Found 58 Results Sorted by Case Date
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Florida – Obstetrics – Missed Indicators Of A Neural Tube Defect



On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/20/2014, 3/17/2014, 3/24/2014, 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms on the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and bloody discharge and/or morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son.  The child was born with a neural tube defect called spina bifida/myelomeningocele.

The obstetrician failed to observe on imaging studies, and follow-up on, known indicators that the patient’s child may have had a neural tube defect, or alternatively, did not create, keep, or maintain adequate legible documentation of observing on imaging studies, and following up on known indicators that the patient’s child may have had a neural tube defect.

The obstetrician failed to order maternal serum alpha-fetoprotein (MSAFP) test, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering a MSAFP test.

The obstetrician failed to order an anatomical survey sonogram, or alternatively, did not create, keep, or maintain adequate legible documentation of ordering an anatomical survey sonogram.

It was requested that the Board order one or more of the following penalties for the obstetrician: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: August 2017


Specialty: Obstetrics


Symptom: Weakness/Fatigue, Bleeding, Abnormal Vaginal Discharge, Back Pain


Diagnosis: Neurological Disease


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


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



New York – Physician Assistant – History Of Bipolar Disorder With Concern For Irregular Menses



On 8/13/2007, a 21-year-old female presented to a physician assistant for follow up treatment of bipolar disorder and concern for irregular menses.

During the examination, the patient advised the physician assistant that her most recent period was the prior November and that she had not had a gynecological examination in ten years. The physician assistant examined the patient’s abdomen, which he found to be benign.  In regard to the patient’s complaints of irregular menses, the physician assistant ordered a variety of blood work and stated that he would follow up with the patient in three months, unless otherwise indicated.  The blood work that he ordered did not include a hCG test.

On 8/16/2007, the patient arrived at the emergency department with a full-term pregnancy and delivered her baby on that same day.

The Board judged that the physician assistant’s medical care deviated from accepted standards of care given failure to perform an adequate physical examination, given failure to order a hCG test, and given failure to recognize signs of pregnancy.

State: New York


Date: July 2017


Specialty: Physician Assistant, Family Medicine, Internal Medicine


Symptom: Gynecological Symptoms


Diagnosis: N/A


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


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



California – Gynecologist – Complications After A Laparoscopic Assisted Vaginal Hysterectomy For Irregular Bleeding And Abdominal Pain



Sometime prior to 2011, a gynecologist began treating a patient with a history of a prior myomectomy in 2011, pre-diabetes, and fibromyalgia.

On 3/8/2011, the patient presented to the gynecologist with complaints of irregular vaginal bleeding with some pain in her right lower quadrant that worsened when she was on her period.  The patient informed the gynecologist that she was “ready for a hysterectomy.”  Medical records for this visit do not document the extent of the bleeding, whether or not the bleeding contributed to any other symptoms, the patient’s level of pain, or whether or not the pain interfered with the patient’s lifestyle.  At the conclusion of this visit, the gynecologist referred the patient for a pelvic ultrasound with plans to follow up after the ultrasound.

On 4/5/2011, the patient had a pelvic ultrasound which showed the uterus was oriented anteverted and located midline.  A fibroid was visualized in the right lateral aspect of the uterus that measured 5.3 by 4.2 by 5.3 centimeters.  The endometrial stripe measured 12 millimeters.  No other fibroids were seen.  The left and right ovary were normal.  There was no fluid in the cul-de-sac.  The fibroid had increased in size compared to a prior ultrasound in 2010.

On 4/11/2011, the patient presented to the gynecologist for a follow-up.  The gynecologist went over the results from the ultrasound and discussed possible treatment options.  The gynecologist did not recommend or perform an endometrial biopsy to determine the reason for endometrial thickening or repeat the ultrasound to watch this condition.  The gynecologist did not consider or document that the irregular bleeding could be caused by endometrial thickening, endometrial hyperplasia, or endometrial polyp.  She did not recommend a dilation and curettage.  At the conclusion of this visit, a decision was made for the patient to undergo a hysterectomy, which was scheduled to occur on 6/27/2011.  The patient indicated that she wanted a bilateral salpingo-oophorectomy, but the gynecologist advised her to leave in the ovaries.

On 6/24/2011, the patient presented to the gynecologist for a preoperative evaluation.  The gynecologist offered the patient medical and surgical options and the patient chose a hysterectomy.  The gynecologist explained various surgical options, including risk factors and complications.  During the physical examination of the patient, the gynecologist noted the patient’s uterus was bulky and that it did not descend well.  The gynecologist did not document any observable vaginal bleeding or any pelvic pain with palpation of the pelvic organs.  At the conclusion of this visit, the gynecologist had formed a surgical plan to include a total vaginal hysterectomy and depending on whether the uterus was mobile in the operation room, possible laparoscopic assisted vaginal hysterectomy, possible exploratory laparotomy, and possible cystoscopy.

On 6/27/2011, the gynecologist performed a laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, cystoscopy, and lysis of adhesions on the patient.  The medical records do not document a specific clinical reason for this choice in surgical technique versus a laparotomy approach.

During the surgery, the gynecologist encountered a web of filmy adhesions that were abundant along the back of both ovaries and continued along the back of the uterus.  The adhesions connected the bowel to the uterus and ovaries.

There were also adhesions from the ovaries to the side walls.  The gynecologist considered converting to an open procedure but opted to continue with laparoscopic dissection.  After dissection of all of the adhesions, the gynecologist obtained a general surgery consultation as a precaution to review the small bowel, which had been adherent, especially near the right ovary.  After observation through the monitor only, neither the surgeon nor the gynecologist noted any bowel injuries.

The gynecologist then proceeded with the vaginal hysterectomy portion of the surgery, which progressed “a bit more difficult than average but not remarkably so.”

Upon completion of the vaginal portion of the surgery, the gynecologist returned to the abdominal cavity.  Upon doing so, she noted a slight oozing from the round ligament on the left, which she cauterized.  The gynecologist then irrigated the pelvis and looked for any bleeding or injury but found none.

Prior to closing, the gynecologist requested a urology consultation.  After cystoscopy and examination revealed no injury to the bladder or ureter, the gynecologist completed the procedure.  The gynecologist’s detailed operative report does not specifically document the difficulties or complexities she encountered during the over eight-hour operation.

During the first three post-operative days, the patient experienced complications from the surgery that began to worsen.  The patient’s symptoms included abdominal pain, distention, lack of appetite, bowel dysfunction, fever, tachycardia, weakness, emesis, and anemia.

After attempting to treat the patient with antibiotics and observation, on 7/5/2011, the patient was taken in for an exploratory laparotomy.

During the surgery, several liters of feces were found in the patient’s abdomen, which were suctioned out.  Then, the abdomen was irrigated.  Further into the surgery, a 1-centimeter tear in the distal sigmoid and another 3-centimeter tear in the proximal rectum were identified, repaired, and treated with a colostomy.

From 7/5/2011 to 8/1/2011, the patient remained hospitalized and experienced complications including but not limited to nausea, vomiting, fatigue, fever, tachycardia, wound infection, anemia, and significant leukocytosis.  During this time period, the patient had to undergo radiological drainage of intraabdominal collections and was on several courses of antibiotics.  The patient was discharged from the hospital on 8/1/2011, approximately thirty-five days after her total hysterectomy.

Per the Board, the gynecologist committed gross negligence in her care and treatment of the patient by continuing with a long and complicated abdominal and pelvic surgery through laparoscopy without converting to laparotomy to prevent multiple intraoperative injuries.

In addition, the Board judged the gynecologist’s conduct to be below the minimum level of competence given the performance of a total abdominal hysterectomy and bilateral salpingo-oophorectomy without definitive clinical indication and without consideration of alternative treatments, prior to consideration of a major surgery, and given failure to maintain adequate and accurate records relating to her care and treatment of the patient.

The Board issued a public reprimand with stipulations to complete a medical record keeping course.

State: California


Date: July 2017


Specialty: Gynecology, General Surgery


Symptom: Abdominal Pain, Fever, Gynecological Symptoms, Nausea Or Vomiting, Weakness/Fatigue


Diagnosis: Post-operative/Operative Complication, Gynecological Disease


Medical Error: Procedural error, Unnecessary or excessive treatment or surgery, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Wisconsin – Gynecology – Pregnancy Test Performed Prior To Hysterectomy Turns Positive



On 12/27/2012, a patient with a history of uterine fibroids by ultrasound, two laparoscopies for adhesiolysis with bladder injury, presented to Gynecologic Oncologist A with complaints of a pelvic mass and endometriosis.  It was noted that there was an enlarged tender mass on exam consistent with endometriosis and fibroids and that the patient wanted definitive surgical intervention.

The patient was scheduled for an elective robotic hysterectomy with bilateral salpingo-oophorectomy on 1/17/2013.  The patient was planned for pre-operative lab testing, including a pregnancy test, within 72 hours of the scheduled surgery date.

The patient presented on 1/15/2013 to have pre-operative labs drawn.  The lab results were logged into the patient’s chart the next day.  These lab results included a positive pregnancy test.  Registered Nurse A was responsible for collecting lab findings prior to the operation on a form.  On that form, the “pregnant” and “lactating” questions were answered with a “no.”

On the day of surgery, Registered Nurse B was responsible for reviewing physician orders and labs.  Registered Nurse C did not confirm the results of the patient’s pre-op pregnancy test.  Anesthesiologist A signed an anesthesia pre-op order form which called for a pregnancy test on all patients similar to the patient, unless specifically waived.  Anesthesiologist A did not obtain a waiver and did not confirm the results of the patient’s pre-op pregnancy test.

Gynecologic Oncologist A performed surgery on patient A, during which it was found that the patient was pregnant.

Anesthesiologist A and Gynecologic Oncologist A were deemed to have engaged in unprofessional conduct by engaging in conduct which increases the risk of danger to the health, welfare, or safety of a patient.

State: Wisconsin


Date: May 2017


Specialty: Gynecology, Anesthesiology


Symptom: Mass (Breast Mass, Lump, etc.), Gynecological Symptoms


Diagnosis: Gynecological Disease


Medical Error: Failure to follow up, Failure of communication with other providers, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Emergency Medicine – Pelvic Pain And Vaginal Bleeding With Urinalysis Revealing A Glucose Level >1000



On 8/21/2014, a patient presented with complaints of pelvic pain and vaginal bleeding.  The patient was examined by a physician assistant supervised by an ED physician.

The physician assistant ordered laboratory evaluation for the patient, which included bloodwork, cervical/vaginal swabs, pelvic ultrasound, and urinalysis.

The urinalysis revealed the patient’s glucose level to be >1000, which was so high that it could not be measured.

The physician assistant gave the patient a prescription for Flagyl, an antibiotic, gave her education materials on uterine bleeding, bacterial vaginosis, dehydration, and ovarian cysts, and instructed her to follow up with her primary care physician and gynecologist.   The physician assistant discussed the patient’s case with the ED physician and the ED physician agreed with the plan of care.

The ED physician did not perform or order a finger stick glucose test or a basic metabolic panel.

The ED physician did not discuss and/or did not order the physician assistant to discuss the patient’s glucose level in relation to her possible new onset of diabetes and did not recommend or order the physician assistant to recommend further evaluation and treatment of her elevated glucose levels.

The ED physician did not administer or order the administration of intravenous fluid and insulin.

On 8/26/2014, the patient expired due to diabetic ketoacidosis.

The Medical Board of Florida judged the ED physician’s conduct to be below the minimal standard of competence give that she failed to administer or order the administration of a finger stick glucose test or basic metabolic panel, discuss or instruct the physician assistant to discuss the patient’s glucose levels in relation to her possible new onset of diabetes and recommend further evaluation and/or treatment of her elevated glucose levels, and failed to administer or order the administration of intravenous fluid and insulin.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ED physician: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: April 2017


Specialty: Emergency Medicine, Endocrinology, Physician Assistant


Symptom: Pelvic/Groin Pain, Abnormal Vaginal Bleeding


Diagnosis: Diabetes


Medical Error: Failure to follow up, Failure to order appropriate diagnostic test, Failure of communication with other providers, Improper supervision, Improper medication management


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

State: Florida


Date: April 2017


Specialty: Emergency Medicine, Obstetrics


Symptom: Abdominal Pain, Abnormal Vaginal Discharge


Diagnosis: Obstetrical Complication


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


Significant Outcome: Death, Hospital Bounce Back


Case Rating: 3


Link to Original Case File: Download PDF



Arizona – Family Medicine – Unaddressed Cervical Issue And Unnecessary Genetic Testing



A 26-year-old woman made an appointment for a well woman exam and refill of her birth control medications at a clinic.  When the woman arrived, she was told that the physician with whom she had made an appointment was not available and that she would be seen by another physician.

Two MAs saw the patient.  One performed an examination, the other acted as a translator.  The patient requested a PAP smear and an STD test.  The patient was not offered a breast exam.  A detailed history was not obtained.  The patient underwent a PAP smear performed by the MA.  A urine sample was requested for the performance of a pregnancy test.  The patient again requested an STD test and was told that she would have to return for another visit for that test, and that she would have to return for a third visit to discuss the results of the lab tests and the PAP smear.  At that time, another MA entered the room and suggested that the patient complete genetic testing.  She reassured the patient that it would be covered by her insurance.  The patient agreed to proceed with the test and submitted to a cheek swab for the testing.

The physician arrived after the examination was completed and asked the patient if she had any questions.  The patient was given a three month prescription for birth control with no refills at the front desk.  The patient asked for additional refills and was told she would have to return for additional appointments.  After consultation with the physician, staff members told the patient that she would not be receiving additional refills because she was probably sterile due to the length of time she had been on birth control.  The patient cancelled her labs, informed the staff that she would not come back, and requested reimbursement and return of her registration fee and paperwork.  The physician returned the patient’s registration paperwork, refunded the registration fee, and called the police due to the patient’s agitated behavior.

The documentation for the examination indicated that the patient’s cervix was “red” or inflamed; however, there is no record that this was addressed or treated during the patient’s visit.

The physician’s office subsequently sent the patient’s sample for genetic testing.  The patient’s insurance denied coverage for the test, and the patient received an explanation of benefits from her insurer stating that she owed $3,800 for it.

In his response to the Board, the physician denied that he allowed his MA to perform the PAP smear on the patient and stated that he entered into the treatment room after the patient was prepped, draped, and “with her legs in the ‘up position’…With her head down and her legs up, the patient was unable to see me perform the Pap smear.”

The Board judged  physician’s conduct to be below the minimum standard of competence given failure to obtain a medical and family history, a medication list, an allergy list, a review of systems, and a complete physical examination.  The abnormal finding on exam was not addressed.  The patient had to pay for unnecessary genetic testing.

The Board ordered the physician to be reprimanded and take 10 of continuing medical education on well-woman examinations.

State: Arizona


Date: March 2017


Specialty: Family Medicine, Gynecology


Symptom: Gynecological Symptoms


Diagnosis: N/A


Medical Error: Failure to examine or evaluate patient properly


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It was requested that the Medical Board of Florida order one or more of the following penalties for the obstetrician: permanent revocation or suspension of her license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: February 2017


Specialty: Obstetrics


Symptom: Abnormal Vaginal Bleeding


Diagnosis: Obstetrical Hemorrhage


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


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Obstetrics – Pregnancy With Elevated Blood Pressure And Proteinuria



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

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

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

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

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

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

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

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

State: Arizona


Date: February 2017


Specialty: Obstetrics


Symptom: Gynecological Symptoms


Diagnosis: Preeclampsia


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Gynecology – Complications After Hysterectomy For Patient With Simple Hyperplasia Without Atypia And A History Of Infraumbilical Midline Incision



A 46-year-old female presented to a gynecologist in July 2011 complaining of vaginal bleeding.  The patient had a history of ulcerative colitis and an infraumbilical midline incision. The patient next presented about one month later.  The laboratory results included small fibroids, a small polyp, and a small ovarian cyst. Based on these findings, the gynecologist recommended and performed an endometrial biopsy.  The result of the endometrial biopsy was simple hyperplasia without atypia. The gynecologist discussed the options for treatment with the patient and offered her medical treatment with repeat endometrial biopsy, dilation, and curettage with ablation, or hysterectomy.

The patient requested a hysterectomy with removal of both ovaries for definitive treatment.  The gynecologist obtained consent for a robotic hysterectomy and discussed the risks of the procedure, which included the possibility of finding extensive adhesions that would require an open abdominal hysterectomy as opposed to the laparoscopic approach.

On 10/19/2011, the patient was taken to the operating room, where she underwent a diagnostic laparoscopy and a total abdominal hysterectomy and bilateral salpingo-oophorectomy.  The findings at the time of surgery included an enlarged uterus with several small fibroids, normal ovaries, and normal fallopian tubes. There were excessive thick adhesions from the small bowel and omentum to the anterior abdominal wall and the left pelvic sidewall.  There were also adhesions in the right upper quadrant from the omentum to the abdominal wall. The gynecologist used a closed technique to enter the abdominal cavity with a Veress needle. The gynecologist placed the patient in maximum Trendelenburg position and then made a small incision in the umbilicus and inserted the Veress needle.  After removing the Veress needle, the gynecologist placed a 5 mm trocar and was able to visualize the adhesions. She then placed a second 5 mm trocar under direct visualization in the area clear of adhesions and used monopolar scissors for approximately 5 minutes in the attempt to lyse the adhesions. The gynecologist noted that the adhesions were very thick and extensive and included the bowel. She did not feel as though it was safe to proceed with the robot.  The gynecologist removed the instruments and proceeded with an uneventful total abdominal hysterectomy and bilateral salpingo-oophorectomy through a Pfannenstiel incision.

The patient’s post-operative course was eventful.  On the first post-operative day, she was noted to have a pulse of 130 bpm.  She was in moderate pain despite IV pain medication. A CBC was drawn, which showed a normal WBC count of 3.5, but it showed 50% bands.  The bandemia was not noted in the post-operative note. On the second post-operative day, the gynecologist saw the patient again at 2 p.m. and noted that the patient remained on oxygen.  Her pulse also remained at 130. The gynecologist ordered an EKG and a chest x-ray, increased the pain medication, and advised the patient to ambulate. A CBC drawn that day was not mentioned in the post-operative note, but it showed a normal WBC count at 4.7 and again showed bandemia of 18%.  The gynecologist wrote a discharge order at 2:20 p.m. on that day without any parameters.

Tachycardia persisted, and the patient developed shortness of breath, pain with breathing, and an oxygen saturation level of 82% for which the nursing staff called the Rapid Response Team.  The patient was transferred to a critical care bed with the diagnosis of acute hypoxic respiratory failure and peritonitis, and the gynecologist on-call was notified. The gynecologist had signed out to the on-call gynecologist for the weekend.  During that weekend, the patient’s condition continued to worsen. A CT scan performed on the evening of 10/22/2011 showed multiple fluid and air collections in the abdomen, mesentery, and abdominal wall. Various medical specialists as well as the gynecologist on-call evaluated the patient throughout the weekend.  On the fifth post-operative day, a general surgeon was consulted, who immediately made the diagnosis of a bowel perforation and took the patient to the operating room for a bowel resection. The patient remained in the hospital and was discharged o 11/9/2011.

During the gynecologist’s care, treatment and management of the patient, the gynecologist obtained informed consent and, on multiple occasions, discussed the risks, benefits, and alternatives to the surgery and included the additional risks due to the patient’s earlier bowel surgery.  As part of the alternatives to surgery, the gynecologist offered the patient an endometrial ablation, which is contraindicated in the presence of endometrial hyperplasia, as this is considered a precancerous condition. During an interview with representatives of the Medical Board of California, the gynecologist explained that she would no longer operate on this patient, but would refer her to the new gynecologic oncologist at another hospital.

At the time of the interview, the gynecologist was aware that the patient’s condition was precancerous since she would now refer the patient to an oncologist.  Simple hyperplasia does not require referral to an oncologist, but, given that the pathology of simple hyperplasia is considered a precancerous condition, the offering of endometrial ablation as an alternative was not appropriate.

Bowel injury is a known complication during the performance of a hysterectomy, whether it is performed laparoscopically or as an open procedure.  The risk of bowel injury is increased in a patient who, like this patient, had undergone a previous abdominal or bowel surgery and in a patient with a vertical midline incision.

The standard of care dictates that when the patient is at high risk for bowel injury, the surgeon must take all available precautions in order to avoid this complication and have a high index of suspicion of bowel injury if the patient’s post-operative course is complicated.  The gynecologist was well aware of the patient’s higher risk for pelvic adhesions. The patient had a vertical midline incision from a previous colectomy, and on multiple occasions, the gynecologist discussed the high likelihood of adhesions with the patient.

The Medical Board of California judged that the gynecologist’s conduct departed from the standard of care because she did not use a safer technique when inserting the Veress needle, offered her the alternative of endometrial ablation, and failed to recognize in a timely manner that the patient had sustained a bowel injury.

The Medical Board of California placed the obstetrician on probation for 35 months and ordered the obstetrician to complete a medical record-keeping course and education course for at least 40 hours for every year of probation.

State: California


Date: November 2016


Specialty: Gynecology


Symptom: Abnormal Vaginal Bleeding, Pelvic/Groin Pain, Shortness of Breath


Diagnosis: Post-operative/Operative Complication, Gynecological Disease


Medical Error: Procedural error, Diagnostic error, Improper treatment


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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