Found 4 Results Sorted by Case Date
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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



Massachusetts – Gynecology – Abdominal Pain And Urological Complications After Total Abdominal Hysterectomy



A 47-year-old female, G2P2, with a history of heavy menses, presented to a gynecologist with complaints of fatigue, needing to wear feminine pads that had to be changed two to three times per day during times of heavy flow and with golf ball-sized clots lasting for days.  Her symptoms had been worsening in the months leading up to the 6/3/2010 procedure.  The patient’s pre-operative ultrasound showed multiple fibroids with one measuring 4×3.6 cm, another measuring 2×2.6 cm, and a third measuring 2.5×2.3 cm.

The gynecologist’s pre-operative impression was menorrhagia and leiomyoma of the uterus.  The gynecologist planned to perform a laparoscopic assisted vaginal hysterectomy, possible total hysterectomy, or possible bilateral salpingo-oophorectomy.  Under laparoscopic visualization, the gynecologist observed several large fibroids.  He decided to perform an abdominal hysterectomy.

The gynecologist documented his intraoperative findings as an enlarged and irregular uterus, secondary to leiomyomata of the uterus, with normal appearing ovaries and tubes.

The gynecologist’s operative notes stated that he removed the uterus and the cervix, closed the vaginal cuff, and irrigated the pelvis with sterile water.  No bleeding was observed and good hemostasis was noted.

While in the post-anesthesia care unit (PACU), the patient was noted to have minimal output of bloody urine.  Physician A ordered an urgent cystogram.  The cystogram identified a single clot which was evacuated at the initiation of the procedure, then a normal 225 ml bladder without any extravasation.

On 6/5/2010, the patient was discharged home.

At 4:00 a.m. on 6/10/2010, the patient awoke with hematuria and severe right lower quadrant pain.  She suddenly developed lightheadedness, could not keep her eyes open, and was seeing stars.

The patient was taken to the emergency department.  She was admitted with dysuria, bladder spasms, and non-specific abdominal pain.

On 6/11/2010, a urologist evaluated the patient.  The urologist’s assessment was possible bladder injury or a suture in the bladder that could have been missed on the cystogram.  The patient was discharged from the emergency department with instructions to follow up with a urologist for a further cystogram.

On 6/14/2010, the patient underwent a further cystogram procedure, which identified a Vicryl suture through the bladder wall with some puckering of the bladder mucosa around it, posterolateral to the right urethral orifice, with no sign of active bleeding.

A Vicryl suture is dissolvable.  Thus, the urologist did not remove it during the cystogram.

The Board judged the gynecologist’s conduct as having fallen below the standard of care given failure to remove the entire cervix when performing an open total abdominal hysterectomy and given that he inserted a suture into the bladder.  He failed to document a note when the patient was readmitted on 6/10/2010.

The Board ordered that the gynecologist’s license be restricted to perform only certain specified office-based procedures.

State: Massachusetts


Date: October 2013


Specialty: Gynecology


Symptom: Abdominal Pain, Bleeding, Gynecological Symptoms, Urinary Problems


Diagnosis: Post-operative/Operative Complication, Gynecological Disease


Medical Error: Procedural error


Significant Outcome: Hospital Bounce Back


Case Rating: 2


Link to Original Case File: Download PDF



Massachusetts – Obstetrics – Complex Postpartum Laceration With Bleeding



On 2/17/2011, a 28-year-old woman at 39 weeks gestation presented to a labor and delivery unit with suspected ruptured membranes.

At 9:58 p.m. on 2/17/2011, Obstetrician A, an obstetrician on call, completed an admission history and physical.  Obstetrician B, the patient’s usual obstetrician, was not available.

Obstetrician A wrote that the patient was Gravida 1, Para 0, with an estimated date of confinement of 2/24/2011.

At 6:32 a.m., Obstetrician A documented that the patient was in “normal progression of labor.”

At 7:04 a.m. on 2/18/2011, Obstetrician A performed a vaginal delivery of the patient’s child.

The patient sustained a periurethral second-degree laceration during the delivery.  Post-delivery, at 7:55 a.m., the patient’s lochia flow was heavy.  The patient was also tachycardic with a heart rate of 127.

At 8:00 a.m., a nurse documented observing clots and called Obstetrician B to the patient’s room.

The patient continued to experience heavy vaginal bleeding, which did not abate with the administration of medications.

Obstetrician B performed a vaginal examination on the patient and observed a suture, which tied two labia minora in the midline, leaving a very small opening in the vagina.

Obstetrician B inserted a finger in the patient’s vagina, whereupon approximately 1000 ml of blood clots were extracted.  Obstetrician B also detected a left vaginal tear, which appeared to extend high toward to the left fornix.

Obstetrician B removed the suture and confirmed the presence of an extensive vaginal tear of the left lateral wall of the vagina.

Obstetrician B took the patient to the operating room and also observed large amounts of blood clots.

Intraoperatively, Obstetrician B found that the patient’s extensive vaginal tear extended to the fornix on the left side with visualization of a blood vessel that was pumping blood steadily through the upper part of the laceration.

Obstetrician B repaired the vaginal tear and also noted the presence of a smaller tear on the upper part of the labia minor that was split in two locations.  Obstetrician B repaired those tears as well as a superficial periurethral tear on the right side.

A post-repair ultrasound confirmed no further bleeding or clots.

The patient experienced an estimated 2300 ml of blood loss as a result of these various tears.

The Board judged Obstetrician A’s conduct as having fallen below the standard of care given failure to accurately document the patient’s clinical course and failure to recognize the vaginal laceration.  In addition, he sewed the labia minor together in a completely aberrant fashion.

The Board placed restrictions on Obstetrician A’s license.

State: Massachusetts


Date: October 2013


Specialty: Obstetrics


Symptom: Bleeding


Diagnosis: Obstetrical Hemorrhage


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Massachusetts – Obstetrics – Repair Of Periurethral Tear With Subsequent Complication



On 5/16/2011, a 23-year-old female presented to her primary obstetrician for a routine office visit.  Her estimated date of confinement was 5/13/2011.  At the time of her visit, her cervix was 4-5 cm dilated and 90% effaced.  Her obstetrician’s plan was to induce labor.

On 5/16/2011, the patient was admitted to the labor and delivery unit for a nonstress test.  Around 6:00 p.m., the patient became uncomfortable.  An epidural was administered.

At 6:27 p.m., the patient’s cervix was 5 cm dilated.  She spontaneously ruptured her membranes and precipitously delivered a 9-pound, 9-ounce female.  A laborist attended the delivery.  She sustained a small periurethral tear.

Obstetrician B repaired the tear.  Surgeon A took the patient to the operating room to complete the surgery under anesthesia.  During an attempt to insert a foley catheter, Surgeon A discovered that the patient’s urethral opening was sewn closed by Obstetrician B.  Obstetrician B had closed off the patient’s urethral meatus when he repaired the right periurethral laceration.

Surgeon A removed Obstetrician B’s sutures to re-open the urethral meatus and discovered extensive damage to the patient’s cervix, which included a long laceration at 7 o’ clock, which extended into the lower uterine segment and a second 2 cm laceration at 12 o’ clock.

Surgeon A repaired both cervical lacerations as well as the right periurethral laceration.

The Board judged Obstetrician B’s conduct as having fallen below the standard of care given failure to accurately document the patient’s delivery and failure to recognize that he had sewn the urethra closed.

For this allegation and others, the Board ordered that Obstetrician B’s license be restricted to perform only certain specified office-based procedures.

State: Massachusetts


Date: October 2013


Specialty: Obstetrics


Symptom: N/A


Diagnosis: Post-operative/Operative Complication


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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