07/19/2007, Obstetrician A provided treatment to a 38 year old woman gravida 3, para 2-1-0-3, for menometrorrhagia and migraine headaches attributed to the patient’s menstrual cycles and stress.  Obstetrician A attempted control of symptoms with multiple medications, including acetaminophen/butalbital/caffeine, acetaminophen/butalbital/caffeine with codeine, propranolol, sumatriptan, rizatriptan, and hormonal manipulation without success.

On 02/17/2006, the patient underwent a laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy for menometrorrhagia and menstrual migraines performed by Obstetrician A.  During the procedure, Obstetrician A noted significant bleeding from the patient’s left port site and along “established endo GIA staple sites that were initially stapled intraoperatively.”  Obstetrician A did not address the intraoperative bleeding until completion of the laparoscopic portion of the procedure.  After the procedure, Obstetrician A was called regarding bleeding at the 5 mm suprapubic site, which had not previously bled.  Patient received 4 units of blood after the surgery on 02/17/2006 and 02/18/2006.

The Board judged that the patient exposed the patient to unacceptable risk by undergoing surgery with risk of significant complication prior to pursuing conservative measures.  In addition, Obstetrician A failed to control bleeding prior to completing the laparoscopic portion of the procedure.  The Board reprimanded Obstetrician A.  In light of other instances of unprofessional conduct, limitations were placed on her license to practice.

State: Wisconsin


Date: February 2013


Specialty: Obstetrics


Symptom: Headache, Bleeding


Diagnosis: Gynecological Disease


Medical Error: Improper treatment, Failure of communication with patient or patient relations, Unnecessary or excessive treatment or surgery


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Obstetrics – Cesarean Section Performed Four Hours After Fetal Heart Decelerations Noted



On 1/28/2009, an 18-year-old pregnant female patient, at 40-weeks gestation, was admitted to the hospital for induction of labor.  On 1/29/2009 at 4:00 a.m., the patient commenced active labor. An artificial rupture of membranes was carried out by the obstetrician at 7:45 a.m.  At 8:00 a.m. to 8:35 a.m., variable fetal heart rate decelerations were noted. At 8:45 a.m,, the obstetrician was notified of an audible fetal heart, bradycardias down to 50 beats per minute (BPM) and recovery to 110 BPM, and average variability.  At 10:15 a.m., variable heart rates were noted, and at or about 10:30 a.m., amnio-infusion was started. Variable decelerations of the fetal heart rates were recorded at 10:45 a.m., with more severe bradycardias with apparent loss of variability. At 11:00 a.m., fetal head stimulation resulted in acceleration of the fetal heart rate.  Fetal heart rate variability began to decline at 11:00 a.m. and by 11:47 a.m. was nearly absent.

At 12:05 p.m., the obstetrician recorded that the option for Cesarean section was given to the patient.  At 12:09 p.m., the obstetrician noted a plan for Cesarean section for persistent variable decelerations. At 12:15 p.m., fetal heart tracings showed further deterioration, fetal heart bradycardias followed by tachycardias, and complete loss of variability.  At 12:20 p.m., the obstetrician ordered an emergency Cesarean section. At 12:24 p.m., the fetal heart rate showed a linear downhill fall, turned to a flat line, and remained flat at lower than 60 BPM. At 12:35 p.m., the patient arrived in surgery. At 12:45 p.m., surgery began when general anesthesia was initiated.

Neonatal delivery time was reported at 12:47 p.m.  A male infant, 7 pounds 10 ounces, was born with the umbilical cord tightly wrapped around its neck, in critical condition.  A pediatrician took over care of the infant. Although an endotracheal tube was placed, oxygen provided, and external cardiac massage was given, the infant’s Apgar score reported by the nursing staff was 0 at one minute, 5 minutes, and 10 minutes.  The infant expired.

The obstetrician committed gross negligence in his care and treatment of the patient, which included: failure to timely recognize and respond to signs and symptoms of severe fetal distress, and failing to perform a timely Cesarean section delivery on the patient, a laboring woman with severe fetal distress.

The Medical Board of California ordered the obstetrician to be placed on probation for three years and attend a PACE program as well as monitoring practice.  The obstetrician was prohibited from supervising physician assistants during the probation.

State: California


Date: January 2013


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Delay in diagnosis, Delay in proper treatment


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



Wisconsin – Obstetrics – Headache, High Blood Pressure, Obesity, And Pregnancy With Patient Declining Hospitalization



On 9/15/2011, a 26-year-old woman presented for her first prenatal visit.  Her weight was 194 pounds and her blood pressure was 140/88.  On 3/30/2011, her pre-pregnancy blood pressure was 138/86.  The physician, a family practitioner, prescribed prenatal vitamins and ordered labs.  He did not order a 24 hour urine protein.  On 9/19/2011, an ultrasound confirmed a 25 week pregnancy.

On 9/22/2011, the patient presented with headache, a weight of 200 pounds and had a blood pressure of 158/120.  The physician documented the possibility of pre-eclampsia.  Labetalol 200 mg twice a day was prescribed.  Urinalysis revealed urine protein of 100.  On 9/23/2011, she was called by the physician to discuss the lab results and to advise her to go to the hospital.  She refused.  The physician obtained the support of the patient’s mother, but the patient still refused.  The physician called a specialist, who agreed to see the patient.  The patient was supposed to call the specialist, but she never did.  The physician documented that he advised the patient on the risk of seizures, but not stroke, maternal death, or fetal death.

On 9/29/2011, the patient complained of nasal congestion and yellow drainage.  Her blood pressure was 150/120.  Again, she was told that she needed to go to the hospital given the risk of seizures and hypertension,  The patient again refused.  Labetalol was increased to 300 mg three times a day.  Amoxicillin 500 mg twice a day was prescribed.  A 24 hour urine study revealed urine protein at 10930 (normal was less than 149).  The physician increased labetalol.

The patient presented on October 3rd (Monday), where her blood pressure was 160/130.  She was again advised to go to the hospital.  The patient declined and said she would see the specialist, but over the next several days, the patient had not seen the specialist.  The physician then called the specialist to set up an appointment for Thursday.  On October 5th, the patient was hospitalized for eclampsia.  She had a code blue with resuscitation, renal failure requiring diuresis, anemia requiring multiple transfusions, and pneumonia requiring intubation.  A Cesarean section was done at 27 weeks of pregnancy.  The baby required managing in the NICU.

The Board concluded that the physician’s care of the patient was below the minimal standard of care.  There was no documentation that he notified the patient of the risk of maternal or fetal death.  He did not order a 24 hour urine protein study at the first visit.  He did not insist that the patient see an obstetrician or a specialist in maternal fetal medicine that day on October 3rd, where the patient was at high risk for complications.  He increased labetalol for management of preeclampsia, when such treatment would be considered insufficient.  The Board reprimanded the physician and ordered completion of 6 hours of continuing medical education in recognizing and managing preeclampsia and obstetrical emergencies.  A pre-approved course was noted to be “Family Centered Maternity Care Self-Study Package” offered by the American Academy of Family Physicians.

State: Wisconsin


Date: December 2012


Specialty: Obstetrics, Family Medicine


Symptom: Headache


Diagnosis: Preeclampsia


Medical Error: Improper treatment, Failure of communication with patient or patient relations, Physician concern overridden, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Obstetrics – Fetal Macrosomia With Breech Presentation



On 9/7/2006, a 25-year-old obese female with a history of gestational diabetes for her last 2 pregnancies and difficult deliveries with severe shoulder dystocia, presented to the obstetrician at 12 weeks gestation for her first prenatal visit.  The obstetrician documented the plan to perform a Cesarean section to avoid complications of shoulder dystocia.

On 01/30/2007, the patient presented to the obstetrician, who noted that the fetal non-stress test was reactive.  An ultrasound was ordered and revealed the following:

Findings: A single live fetus lives in the breech position.  There is appropriate movement and documented cardiac activity.  Fetal survey was normal and a three-vessel umbilical cord present.

Biparietal diameter: 8.3 (33 weeks, 5 days)

Head circumference: 31.9 cm (36 weeks)

Abdominal circumference: 33.2 (37 weeks, 1 day)

Femur length: 6.7 cm (37 weeks, 5 days)

Average sonogestational age: 35 weeks, 3 days.  By previous ultrasound of 10/24/2006, interval growth would be consistent with 33 weeks, 4 days and clinical menstrual age would be 34 weeks based on Patient A’s LMP of 6/6/2006.  Estimated fetal weight was 2,820 grams.

Volume of amniotic fluid normal.  Placenta is fundal, posterior and lateral and is well away from the internal cervical os.  The previously noted marginal placenta previa is no longer visible.  No abruption or uterine wall abnormality.

Impression: Normal obstetrical ultrasound with appropriate interval growth.  Current measurements are slightly greater than expected from the previous ultrasound.  Placenta is now normal.

On 02/7/2007, the patient presented for follow-up and was seen by a certified nurse midwife with documentation done by the obstetrician.  The obstetrician noted that the NST was reactive and that the patient had occasional contractions.  She also noted that the ultrasound of 01/30/2007 revealed an estimated weight of 2,820 grams with no placenta previa.

On 02/14/2007, the patient presented to the hospital for elective Cesarean section.  The obstetrician documented:

Assessment: Fetal heart tones were obtained and are reactive.  The baby remains in the breech presentation.  Gestation diabetic, EDC of 03/09/2007.

Plan: Cesarean delivery today and add a note that the patient did have antenatal testing as recommended with gestation diabetics and had serial growth ultrasounds and reactive NSTs with 8 out (sic) 8 bio-physical’s weekly from 32 weeks on.  Our last estimated fetal weight on 02/07/2007 was 2800 grams.

The perioperative record indicated a preoperative diagnosis of macrosomia and 36 weeks gestation.  Cesarean section was performed with the patient’s birth time being recorded as 2:12 p.m.  The birth weight was 3062 grams.

The baby was transferred to a different hospital with diagnoses of prematurity and respiratory distress.  The admitting physician estimated the baby’s gestational age at 34 2/7 weeks.

The Board judged the obstetrician fell below the minimum standards of care by failing to perform an amniocentesis and performing an elective Cesarean section prior to term.

On 05/30/2012, the obstetrician completed the ACOB Prolog Course, Obstetrics, Sixth Edition and achieved a score of greater than 95% in the accompanying test.  The Board reprimanded the obstetrician for her conduct and ordered a fine to be paid.

State: Wisconsin


Date: August 2012


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Procedural error, Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Wisconsin – Obstetrician – Pregnancy With High Grade Squamous Intraepithelial Lesion



On 01/22/2009, a 29-year-old pregnant woman underwent a colposcopy examination by Obstetrician/Gynecologist A. Results indicated high grade squamous intraepithelial lesion in the cervical region.

On 02/05/2009, the patient presented for follow up.  Obstetrician/Gynecologist A documented:

CIN III, on colposcopy bx.  Pt is pregnant (75).  D/w pt she needs LEEP and should not wait until [after] delivery.  D/w pt cervical dysplasia & progression to cervical cancer.  Pt has [positive] HR HPV also.

Obstetrician/Gynecologist A further discussed loop electrosurgical excision procedure with the patient.

On 02/16/2009, the patient was referred to Obstetrician/Gynecologist B for a second opinion.    It was his opinion that the risks of pregnancy loss outweighed the risks of the lesion becoming cancerous.  The American College of Obstetrician guidelines recommended waiting for delivery and proceeding with LEEP at approximately 6 weeks postpartum.  A letter was sent to Obstetrician/Gynecologist A.

On 03/12/2009, the patient presented to Obstetrician/Gynecologist A for follow up, who again recommended the LEEP procedure.  The patient wanted to wait until after the baby was delivered.

On 06/04/2009, the patient presented to Obstetrician/Gynecologist A with concern for exhaustion after work.  Obstetrician/Gynecologist A recommended that she work only 6 hours a day.  Examination of the cervix showed no lesions or bleeding.  There is no documentation that a colposcopy was performed.

On 07/02/2009, Obstetrician/Gynecologist A discussed with the patient that with untreated CIN III, she would be at higher risk for cervical laceration and bleeding.  She said that the patient would be a candidate for Cesarean section, which the patient seemed to be preferring.

On 07/30/2009, the patient reported no cervical bleeding or abnormal discharge.  She understood that the Cesarean section would be done at 39 weeks or greater.

On 08/25/2009, Obstetrician/Gynecologist A documented that the patient “definitely will have csxn.”

On 09/09/2009, the patient presented to the hospital at 38 weeks in active labor.  Obstetrician/Gynecologist A discussed the risks and benefits of Cesarean section.  Informed consent was obtained.  Cesarian section was performed.

From the initial colposcopy through to Cesarean delivery, Obstetrician/Gynecologist A failed to perform any additional colposcopy evaluations to monitor the status of the cervical lesion.  Obstetrician/Gynecologist A said that the patient refused additional colposcopy, but this refusal was not documented.

The Board judged that Obstetrician/Gynecologist A’s care of the patient fell below minimum standards of competence given failure to monitor the cervical lesion and failing to document adequate justification for performing an elective Cesarean section.

On 05/30/2012, Obstetrician/Gynecologist A completed the ACOB Prolog Course, Obstetrics, Sixth Edition and achieved a score of greater than 95% in the accompanying test.  The Board reprimanded Obstetrician/Gynecologist A for her conduct and ordered a fine to be paid.

State: Wisconsin


Date: August 2012


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


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


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



California – Gynecology – Labor Induced At 33.5 Weeks Gestation For Blood Pressure Of 140/80 And Increasing Proteinuria



On 5/28/2008, a 37-year-old patient, gravida 1 with in-vitro fertilization twins and an estimated date of confinement (EDC) of 12/19/2008 began her prenatal care with an obstetrician.  From 5/28/2008 to 10/22/2008, the patient’s blood pressures were normal with no indication of pre-eclampsia.

On 10/23/2008, proteinuria was noted. On 10/27/2008, the patient’s blood pressure was recorded 130/80 and she had edema.  On 10/30/2008, the patient’s blood pressure was recorded between 135-140/80 all day. On 10/31/2008, the patient was seen in the obstetrician’s office at 33.5 weeks gestation and was noted to have a cervical dilatation of 2-3 cm.  She was admitted to the hospital for induction of labor for pregnancy-induced hypertension with increasing uric acid and increasing proteinuria.

At the hospital, the patient’s intrapartum blood pressure readings were intermittently elevated with ranges between 134-157/68-95.  There were no signs of severe pre-eclampsia or fetal compromise due to pre-eclampsia. The patient’s induction of labor failed.  The obstetrician decided to perform a Cesarean section.  The obstetrician did not perform any test to determine the lung maturity of the patient’s twin fetuses. The patient underwent a Cesarean section and delivered viable twins.

The obstetrician committed negligent acts in his care and treatment of the patient, which included, but were not limited to, the following: the obstetrician failed to determine the lung maturity of the patient’s twin fetuses once he felt that delivery was indicated at 33.5 weeks gestation.  The obstetrician induced labor in the patient at 33.5 weeks gestation, with only mild pre-eclampsia, and without evidence of severe pre-eclampsia or fetal compromise.

For the allegations in this case and others, the Medical Board Of California ordered that the obstetrician be placed on probation for a period of 7 years, be suspended from practicing medicine for a period of 60 days, complete a prescribing practices course, complete a wrong-site surgery course, complete a medical record keeping course, complete an ethics course, complete a clinical training program, be assigned a practice monitor for the duration of his probation, and be prohibited engaging in the solo practice of medicine.

State: California


Date: August 2012


Specialty: Obstetrics


Symptom: Swelling


Diagnosis: Preeclampsia


Medical Error: Improper treatment


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Obstetrics – Nifedipine Prescribed Over The Phone For Intense Contractions At 32 Weeks Gestation



By way of background, an obstetrician provided gynecological care and treatment to a patient in February 2008, when he delivered her second child, and thereafter, about 10 months later, when he performed a surgery on the patient.

In the spring of 2010, when the patient became pregnant again, she contacted the obstetrician to arrange for pre-natal care.  When she learned that the obstetrician had lost his hospital privileges, the patient told the obstetrician that she wanted to have him deliver her baby at her home. The obstetrician suggested that she contact midwives to provide backup assistance with the delivery.  The patient scheduled an examination with San Diego Midwife that would be held in November 2010, when she was over 32 weeks pregnant. It was the patient’s understanding that the obstetrician would attend the home birth as her physician and that a midwife from San Diego Midwife would assist him.

On 11/14/2010, the patient was 32 weeks pregnant, and at 5:00 a.m., she began spotting.  She called the obstetrician at 7:30 a.m. He called her right back. In response to the obstetrician’s questions, the patient told the obstetrician about the spotting, that she was cramping, and that she had previously been swimming in the ocean.  The obstetrician told her to spend the day in bed.

At 6:00 p.m. that night, the patient started having contractions.  She again called the obstetrician at 7:00 p.m. The obstetrician returned the call at 7:30 p.m.  The patient explained that the contractions were intense. The patient asked the obstetrician if she should go to the hospital.  The obstetrician told her “no.” The obstetrician did not tell her to go to the hospital or to call San Diego Midwife. Instead, and without examining the patient, the obstetrician prescribed the drug nifedipine, a drug commonly prescribed to stop or slow contractions when a woman is in labor.  At a time between 7:51 p.m. and 8:13 p.m., the obstetrician called the prescription into a CVS pharmacy.

The patient’s husband went to CVS and picked up the 30 pill prescription.  The label indicated that the patient should take “one capsule by mouth every 3-4 hours as needed for contraction.”  The patient’s contractions were coming about 5 minutes apart when she took the first dose at 9:00 p.m. She texted the obstetrician and asked him how long it would take for the drug to work.  The obstetrician did not text back. By 9:44 p.m., her contractions eased a bit, but then returned. Concerned because of the continuing contractions, the patient’s husband called the obstetrician.  The obstetrician told the husband words to the effect that: “Buddy, your baby is not going to be born tonight.” He told the patient’s husband that the patient should take another nifedipine and a Benadryl and try to get some sleep

Shortly thereafter, the patient took a bath.  While in the bathtub, her water broke. After arranging for coverage for their children, the patient and her husband went to the emergency department.  They selected this hospital because they knew she was delivering prematurely and the hospital had a NICU. The patient texted the obstetrician that she was on her way to the hospital.  When she arrived, she had advanced cervical dilation and presented with a footling breach. An emergency repeat Cesarean section was performed.

The obstetrician created chart entries dated 11/14/2010 and 11/24/2010.  On 1/24/2011, the patient requested and received her medical records from the obstetrician.  The records provided to the patient did not include the obstetrician’s chart entries for 11/14/2010 or 11/24/2010.

The obstetrician’s chart entries for 11/14/2010 and 11/24/2010 were not accurate.  The chart entries for both dates falsely stated that during his conversations with the patient on 11/14/2010 the patient only conveyed cramping and that “there were no actual contractions.”  The obstetrician’s entry for 9:06 p.m., falsely stated that there were “no signs of labor.” The entry for 11/14/2010 at 9:44 p.m., stated that he discussed with the patient’s husband “use of the closest L&D/ER at TriCity” and that the husband “expressed understanding of same plan follow up with midwives given transfer of care.”  Both the 11/14/2010 and 11/24/2010 entries failed to state that the obstetrician prescribed nifedipine for the patient or that he called in the prescription to the pharmacy.

The obstetrician committed repeated negligent acts in his care and treatment of the patient, which include, but were not limited to, the following: the obstetrician prescribed nifedipine without an appropriate in person evaluation, which would have included checking the patient’s cervix to determine her level of dilation and if she was an appropriate candidate for nifedipine.  The obstetrician failed to appropriately monitor her condition after prescribing and calling in a prescription for nifedipine to stop or slow the patient’s contractions. The obstetrician failed to timely place his chart entries for 11/14/2010 and 11/24/2010 into the patient’s chart.

For the allegations in this case and others, the Medical Board Of California ordered that the obstetrician be placed on probation for a period of 7 years, be suspended from practicing medicine for a period of 60 days, complete a prescribing practices course, complete a wrong-site surgery course, complete a medical record keeping course, complete an ethics course, complete a clinical training program, be assigned a practice monitor for the duration of his probation, and be prohibited engaging in the solo practice of medicine.

State: California


Date: August 2012


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Obstetrical Complication


Medical Error: Improper medication management, Failure to properly monitor patient, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Page 10 of 15