Medical Verdicts

BABY SEVERELY HANDICAPPED AFTER PREMATURE LABOR: $42.9M VERDICT
A 27-year-old mother had a normal prenatal ultrasonography (US) result in March 2007. In July, she went to the emergency department (ED) with pelvic pressure. A maternal-fetal medicine (MFM) specialist noted that the patient’s cervix had shortened to 1.3 cm. US showed that excessive amniotic fluid was causing uterine distention. The patient was monitored by an on-call ObGyn for 3.5 hours before being discharged home on pelvic and modified bed rest.

Two days later, the mother reported frequent contractions to her ObGyn. The baby was born the next day by emergency cesarean delivery at 25 weeks’ gestation. The newborn had seizures and a brain hemorrhage. The child has mental disabilities, blindness, spastic quadriparesis, cerebral palsy, gastroesophageal reflux, and complex feeding disorder.

PARENTS’ CLAIM The on-call ObGyn did not give the patient specific instructions for pelvic and bed rest upon discharge. The MFM specialist and on-call ObGyn failed to admit the patient to the hospital, and failed to administer intravenous steroids (betamethasone) to protect the fetal brain and induce respiratory development.

DEFENDANTS’ DEFENSE There was no indication during the MFM specialist’s examination that delivery was imminent. The use of betamethasone would not have prevented or inhibited premature labor. The infant’s problems were due to prematurity and low birth weight.

VERDICT A $42.9 million Pennsylvania verdict was returned against the MFM specialist; the on-call ObGyn and hospital were vindicated.

PELVIC LYMPH NODES NOT SAMPLED
When a 68-year-old woman reported vaginal spotting to her gynecologist (Dr. A) in March 2006, the results of an endometrial biopsy were negative. She saw another gynecologist (Dr. B) for a second opinion when bleeding continued. After dilation and curettage, grade 1B endometrial cancer was identified. The patient underwent a hysterectomy and bilateral salpingo-oophorectomy. She received a diagnosis of metastatic cancer of the pelvis and pelvic and para-aortic lymph nodes 18 months later. After additional surgery, the patient died in March 2008.

ESTATE’S CLAIM Dr. A was negligent in failing to diagnose the cancer in March 2006. Dr. B should have performed pelvic lymphadenectomy at hysterectomy; a lymphadenectomy would have accurately staged metastatic cancer.

DEFENDANTS’ DEFENSE Care and treatment were appropriate. Performing a lymphadenectomy would have exposed the patient to a significant risk of morbidity.

VERDICT A $750,000 California verdict was reduced to $250,000 under the state cap.

LARGE BABY: ERB’S PALSY
Shoulder dystocia was encountered when a 38-year-old woman gave birth. The child later received a diagnosis of Erb’s palsy, and has had several operations. At trial, the child had loss of function of the affected arm and wore a brace.

PARENTS’ CLAIM A vaginal delivery should not have been performed because the mother had gestational diabetes and the baby weighed 8 lb 8 oz at birth. Cesarean delivery was never offered.

DEFENDANTS’ DEFENSE Labor appeared normal. Proper delivery techniques were used when shoulder dystocia was encountered.

VERDICT A $12.9 million Michigan verdict was reduced to $4 million under the state cap.

Related articles:
You are the second responder to a shoulder dystocia emergency. What do you do first? Robert L. Barbieri, MD (Editorial; May 2013)
STOP all activities that may lead to further shoulder impaction when you suspect possible shoulder dystocia  Ronald T. Burkman, MD (Stop/Start; March 2013)
The natural history of obstetric brachial plexus injury Robert L. Barbieri, MD (Editorial, February 2013)

SPINAL CORD INJURY
During anesthesia administration before cesarean delivery, a mother’s spinal cord was injured, resulting in irritation of multiple nerve roots. She has chronic nerve pain syndrome.

PATIENT’S CLAIM The anesthesiologist was negligent in how he administered the spinal block.

PHYSICIAN’S DEFENSE There was no negligence. The injury is a known complication of the procedure.

VERDICT An Indiana defense verdict was returned.

AORTA PUNCTURED: $4M VERDICT
A 35-year-old woman underwent laparoscopic cystectomy on her left ovary performed by her gynecologist. During the procedure, the patient’s aorta was punctured, and she lost more than half her blood volume. After immediate surgery to repair the aorta, she was hospitalized for 5 days.

PATIENT’S CLAIM The injury was due to improper insertion of the laparoscopic instruments; the trocars were improperly angled and too forcefully inserted. The injury was a known risk of the procedure for obese patients, but she is not obese. She has a residual scar and is at increased risk of developing adhesions.

PHYSICIAN’S DEFENSE The instruments were properly inserted. The injury is a known risk of the procedure.

VERDICT A $4 million New York verdict was returned.

RESUSCITATION TOOK 22 MINUTES
At 40 6/7 weeks’ gestation, a mother went to the ED after her membranes spontaneously ruptured. The child was delivered by vacuum extraction 30 hours later.

At birth, the baby was blue and limp with Apgar scores of 2, 3, and 7, at 1, 5, and 10 minutes, respectively. The infant required 22 minutes of resuscitation. The neonatal record included metabolic acidosis, respiratory distress, possible sepsis, shoulder dystocia, and seizure activity. The child suffered hypoxic ischemic encephalopathy and permanent neurologic injury.

PARENTS’ CLAIM Cesarean delivery should have been performed due to repetitive decelerations, fetal tachycardia, and increasingly long uterine contractions. Continued use of oxytocin contributed to the infant’s injuries.

DEFENDANTS’ DEFENSE Fetal heart-rate tracings were reassuring during labor. Decreased variability, rising fetal heart rate, and late decelerations are normal during labor and delivery. The infant’s blood gas did not fall below 7.0 pH. The use of oxytocin was proper. There was no way to determine cephalopelvic disproportion or the baby’s size at 6 days postterm. The mother was opposed to a cesarean delivery and requested vaginal delivery (although no such request was included in the medical records).

VERDICT A $55 million Pennsylvania verdict was returned.

INJURY DURING OVARIAN REMNANT RESECTION
A woman in her 40s reported lower left quadrant pain. A previous oophorectomy report indicated that ovarian tissue attached to the bowel had not been removed. Thinking the pain might be related to residual ovarian tissue, her gynecologist recommended resection. During surgery, the patient’s bowel was injured. Four additional operations were required, including bowel resection with colostomy, and then colostomy reversal 5 months later.

PATIENT’S CLAIM The gynecologist was negligent in failing to properly perform surgery. The surgeon’s report from the oophorectomy indicated that there were extensive adhesions, which increased the risk of complications from surgery to remove the remnant. Ovarian remnant syndrome could have been treated with medication to induce menopause.

PHYSICIAN’S DEFENSE The patient might have suffered injury from medication-induced menopause. Surgery was appropriate; the injury is a known risk of the procedure.

VERDICT A $200,000 New York verdict was returned.

SEVERE INFECTION AFTER BIRTH
A 32-year-old woman left the hospital within hours of giving birth because her mother was ill. Before discharge, she reported severe abdominal pain and was examined by a first-year resident. The patient returned to the hospital 6 hours later with a severe uterine infection. She was hospitalized for a month.

PATIENT’S CLAIM The resident failed to properly assess her symptom reports, failed to order testing, and was negligent in allowing her to leave the hospital.

DEFENDANTS’ DEFENSE The patient left the hospital against medical recommendations. She might have acquired the infection after leaving the hospital.

VERDICT A $285,000 Michigan verdict was returned. The patient was found to be 40% at fault.

TERMINAL BRADYCARDIA: $12M VERDICT WITH MIXED FAULT
Four days after her due date, a mother’s blood pressure was elevated, and labor was induced. Two days after oxytocin was started, decelerations occurred. The ObGyn was called after the second deceleration, and witnessed the fourth deceleration about an hour later. After six decelerations, the fetal heart rate dropped to 70 bpm and did not return to baseline. A cesarean delivery was performed 26 minutes later. The child was born with a severe brain injury.

PARENTS’ CLAIM The nurses and ObGyn failed to recognize, report, and address nonreassuring fetal heart signs, and did not discontinue oxytocin after the second deceleration. Hospital protocols were ignored. An earlier cesarean delivery would have avoided injury; the fetus was without oxygen from the sixth deceleration until delivery.

DEFENDANTS’ DEFENSE There was no causation between the alleged violation of hospital protocols and the outcome. The ObGyn was appropriately notified. The injury was caused by terminal bradycardia during a prolonged deceleration that resulted from cord compression; it was unpredictable.

The ObGyn claimed earlier delivery was not indicated. Decelerations did not predict a bradycardic event from which the fetus would not recover nor indicate a need to stop oxytocin. The fetal heart rate had always recovered until the final deceleration. Bradycardia is unpredictable.

VERDICT A $12.165 million Hawaii verdict was returned, with the ObGyn 35% at fault, and the hospital 65% at fault. 

Related article: Stop staring at that Category-II fetal heart-rate tracing… Robert L. Barbieri, MD (Editorial, April 2011)

BREAST BIOPSY MIXUP; SHE DIDN’T HAVE CANCER
A 53-year-old woman reported right breast pain. Mammography revealed scattered fibroglandular elements. Targeted US showed a solid nodule that could be an intramammary lymph node or small fibroadenoma. After an office-based biopsy, the breast surgeon (Dr. A) told the patient that she had breast cancer. 

Because Dr. A was not in her health insurance plan, the patient took her imaging studies and biopsy results to Dr. B, another surgeon. Dr. B performed a mastectomy with lymphadenectomy. There was no evidence of malignancy in the pathologic review of breast and lymph tissue.

PATIENT’S CLAIM Dr. A performed biopsies on several women that same day; all were sent to the same laboratory for analysis. Dr. A and the laboratory failed to properly label and handle the biopsy specimens. Incorrect diagnosis caused her to undergo unnecessary mastectomy, lymph node biopsy, and a long, complicated breast reconstruction.

DEFENDANTS’ DEFENSE The case was settled at trial.

VERDICT A $1,780,000 Virginia settlement was reached.

Related article: Does screening mammography save lives? Janelle Yates (April 2014)

CLUES MISSED; BABY HAS CP, OTHER INJURIES
A 19-year-old mother had regular prenatal care. In early June, she weighed 221 lb and had a fundal height of 36 cm. The certified nurse midwife (CNM) noted little fetal movement, was uncertain of the fetal position, and made a note to check the amniotic fluid at the next visit. A week later, US did not indicate a decrease in amniotic fluid. Records do not indicate that the amniotic fluid index was checked at the next visit (38 weeks’ gestation).

Two days later, the patient reported decreased fetal movement. At the ED, nonreassuring fetal heart tracings were recorded. Fifteen minutes later, the fetal heart rate fell to 50 bpm and did not recover. The on-call ObGyn artificially ruptured the membranes and placed a direct fetal lead. An emergency cesarean delivery was performed in 15 minutes through thick meconium.

Apgar scores were 0, 2, and 4 at 1, 5, and 10 minutes, respectively. The baby weighed 4 lb 4 oz, and was transferred to a children’s hospital, where she stayed for 6 weeks. She suffered seizures and was tube fed. The child has cerebral palsy and profound neurologic impairment. At age 7, she is unable to speak.

PATIENT’S CLAIM The CNM was negligent for not being more proactive when she questioned the amniotic fluid index and noted reduced fetal movement in early June and at subsequent visits. The presence of meconium at birth attested that the fetus had been in distress.

DEFENDANTS’ DEFENSE The case was settled at trial.

VERDICT A $2 million Massachusetts settlement was reached.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

TELL US WHAT YOU THINK!
Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state.
Stay in touch! Your feedback is important to us!

BABY SEVERELY HANDICAPPED AFTER PREMATURE LABOR: $42.9M VERDICT
A 27-year-old mother had a normal prenatal ultrasonography (US) result in March 2007. In July, she went to the emergency department (ED) with pelvic pressure. A maternal-fetal medicine (MFM) specialist noted that the patient’s cervix had shortened to 1.3 cm. US showed that excessive amniotic fluid was causing uterine distention. The patient was monitored by an on-call ObGyn for 3.5 hours before being discharged home on pelvic and modified bed rest.

Two days later, the mother reported frequent contractions to her ObGyn. The baby was born the next day by emergency cesarean delivery at 25 weeks’ gestation. The newborn had seizures and a brain hemorrhage. The child has mental disabilities, blindness, spastic quadriparesis, cerebral palsy, gastroesophageal reflux, and complex feeding disorder.

PARENTS’ CLAIM The on-call ObGyn did not give the patient specific instructions for pelvic and bed rest upon discharge. The MFM specialist and on-call ObGyn failed to admit the patient to the hospital, and failed to administer intravenous steroids (betamethasone) to protect the fetal brain and induce respiratory development.

DEFENDANTS’ DEFENSE There was no indication during the MFM specialist’s examination that delivery was imminent. The use of betamethasone would not have prevented or inhibited premature labor. The infant’s problems were due to prematurity and low birth weight.

VERDICT A $42.9 million Pennsylvania verdict was returned against the MFM specialist; the on-call ObGyn and hospital were vindicated.

PELVIC LYMPH NODES NOT SAMPLED
When a 68-year-old woman reported vaginal spotting to her gynecologist (Dr. A) in March 2006, the results of an endometrial biopsy were negative. She saw another gynecologist (Dr. B) for a second opinion when bleeding continued. After dilation and curettage, grade 1B endometrial cancer was identified. The patient underwent a hysterectomy and bilateral salpingo-oophorectomy. She received a diagnosis of metastatic cancer of the pelvis and pelvic and para-aortic lymph nodes 18 months later. After additional surgery, the patient died in March 2008.

ESTATE’S CLAIM Dr. A was negligent in failing to diagnose the cancer in March 2006. Dr. B should have performed pelvic lymphadenectomy at hysterectomy; a lymphadenectomy would have accurately staged metastatic cancer.

DEFENDANTS’ DEFENSE Care and treatment were appropriate. Performing a lymphadenectomy would have exposed the patient to a significant risk of morbidity.

VERDICT A $750,000 California verdict was reduced to $250,000 under the state cap.

LARGE BABY: ERB’S PALSY
Shoulder dystocia was encountered when a 38-year-old woman gave birth. The child later received a diagnosis of Erb’s palsy, and has had several operations. At trial, the child had loss of function of the affected arm and wore a brace.

PARENTS’ CLAIM A vaginal delivery should not have been performed because the mother had gestational diabetes and the baby weighed 8 lb 8 oz at birth. Cesarean delivery was never offered.

DEFENDANTS’ DEFENSE Labor appeared normal. Proper delivery techniques were used when shoulder dystocia was encountered.

VERDICT A $12.9 million Michigan verdict was reduced to $4 million under the state cap.

Related articles:
You are the second responder to a shoulder dystocia emergency. What do you do first? Robert L. Barbieri, MD (Editorial; May 2013)
STOP all activities that may lead to further shoulder impaction when you suspect possible shoulder dystocia  Ronald T. Burkman, MD (Stop/Start; March 2013)
The natural history of obstetric brachial plexus injury Robert L. Barbieri, MD (Editorial, February 2013)

SPINAL CORD INJURY
During anesthesia administration before cesarean delivery, a mother’s spinal cord was injured, resulting in irritation of multiple nerve roots. She has chronic nerve pain syndrome.

PATIENT’S CLAIM The anesthesiologist was negligent in how he administered the spinal block.

PHYSICIAN’S DEFENSE There was no negligence. The injury is a known complication of the procedure.

VERDICT An Indiana defense verdict was returned.

AORTA PUNCTURED: $4M VERDICT
A 35-year-old woman underwent laparoscopic cystectomy on her left ovary performed by her gynecologist. During the procedure, the patient’s aorta was punctured, and she lost more than half her blood volume. After immediate surgery to repair the aorta, she was hospitalized for 5 days.

PATIENT’S CLAIM The injury was due to improper insertion of the laparoscopic instruments; the trocars were improperly angled and too forcefully inserted. The injury was a known risk of the procedure for obese patients, but she is not obese. She has a residual scar and is at increased risk of developing adhesions.

PHYSICIAN’S DEFENSE The instruments were properly inserted. The injury is a known risk of the procedure.

VERDICT A $4 million New York verdict was returned.

RESUSCITATION TOOK 22 MINUTES
At 40 6/7 weeks’ gestation, a mother went to the ED after her membranes spontaneously ruptured. The child was delivered by vacuum extraction 30 hours later.

At birth, the baby was blue and limp with Apgar scores of 2, 3, and 7, at 1, 5, and 10 minutes, respectively. The infant required 22 minutes of resuscitation. The neonatal record included metabolic acidosis, respiratory distress, possible sepsis, shoulder dystocia, and seizure activity. The child suffered hypoxic ischemic encephalopathy and permanent neurologic injury.

PARENTS’ CLAIM Cesarean delivery should have been performed due to repetitive decelerations, fetal tachycardia, and increasingly long uterine contractions. Continued use of oxytocin contributed to the infant’s injuries.

DEFENDANTS’ DEFENSE Fetal heart-rate tracings were reassuring during labor. Decreased variability, rising fetal heart rate, and late decelerations are normal during labor and delivery. The infant’s blood gas did not fall below 7.0 pH. The use of oxytocin was proper. There was no way to determine cephalopelvic disproportion or the baby’s size at 6 days postterm. The mother was opposed to a cesarean delivery and requested vaginal delivery (although no such request was included in the medical records).

VERDICT A $55 million Pennsylvania verdict was returned.

INJURY DURING OVARIAN REMNANT RESECTION
A woman in her 40s reported lower left quadrant pain. A previous oophorectomy report indicated that ovarian tissue attached to the bowel had not been removed. Thinking the pain might be related to residual ovarian tissue, her gynecologist recommended resection. During surgery, the patient’s bowel was injured. Four additional operations were required, including bowel resection with colostomy, and then colostomy reversal 5 months later.

PATIENT’S CLAIM The gynecologist was negligent in failing to properly perform surgery. The surgeon’s report from the oophorectomy indicated that there were extensive adhesions, which increased the risk of complications from surgery to remove the remnant. Ovarian remnant syndrome could have been treated with medication to induce menopause.

PHYSICIAN’S DEFENSE The patient might have suffered injury from medication-induced menopause. Surgery was appropriate; the injury is a known risk of the procedure.

VERDICT A $200,000 New York verdict was returned.

SEVERE INFECTION AFTER BIRTH
A 32-year-old woman left the hospital within hours of giving birth because her mother was ill. Before discharge, she reported severe abdominal pain and was examined by a first-year resident. The patient returned to the hospital 6 hours later with a severe uterine infection. She was hospitalized for a month.

PATIENT’S CLAIM The resident failed to properly assess her symptom reports, failed to order testing, and was negligent in allowing her to leave the hospital.

DEFENDANTS’ DEFENSE The patient left the hospital against medical recommendations. She might have acquired the infection after leaving the hospital.

VERDICT A $285,000 Michigan verdict was returned. The patient was found to be 40% at fault.

TERMINAL BRADYCARDIA: $12M VERDICT WITH MIXED FAULT
Four days after her due date, a mother’s blood pressure was elevated, and labor was induced. Two days after oxytocin was started, decelerations occurred. The ObGyn was called after the second deceleration, and witnessed the fourth deceleration about an hour later. After six decelerations, the fetal heart rate dropped to 70 bpm and did not return to baseline. A cesarean delivery was performed 26 minutes later. The child was born with a severe brain injury.

PARENTS’ CLAIM The nurses and ObGyn failed to recognize, report, and address nonreassuring fetal heart signs, and did not discontinue oxytocin after the second deceleration. Hospital protocols were ignored. An earlier cesarean delivery would have avoided injury; the fetus was without oxygen from the sixth deceleration until delivery.

DEFENDANTS’ DEFENSE There was no causation between the alleged violation of hospital protocols and the outcome. The ObGyn was appropriately notified. The injury was caused by terminal bradycardia during a prolonged deceleration that resulted from cord compression; it was unpredictable.

The ObGyn claimed earlier delivery was not indicated. Decelerations did not predict a bradycardic event from which the fetus would not recover nor indicate a need to stop oxytocin. The fetal heart rate had always recovered until the final deceleration. Bradycardia is unpredictable.

VERDICT A $12.165 million Hawaii verdict was returned, with the ObGyn 35% at fault, and the hospital 65% at fault. 

Related article: Stop staring at that Category-II fetal heart-rate tracing… Robert L. Barbieri, MD (Editorial, April 2011)

BREAST BIOPSY MIXUP; SHE DIDN’T HAVE CANCER
A 53-year-old woman reported right breast pain. Mammography revealed scattered fibroglandular elements. Targeted US showed a solid nodule that could be an intramammary lymph node or small fibroadenoma. After an office-based biopsy, the breast surgeon (Dr. A) told the patient that she had breast cancer. 

Because Dr. A was not in her health insurance plan, the patient took her imaging studies and biopsy results to Dr. B, another surgeon. Dr. B performed a mastectomy with lymphadenectomy. There was no evidence of malignancy in the pathologic review of breast and lymph tissue.

PATIENT’S CLAIM Dr. A performed biopsies on several women that same day; all were sent to the same laboratory for analysis. Dr. A and the laboratory failed to properly label and handle the biopsy specimens. Incorrect diagnosis caused her to undergo unnecessary mastectomy, lymph node biopsy, and a long, complicated breast reconstruction.

DEFENDANTS’ DEFENSE The case was settled at trial.

VERDICT A $1,780,000 Virginia settlement was reached.

Related article: Does screening mammography save lives? Janelle Yates (April 2014)

CLUES MISSED; BABY HAS CP, OTHER INJURIES
A 19-year-old mother had regular prenatal care. In early June, she weighed 221 lb and had a fundal height of 36 cm. The certified nurse midwife (CNM) noted little fetal movement, was uncertain of the fetal position, and made a note to check the amniotic fluid at the next visit. A week later, US did not indicate a decrease in amniotic fluid. Records do not indicate that the amniotic fluid index was checked at the next visit (38 weeks’ gestation).

Two days later, the patient reported decreased fetal movement. At the ED, nonreassuring fetal heart tracings were recorded. Fifteen minutes later, the fetal heart rate fell to 50 bpm and did not recover. The on-call ObGyn artificially ruptured the membranes and placed a direct fetal lead. An emergency cesarean delivery was performed in 15 minutes through thick meconium.

Apgar scores were 0, 2, and 4 at 1, 5, and 10 minutes, respectively. The baby weighed 4 lb 4 oz, and was transferred to a children’s hospital, where she stayed for 6 weeks. She suffered seizures and was tube fed. The child has cerebral palsy and profound neurologic impairment. At age 7, she is unable to speak.

PATIENT’S CLAIM The CNM was negligent for not being more proactive when she questioned the amniotic fluid index and noted reduced fetal movement in early June and at subsequent visits. The presence of meconium at birth attested that the fetus had been in distress.

DEFENDANTS’ DEFENSE The case was settled at trial.

VERDICT A $2 million Massachusetts settlement was reached.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

TELL US WHAT YOU THINK!
Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state.
Stay in touch! Your feedback is important to us!

BABY SEVERELY HANDICAPPED AFTER PREMATURE LABOR: $42.9M VERDICT
A 27-year-old mother had a normal prenatal ultrasonography (US) result in March 2007. In July, she went to the emergency department (ED) with pelvic pressure. A maternal-fetal medicine (MFM) specialist noted that the patient’s cervix had shortened to 1.3 cm. US showed that excessive amniotic fluid was causing uterine distention. The patient was monitored by an on-call ObGyn for 3.5 hours before being discharged home on pelvic and modified bed rest.

Two days later, the mother reported frequent contractions to her ObGyn. The baby was born the next day by emergency cesarean delivery at 25 weeks’ gestation. The newborn had seizures and a brain hemorrhage. The child has mental disabilities, blindness, spastic quadriparesis, cerebral palsy, gastroesophageal reflux, and complex feeding disorder.

PARENTS’ CLAIM The on-call ObGyn did not give the patient specific instructions for pelvic and bed rest upon discharge. The MFM specialist and on-call ObGyn failed to admit the patient to the hospital, and failed to administer intravenous steroids (betamethasone) to protect the fetal brain and induce respiratory development.

DEFENDANTS’ DEFENSE There was no indication during the MFM specialist’s examination that delivery was imminent. The use of betamethasone would not have prevented or inhibited premature labor. The infant’s problems were due to prematurity and low birth weight.

VERDICT A $42.9 million Pennsylvania verdict was returned against the MFM specialist; the on-call ObGyn and hospital were vindicated.

PELVIC LYMPH NODES NOT SAMPLED
When a 68-year-old woman reported vaginal spotting to her gynecologist (Dr. A) in March 2006, the results of an endometrial biopsy were negative. She saw another gynecologist (Dr. B) for a second opinion when bleeding continued. After dilation and curettage, grade 1B endometrial cancer was identified. The patient underwent a hysterectomy and bilateral salpingo-oophorectomy. She received a diagnosis of metastatic cancer of the pelvis and pelvic and para-aortic lymph nodes 18 months later. After additional surgery, the patient died in March 2008.

ESTATE’S CLAIM Dr. A was negligent in failing to diagnose the cancer in March 2006. Dr. B should have performed pelvic lymphadenectomy at hysterectomy; a lymphadenectomy would have accurately staged metastatic cancer.

DEFENDANTS’ DEFENSE Care and treatment were appropriate. Performing a lymphadenectomy would have exposed the patient to a significant risk of morbidity.

VERDICT A $750,000 California verdict was reduced to $250,000 under the state cap.

LARGE BABY: ERB’S PALSY
Shoulder dystocia was encountered when a 38-year-old woman gave birth. The child later received a diagnosis of Erb’s palsy, and has had several operations. At trial, the child had loss of function of the affected arm and wore a brace.

PARENTS’ CLAIM A vaginal delivery should not have been performed because the mother had gestational diabetes and the baby weighed 8 lb 8 oz at birth. Cesarean delivery was never offered.

DEFENDANTS’ DEFENSE Labor appeared normal. Proper delivery techniques were used when shoulder dystocia was encountered.

VERDICT A $12.9 million Michigan verdict was reduced to $4 million under the state cap.

Related articles:
You are the second responder to a shoulder dystocia emergency. What do you do first? Robert L. Barbieri, MD (Editorial; May 2013)
STOP all activities that may lead to further shoulder impaction when you suspect possible shoulder dystocia  Ronald T. Burkman, MD (Stop/Start; March 2013)
The natural history of obstetric brachial plexus injury Robert L. Barbieri, MD (Editorial, February 2013)

SPINAL CORD INJURY
During anesthesia administration before cesarean delivery, a mother’s spinal cord was injured, resulting in irritation of multiple nerve roots. She has chronic nerve pain syndrome.

PATIENT’S CLAIM The anesthesiologist was negligent in how he administered the spinal block.

PHYSICIAN’S DEFENSE There was no negligence. The injury is a known complication of the procedure.

VERDICT An Indiana defense verdict was returned.

AORTA PUNCTURED: $4M VERDICT
A 35-year-old woman underwent laparoscopic cystectomy on her left ovary performed by her gynecologist. During the procedure, the patient’s aorta was punctured, and she lost more than half her blood volume. After immediate surgery to repair the aorta, she was hospitalized for 5 days.

PATIENT’S CLAIM The injury was due to improper insertion of the laparoscopic instruments; the trocars were improperly angled and too forcefully inserted. The injury was a known risk of the procedure for obese patients, but she is not obese. She has a residual scar and is at increased risk of developing adhesions.

PHYSICIAN’S DEFENSE The instruments were properly inserted. The injury is a known risk of the procedure.

VERDICT A $4 million New York verdict was returned.

RESUSCITATION TOOK 22 MINUTES
At 40 6/7 weeks’ gestation, a mother went to the ED after her membranes spontaneously ruptured. The child was delivered by vacuum extraction 30 hours later.

At birth, the baby was blue and limp with Apgar scores of 2, 3, and 7, at 1, 5, and 10 minutes, respectively. The infant required 22 minutes of resuscitation. The neonatal record included metabolic acidosis, respiratory distress, possible sepsis, shoulder dystocia, and seizure activity. The child suffered hypoxic ischemic encephalopathy and permanent neurologic injury.

PARENTS’ CLAIM Cesarean delivery should have been performed due to repetitive decelerations, fetal tachycardia, and increasingly long uterine contractions. Continued use of oxytocin contributed to the infant’s injuries.

DEFENDANTS’ DEFENSE Fetal heart-rate tracings were reassuring during labor. Decreased variability, rising fetal heart rate, and late decelerations are normal during labor and delivery. The infant’s blood gas did not fall below 7.0 pH. The use of oxytocin was proper. There was no way to determine cephalopelvic disproportion or the baby’s size at 6 days postterm. The mother was opposed to a cesarean delivery and requested vaginal delivery (although no such request was included in the medical records).

VERDICT A $55 million Pennsylvania verdict was returned.

INJURY DURING OVARIAN REMNANT RESECTION
A woman in her 40s reported lower left quadrant pain. A previous oophorectomy report indicated that ovarian tissue attached to the bowel had not been removed. Thinking the pain might be related to residual ovarian tissue, her gynecologist recommended resection. During surgery, the patient’s bowel was injured. Four additional operations were required, including bowel resection with colostomy, and then colostomy reversal 5 months later.

PATIENT’S CLAIM The gynecologist was negligent in failing to properly perform surgery. The surgeon’s report from the oophorectomy indicated that there were extensive adhesions, which increased the risk of complications from surgery to remove the remnant. Ovarian remnant syndrome could have been treated with medication to induce menopause.

PHYSICIAN’S DEFENSE The patient might have suffered injury from medication-induced menopause. Surgery was appropriate; the injury is a known risk of the procedure.

VERDICT A $200,000 New York verdict was returned.

SEVERE INFECTION AFTER BIRTH
A 32-year-old woman left the hospital within hours of giving birth because her mother was ill. Before discharge, she reported severe abdominal pain and was examined by a first-year resident. The patient returned to the hospital 6 hours later with a severe uterine infection. She was hospitalized for a month.

PATIENT’S CLAIM The resident failed to properly assess her symptom reports, failed to order testing, and was negligent in allowing her to leave the hospital.

DEFENDANTS’ DEFENSE The patient left the hospital against medical recommendations. She might have acquired the infection after leaving the hospital.

VERDICT A $285,000 Michigan verdict was returned. The patient was found to be 40% at fault.

TERMINAL BRADYCARDIA: $12M VERDICT WITH MIXED FAULT
Four days after her due date, a mother’s blood pressure was elevated, and labor was induced. Two days after oxytocin was started, decelerations occurred. The ObGyn was called after the second deceleration, and witnessed the fourth deceleration about an hour later. After six decelerations, the fetal heart rate dropped to 70 bpm and did not return to baseline. A cesarean delivery was performed 26 minutes later. The child was born with a severe brain injury.

PARENTS’ CLAIM The nurses and ObGyn failed to recognize, report, and address nonreassuring fetal heart signs, and did not discontinue oxytocin after the second deceleration. Hospital protocols were ignored. An earlier cesarean delivery would have avoided injury; the fetus was without oxygen from the sixth deceleration until delivery.

DEFENDANTS’ DEFENSE There was no causation between the alleged violation of hospital protocols and the outcome. The ObGyn was appropriately notified. The injury was caused by terminal bradycardia during a prolonged deceleration that resulted from cord compression; it was unpredictable.

The ObGyn claimed earlier delivery was not indicated. Decelerations did not predict a bradycardic event from which the fetus would not recover nor indicate a need to stop oxytocin. The fetal heart rate had always recovered until the final deceleration. Bradycardia is unpredictable.

VERDICT A $12.165 million Hawaii verdict was returned, with the ObGyn 35% at fault, and the hospital 65% at fault. 

Related article: Stop staring at that Category-II fetal heart-rate tracing… Robert L. Barbieri, MD (Editorial, April 2011)

BREAST BIOPSY MIXUP; SHE DIDN’T HAVE CANCER
A 53-year-old woman reported right breast pain. Mammography revealed scattered fibroglandular elements. Targeted US showed a solid nodule that could be an intramammary lymph node or small fibroadenoma. After an office-based biopsy, the breast surgeon (Dr. A) told the patient that she had breast cancer. 

Because Dr. A was not in her health insurance plan, the patient took her imaging studies and biopsy results to Dr. B, another surgeon. Dr. B performed a mastectomy with lymphadenectomy. There was no evidence of malignancy in the pathologic review of breast and lymph tissue.

PATIENT’S CLAIM Dr. A performed biopsies on several women that same day; all were sent to the same laboratory for analysis. Dr. A and the laboratory failed to properly label and handle the biopsy specimens. Incorrect diagnosis caused her to undergo unnecessary mastectomy, lymph node biopsy, and a long, complicated breast reconstruction.

DEFENDANTS’ DEFENSE The case was settled at trial.

VERDICT A $1,780,000 Virginia settlement was reached.

Related article: Does screening mammography save lives? Janelle Yates (April 2014)

CLUES MISSED; BABY HAS CP, OTHER INJURIES
A 19-year-old mother had regular prenatal care. In early June, she weighed 221 lb and had a fundal height of 36 cm. The certified nurse midwife (CNM) noted little fetal movement, was uncertain of the fetal position, and made a note to check the amniotic fluid at the next visit. A week later, US did not indicate a decrease in amniotic fluid. Records do not indicate that the amniotic fluid index was checked at the next visit (38 weeks’ gestation).

Two days later, the patient reported decreased fetal movement. At the ED, nonreassuring fetal heart tracings were recorded. Fifteen minutes later, the fetal heart rate fell to 50 bpm and did not recover. The on-call ObGyn artificially ruptured the membranes and placed a direct fetal lead. An emergency cesarean delivery was performed in 15 minutes through thick meconium.

Apgar scores were 0, 2, and 4 at 1, 5, and 10 minutes, respectively. The baby weighed 4 lb 4 oz, and was transferred to a children’s hospital, where she stayed for 6 weeks. She suffered seizures and was tube fed. The child has cerebral palsy and profound neurologic impairment. At age 7, she is unable to speak.

PATIENT’S CLAIM The CNM was negligent for not being more proactive when she questioned the amniotic fluid index and noted reduced fetal movement in early June and at subsequent visits. The presence of meconium at birth attested that the fetus had been in distress.

DEFENDANTS’ DEFENSE The case was settled at trial.

VERDICT A $2 million Massachusetts settlement was reached.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

TELL US WHAT YOU THINK!
Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state.
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PATIENT’S CLAIM The hemorrhage was caused when enoxaparin was given at 1.5 times the proper dosage because the patient’s weight was overestimated by 50%. Excessive blood, plasma, and fluids caused her weight to double after resuscitation. Her intestines were forced out of her abdominal cavity by the hemorrhage. A permanent hernia, visible underneath her skin, causes pain.

DEFENDANTS’ DEFENSE The patient’s preexisting diabetes, heart condition, high cholesterol levels, and orthopedic issues impacted her condition. She was not compliant in managing her diabetes, causing many of the current problems.

VERDICT A $9.3 million Connecticut verdict was returned.

Related article: Update: Pelvic floor dysfunction Autumn L. Edenfield, MD, and Cindy L. Amundsen, MD (October 2012)

CESAREAN DELAYED UNNECESSARILY
At 37 weeks’ gestation, a mother reported decreased fetal movement. When the biophysical profile test scored 8/8 and the fetal heart rate was reassuring, the attending ObGyn discharged the patient. However, it was the middle of the night, and the nurse kept the mother in the emergency department (ED). At 8:30 am, the fetus began to show signs of fetal distress. Three ObGyns agreed to monitor labor, although one physician wanted delivery to occur that morning.

The next morning, a second biophysical profile scored 2/8, but the on-call ObGyn misunderstood the score as 6/8 and scheduled cesarean delivery for noon. Two hours after the second biophysical profile, the fetal heart rate crashed. A nurse called the ObGyn, who began an emergency cesarean 15 minutes later. The baby, born lifeless, was resuscitated. The child suffered permanent brain damage, and has cerebral palsy, severe cognitive deficits and speech deficits, and walks with an abnormal gait.

PARENTS’ CLAIM A physician did not see the patient for 24 hours, once the decision was made to monitor the mother, even though the fetal heart rate continued to decline. A biophysical profile test score of 2/8 indicates the need for immediate delivery. An earlier cesarean delivery could have reduced the child’s injuries.

DEFENDANTS’ DEFENSE After a settlement was reached with the hospital, the trial continued against the delivering ObGyn. He claimed that decreased fetal movement indicated that the brain injury had occurred 1 to 4 days before the mother came to the ED. The technician had manipulated the mother’s abdomen to wake the fetus before starting the first biophysical profile, which invalidated the score. The nurse miscommunicated the score of the second biophysical profile.

VERDICT A gross $29.8 million Illinois verdict was returned that included a $1.65 million settlement with the hospital.

WAS FACILITY ADEQUATELY STAFFED AFTER HURRICANE IKE?
A mother was admitted to a hospital for induction of labor in September 2008. After birth, the child was found to have cerebral palsy.

PARENTS’ CLAIM The mother should have been sent to another facility before delivery was induced because the hospital was short-staffed and low on resources due to Hurricane Ike. Too much oxytocin was used to induce contractions, which led to a lack of oxygen for the fetus. All prenatal testing had shown a healthy fetus. A cesarean delivery should have occurred when fetal distress was noted.

DEFENDANTS’ DEFENSE The mother had gastric bypass surgery 8 months before she became pregnant, and smoked during pregnancy, which accounted for the infant’s injuries. Treatment during labor and delivery was appropriate. Hospital staffing and resources were adequate.

VERDICT A $6.5 million Texas settlement was reached. 

PLACENTA ACCRETA; MOTHER DIES
A 33-year-old woman became pregnant with her second child. A variety of conditions caused this to be high-risk pregnancy, so she saw a maternal-fetal medicine (MFM) specialist 2 months before delivery. The MFM reported that his examination and the ultrasonography (US) results were normal.

The ObGyn who provided prenatal care and delivered her first child scheduled cesarean delivery. During the procedure, the ObGyn noticed a 3- to 4-inch lesion where the placenta had penetrated the uterus. When the placenta was removed, the patient began to hemorrhage and a hysterectomy was performed. The hemorrhage created blood clots that led to gangrene in the patient’s extremities. She died 5 days after giving birth.

ESTATE’S CLAIM Both the MFM and the ObGyn failed to recognize placenta accreta on US prior to delivery. The ObGyn should have performed US prior to beginning cesarean delivery. The hospital’s protocols were not followed: the ObGyn should have stopped the procedure and called for extra surgical assistance and additional blood when he encountered placenta accreta, and again when the patient began to hemorrhage. Placenta accreta does not have to be fatal if detected and managed properly.

DEFENDANTS’ DEFENSE There was no negligence; the patient was treated properly.

VERDICT A $15.5 million Illinois verdict was returned against both physicians and the medical center. 

Related article: Is the risk of placenta accreta in a subsequent pregnancy higher after emergent primary cesarean or after elective primary cesarean? Yinka Oyelese, MD (Examining the Evidence, December 2013)

ANTICONVULSANT AND MIGRAINE MEDS TAKEN DURING PREGNANCY
A woman was prescribed topiramate (Topamax) for migraine headaches and hand tremors during the first trimester of her pregnancy in 2007. With a history of seizures, she also took several anticonvulsants throughout her pregnancy. Her child was diagnosed with right unilateral cleft lip (cheiloschisis) in utero. The condition had not been surgically corrected at the time of trial.

PARENTS’ CLAIM The use of topiramate caused the child’s cleft lip. Janssen Pharmaceuticals, the manufacturer of Topamax, knew about the risk of birth defects associated with the drug in 2007, but failed to provide adequate warnings.

DEFENDANTS’ DEFENSE The mother received at least two warnings from her physician regarding the potential risks of anticonvulsant and antiepileptic drugs and the importance of not becoming pregnant while taking the medications. An action against the physician was barred by the applicable statute of limitations. The mother had taken topiramate prescribed to her mother for a time; such actions should release Janssen from liability.

VERDICT A $11 million Pennsylvania verdict was returned.

PID MASKS ECTOPIC PREGNANCY
A woman in her 40s became pregnant. On the first two prenatal diagnostic imaging studies, the ObGyn saw an intrauterine pregnancy. He later realized that the pregnancy was ectopic after beta human chorionic gonadotrophin (beta-hCG) blood levels were abnormal. During surgery to terminate the pregnancy, he found he had to perform a total hysterectomy because the patient had extensive pelvic inflammatory disease (PID) caused by a long history of sexually transmitted disease.

PATIENT’S CLAIM If the ectopic pregnancy had been diagnosed earlier, one of her ovaries could have been preserved, saving her from the symptoms of surgical menopause.

PHYSICIAN’S DEFENSE PID had caused the ovaries, numerous fibroid tumors, and the uterus to fuse into one mass. That was why the first two imaging studies appeared to show an intrauterine pregnancy. It was not possible to diagnose the extent of the problem until surgery. The patient did not have a true ectopic pregnancy.

The patient’s difficulties occurred during a 2-week time period in which she had one visit with him and another visit to an ED where two other physicians examined her and missed the diagnosis.

VERDICT A Michigan defense verdict was returned. 

ILIAC ARTERY INJURED DURING LAPAROSCOPIC SURGERY; PATIENT DIES
A 40-year-old woman underwent laparoscopic gynecologic surgery performed by her ObGyn. During the procedure, the patient’s left internal iliac artery was punctured, but the injury was not recognized at the time. She was discharged the same day. The next morning, she went into hypovolemic shock due to internal bleeding. She was taken to the ED, where she died.

ESTATE’S CLAIM The ObGyn, anesthesiologist, and hospital staff were negligent in their postoperative care. The anesthesiologist prescribed pain medication that masked the injury; the patient was discharged from the postanesthesia unit too early and without proper examination. The nursing staff did not react to the patient’s reports of abdominal pain, nor did they properly assess her condition prior to discharge. The ObGyn failed to return a phone call the evening after the procedure.

DEFENDANTS’ DEFENSE The ObGyn settled before trial. The anesthesiologist and hospital denied negligence: care was proper and followed all protocols.

VERDICT A confidential California settlement was reached with the ObGyn. A defense verdict was returned for the anesthesiologist and hospital. 

Related article: Anatomy for the laparoscopic surgeon Emad Mikhail, MD; Lauren Scott, MD; Stuart Hart, MD, MS (April 2014)

GENETIC TESTING MISSED A KEY DIAGNOSIS
A 40-year-old woman underwent genetic testing after she became pregnant. She was assured that there were no abnormalities that would impact her child.

The baby was born with Wolf-Hirschhorn syndrome, characterized by facial deformities, intellectual disabilities, delayed growth, and seizures. The child is nonverbal, deaf, and blind. She uses a feeding tube and requires 24-hour care.

PARENTS’ CLAIM The genetic testing was improperly conducted. The mother would have had an abortion if she’d known that the child was so disabled.

DEFENDANTS’ DEFENSE Settlements were mediated.

VERDICT A $6.15 million New Jersey settlement was reached on behalf of the hospital and two laboratory technicians, and a $1 million settlement was reached with the director of the genetic laboratory. 

HEAT INJURY TO COLON: ABSCESSES, PERITONITIS
A 43-year-old patient had a history of symptomatic uterine fibroids and infertility. Her ObGyn performed a hysteroscopy because he suspected endometriosis, but found none. He then successfully removed a large uterine fibroid during laparoscopic myomectomy. The patient was discharged the same day.

Two days later, the patient developed abdominal pain, nausea, and fever. She went to the ED and was taken into emergency surgery after a CT scan showed free air and fluid in her abdomen. She suffered multiple abscesses and peritonitis.

PATIENT’S CLAIM The ObGyn was negligent in performing the surgery: the sigmoid colon sustained a thermal injury, which caused the abscesses and peritonitis.

PHYSICIAN’S DEFENSE There was no evidence of thermal injury during the original operation; heat damage can and does occur in the absence of negligence. The patient’s previously unknown diverticulitis contributed to the development of the recurrent abscesses and peritonitis.

VERDICT A Florida defense verdict was returned.

RUPTURED UTERUS IS UNDETECTED
During labor and delivery, a declining fetal heart rate was observed, but there was an hour’s delay before cesarean delivery was started. The child suffered a hypoxic brain injury. He has spastic quadriplegia, cannot speak, and requires a respirator and feeding tube.

PARENTS’ CLAIM The mother suffered a ruptured uterus during labor that was not recognized by the ObGyn or nursing staff.

DEFENDANTS’ DEFENSE A settlement was reached during trial.

VERDICT A $7.5 million New Jersey settlement was reached.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Tell us what you think!
Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state.
Stay in touch! Your feedback is important to us!

PATIENT’S CLAIM The hemorrhage was caused when enoxaparin was given at 1.5 times the proper dosage because the patient’s weight was overestimated by 50%. Excessive blood, plasma, and fluids caused her weight to double after resuscitation. Her intestines were forced out of her abdominal cavity by the hemorrhage. A permanent hernia, visible underneath her skin, causes pain.

DEFENDANTS’ DEFENSE The patient’s preexisting diabetes, heart condition, high cholesterol levels, and orthopedic issues impacted her condition. She was not compliant in managing her diabetes, causing many of the current problems.

VERDICT A $9.3 million Connecticut verdict was returned.

Related article: Update: Pelvic floor dysfunction Autumn L. Edenfield, MD, and Cindy L. Amundsen, MD (October 2012)

CESAREAN DELAYED UNNECESSARILY
At 37 weeks’ gestation, a mother reported decreased fetal movement. When the biophysical profile test scored 8/8 and the fetal heart rate was reassuring, the attending ObGyn discharged the patient. However, it was the middle of the night, and the nurse kept the mother in the emergency department (ED). At 8:30 am, the fetus began to show signs of fetal distress. Three ObGyns agreed to monitor labor, although one physician wanted delivery to occur that morning.

The next morning, a second biophysical profile scored 2/8, but the on-call ObGyn misunderstood the score as 6/8 and scheduled cesarean delivery for noon. Two hours after the second biophysical profile, the fetal heart rate crashed. A nurse called the ObGyn, who began an emergency cesarean 15 minutes later. The baby, born lifeless, was resuscitated. The child suffered permanent brain damage, and has cerebral palsy, severe cognitive deficits and speech deficits, and walks with an abnormal gait.

PARENTS’ CLAIM A physician did not see the patient for 24 hours, once the decision was made to monitor the mother, even though the fetal heart rate continued to decline. A biophysical profile test score of 2/8 indicates the need for immediate delivery. An earlier cesarean delivery could have reduced the child’s injuries.

DEFENDANTS’ DEFENSE After a settlement was reached with the hospital, the trial continued against the delivering ObGyn. He claimed that decreased fetal movement indicated that the brain injury had occurred 1 to 4 days before the mother came to the ED. The technician had manipulated the mother’s abdomen to wake the fetus before starting the first biophysical profile, which invalidated the score. The nurse miscommunicated the score of the second biophysical profile.

VERDICT A gross $29.8 million Illinois verdict was returned that included a $1.65 million settlement with the hospital.

WAS FACILITY ADEQUATELY STAFFED AFTER HURRICANE IKE?
A mother was admitted to a hospital for induction of labor in September 2008. After birth, the child was found to have cerebral palsy.

PARENTS’ CLAIM The mother should have been sent to another facility before delivery was induced because the hospital was short-staffed and low on resources due to Hurricane Ike. Too much oxytocin was used to induce contractions, which led to a lack of oxygen for the fetus. All prenatal testing had shown a healthy fetus. A cesarean delivery should have occurred when fetal distress was noted.

DEFENDANTS’ DEFENSE The mother had gastric bypass surgery 8 months before she became pregnant, and smoked during pregnancy, which accounted for the infant’s injuries. Treatment during labor and delivery was appropriate. Hospital staffing and resources were adequate.

VERDICT A $6.5 million Texas settlement was reached. 

PLACENTA ACCRETA; MOTHER DIES
A 33-year-old woman became pregnant with her second child. A variety of conditions caused this to be high-risk pregnancy, so she saw a maternal-fetal medicine (MFM) specialist 2 months before delivery. The MFM reported that his examination and the ultrasonography (US) results were normal.

The ObGyn who provided prenatal care and delivered her first child scheduled cesarean delivery. During the procedure, the ObGyn noticed a 3- to 4-inch lesion where the placenta had penetrated the uterus. When the placenta was removed, the patient began to hemorrhage and a hysterectomy was performed. The hemorrhage created blood clots that led to gangrene in the patient’s extremities. She died 5 days after giving birth.

ESTATE’S CLAIM Both the MFM and the ObGyn failed to recognize placenta accreta on US prior to delivery. The ObGyn should have performed US prior to beginning cesarean delivery. The hospital’s protocols were not followed: the ObGyn should have stopped the procedure and called for extra surgical assistance and additional blood when he encountered placenta accreta, and again when the patient began to hemorrhage. Placenta accreta does not have to be fatal if detected and managed properly.

DEFENDANTS’ DEFENSE There was no negligence; the patient was treated properly.

VERDICT A $15.5 million Illinois verdict was returned against both physicians and the medical center. 

Related article: Is the risk of placenta accreta in a subsequent pregnancy higher after emergent primary cesarean or after elective primary cesarean? Yinka Oyelese, MD (Examining the Evidence, December 2013)

ANTICONVULSANT AND MIGRAINE MEDS TAKEN DURING PREGNANCY
A woman was prescribed topiramate (Topamax) for migraine headaches and hand tremors during the first trimester of her pregnancy in 2007. With a history of seizures, she also took several anticonvulsants throughout her pregnancy. Her child was diagnosed with right unilateral cleft lip (cheiloschisis) in utero. The condition had not been surgically corrected at the time of trial.

PARENTS’ CLAIM The use of topiramate caused the child’s cleft lip. Janssen Pharmaceuticals, the manufacturer of Topamax, knew about the risk of birth defects associated with the drug in 2007, but failed to provide adequate warnings.

DEFENDANTS’ DEFENSE The mother received at least two warnings from her physician regarding the potential risks of anticonvulsant and antiepileptic drugs and the importance of not becoming pregnant while taking the medications. An action against the physician was barred by the applicable statute of limitations. The mother had taken topiramate prescribed to her mother for a time; such actions should release Janssen from liability.

VERDICT A $11 million Pennsylvania verdict was returned.

PID MASKS ECTOPIC PREGNANCY
A woman in her 40s became pregnant. On the first two prenatal diagnostic imaging studies, the ObGyn saw an intrauterine pregnancy. He later realized that the pregnancy was ectopic after beta human chorionic gonadotrophin (beta-hCG) blood levels were abnormal. During surgery to terminate the pregnancy, he found he had to perform a total hysterectomy because the patient had extensive pelvic inflammatory disease (PID) caused by a long history of sexually transmitted disease.

PATIENT’S CLAIM If the ectopic pregnancy had been diagnosed earlier, one of her ovaries could have been preserved, saving her from the symptoms of surgical menopause.

PHYSICIAN’S DEFENSE PID had caused the ovaries, numerous fibroid tumors, and the uterus to fuse into one mass. That was why the first two imaging studies appeared to show an intrauterine pregnancy. It was not possible to diagnose the extent of the problem until surgery. The patient did not have a true ectopic pregnancy.

The patient’s difficulties occurred during a 2-week time period in which she had one visit with him and another visit to an ED where two other physicians examined her and missed the diagnosis.

VERDICT A Michigan defense verdict was returned. 

ILIAC ARTERY INJURED DURING LAPAROSCOPIC SURGERY; PATIENT DIES
A 40-year-old woman underwent laparoscopic gynecologic surgery performed by her ObGyn. During the procedure, the patient’s left internal iliac artery was punctured, but the injury was not recognized at the time. She was discharged the same day. The next morning, she went into hypovolemic shock due to internal bleeding. She was taken to the ED, where she died.

ESTATE’S CLAIM The ObGyn, anesthesiologist, and hospital staff were negligent in their postoperative care. The anesthesiologist prescribed pain medication that masked the injury; the patient was discharged from the postanesthesia unit too early and without proper examination. The nursing staff did not react to the patient’s reports of abdominal pain, nor did they properly assess her condition prior to discharge. The ObGyn failed to return a phone call the evening after the procedure.

DEFENDANTS’ DEFENSE The ObGyn settled before trial. The anesthesiologist and hospital denied negligence: care was proper and followed all protocols.

VERDICT A confidential California settlement was reached with the ObGyn. A defense verdict was returned for the anesthesiologist and hospital. 

Related article: Anatomy for the laparoscopic surgeon Emad Mikhail, MD; Lauren Scott, MD; Stuart Hart, MD, MS (April 2014)

GENETIC TESTING MISSED A KEY DIAGNOSIS
A 40-year-old woman underwent genetic testing after she became pregnant. She was assured that there were no abnormalities that would impact her child.

The baby was born with Wolf-Hirschhorn syndrome, characterized by facial deformities, intellectual disabilities, delayed growth, and seizures. The child is nonverbal, deaf, and blind. She uses a feeding tube and requires 24-hour care.

PARENTS’ CLAIM The genetic testing was improperly conducted. The mother would have had an abortion if she’d known that the child was so disabled.

DEFENDANTS’ DEFENSE Settlements were mediated.

VERDICT A $6.15 million New Jersey settlement was reached on behalf of the hospital and two laboratory technicians, and a $1 million settlement was reached with the director of the genetic laboratory. 

HEAT INJURY TO COLON: ABSCESSES, PERITONITIS
A 43-year-old patient had a history of symptomatic uterine fibroids and infertility. Her ObGyn performed a hysteroscopy because he suspected endometriosis, but found none. He then successfully removed a large uterine fibroid during laparoscopic myomectomy. The patient was discharged the same day.

Two days later, the patient developed abdominal pain, nausea, and fever. She went to the ED and was taken into emergency surgery after a CT scan showed free air and fluid in her abdomen. She suffered multiple abscesses and peritonitis.

PATIENT’S CLAIM The ObGyn was negligent in performing the surgery: the sigmoid colon sustained a thermal injury, which caused the abscesses and peritonitis.

PHYSICIAN’S DEFENSE There was no evidence of thermal injury during the original operation; heat damage can and does occur in the absence of negligence. The patient’s previously unknown diverticulitis contributed to the development of the recurrent abscesses and peritonitis.

VERDICT A Florida defense verdict was returned.

RUPTURED UTERUS IS UNDETECTED
During labor and delivery, a declining fetal heart rate was observed, but there was an hour’s delay before cesarean delivery was started. The child suffered a hypoxic brain injury. He has spastic quadriplegia, cannot speak, and requires a respirator and feeding tube.

PARENTS’ CLAIM The mother suffered a ruptured uterus during labor that was not recognized by the ObGyn or nursing staff.

DEFENDANTS’ DEFENSE A settlement was reached during trial.

VERDICT A $7.5 million New Jersey settlement was reached.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Tell us what you think!
Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state.
Stay in touch! Your feedback is important to us!

PATIENT’S CLAIM The hemorrhage was caused when enoxaparin was given at 1.5 times the proper dosage because the patient’s weight was overestimated by 50%. Excessive blood, plasma, and fluids caused her weight to double after resuscitation. Her intestines were forced out of her abdominal cavity by the hemorrhage. A permanent hernia, visible underneath her skin, causes pain.

DEFENDANTS’ DEFENSE The patient’s preexisting diabetes, heart condition, high cholesterol levels, and orthopedic issues impacted her condition. She was not compliant in managing her diabetes, causing many of the current problems.

VERDICT A $9.3 million Connecticut verdict was returned.

Related article: Update: Pelvic floor dysfunction Autumn L. Edenfield, MD, and Cindy L. Amundsen, MD (October 2012)

CESAREAN DELAYED UNNECESSARILY
At 37 weeks’ gestation, a mother reported decreased fetal movement. When the biophysical profile test scored 8/8 and the fetal heart rate was reassuring, the attending ObGyn discharged the patient. However, it was the middle of the night, and the nurse kept the mother in the emergency department (ED). At 8:30 am, the fetus began to show signs of fetal distress. Three ObGyns agreed to monitor labor, although one physician wanted delivery to occur that morning.

The next morning, a second biophysical profile scored 2/8, but the on-call ObGyn misunderstood the score as 6/8 and scheduled cesarean delivery for noon. Two hours after the second biophysical profile, the fetal heart rate crashed. A nurse called the ObGyn, who began an emergency cesarean 15 minutes later. The baby, born lifeless, was resuscitated. The child suffered permanent brain damage, and has cerebral palsy, severe cognitive deficits and speech deficits, and walks with an abnormal gait.

PARENTS’ CLAIM A physician did not see the patient for 24 hours, once the decision was made to monitor the mother, even though the fetal heart rate continued to decline. A biophysical profile test score of 2/8 indicates the need for immediate delivery. An earlier cesarean delivery could have reduced the child’s injuries.

DEFENDANTS’ DEFENSE After a settlement was reached with the hospital, the trial continued against the delivering ObGyn. He claimed that decreased fetal movement indicated that the brain injury had occurred 1 to 4 days before the mother came to the ED. The technician had manipulated the mother’s abdomen to wake the fetus before starting the first biophysical profile, which invalidated the score. The nurse miscommunicated the score of the second biophysical profile.

VERDICT A gross $29.8 million Illinois verdict was returned that included a $1.65 million settlement with the hospital.

WAS FACILITY ADEQUATELY STAFFED AFTER HURRICANE IKE?
A mother was admitted to a hospital for induction of labor in September 2008. After birth, the child was found to have cerebral palsy.

PARENTS’ CLAIM The mother should have been sent to another facility before delivery was induced because the hospital was short-staffed and low on resources due to Hurricane Ike. Too much oxytocin was used to induce contractions, which led to a lack of oxygen for the fetus. All prenatal testing had shown a healthy fetus. A cesarean delivery should have occurred when fetal distress was noted.

DEFENDANTS’ DEFENSE The mother had gastric bypass surgery 8 months before she became pregnant, and smoked during pregnancy, which accounted for the infant’s injuries. Treatment during labor and delivery was appropriate. Hospital staffing and resources were adequate.

VERDICT A $6.5 million Texas settlement was reached. 

PLACENTA ACCRETA; MOTHER DIES
A 33-year-old woman became pregnant with her second child. A variety of conditions caused this to be high-risk pregnancy, so she saw a maternal-fetal medicine (MFM) specialist 2 months before delivery. The MFM reported that his examination and the ultrasonography (US) results were normal.

The ObGyn who provided prenatal care and delivered her first child scheduled cesarean delivery. During the procedure, the ObGyn noticed a 3- to 4-inch lesion where the placenta had penetrated the uterus. When the placenta was removed, the patient began to hemorrhage and a hysterectomy was performed. The hemorrhage created blood clots that led to gangrene in the patient’s extremities. She died 5 days after giving birth.

ESTATE’S CLAIM Both the MFM and the ObGyn failed to recognize placenta accreta on US prior to delivery. The ObGyn should have performed US prior to beginning cesarean delivery. The hospital’s protocols were not followed: the ObGyn should have stopped the procedure and called for extra surgical assistance and additional blood when he encountered placenta accreta, and again when the patient began to hemorrhage. Placenta accreta does not have to be fatal if detected and managed properly.

DEFENDANTS’ DEFENSE There was no negligence; the patient was treated properly.

VERDICT A $15.5 million Illinois verdict was returned against both physicians and the medical center. 

Related article: Is the risk of placenta accreta in a subsequent pregnancy higher after emergent primary cesarean or after elective primary cesarean? Yinka Oyelese, MD (Examining the Evidence, December 2013)

ANTICONVULSANT AND MIGRAINE MEDS TAKEN DURING PREGNANCY
A woman was prescribed topiramate (Topamax) for migraine headaches and hand tremors during the first trimester of her pregnancy in 2007. With a history of seizures, she also took several anticonvulsants throughout her pregnancy. Her child was diagnosed with right unilateral cleft lip (cheiloschisis) in utero. The condition had not been surgically corrected at the time of trial.

PARENTS’ CLAIM The use of topiramate caused the child’s cleft lip. Janssen Pharmaceuticals, the manufacturer of Topamax, knew about the risk of birth defects associated with the drug in 2007, but failed to provide adequate warnings.

DEFENDANTS’ DEFENSE The mother received at least two warnings from her physician regarding the potential risks of anticonvulsant and antiepileptic drugs and the importance of not becoming pregnant while taking the medications. An action against the physician was barred by the applicable statute of limitations. The mother had taken topiramate prescribed to her mother for a time; such actions should release Janssen from liability.

VERDICT A $11 million Pennsylvania verdict was returned.

PID MASKS ECTOPIC PREGNANCY
A woman in her 40s became pregnant. On the first two prenatal diagnostic imaging studies, the ObGyn saw an intrauterine pregnancy. He later realized that the pregnancy was ectopic after beta human chorionic gonadotrophin (beta-hCG) blood levels were abnormal. During surgery to terminate the pregnancy, he found he had to perform a total hysterectomy because the patient had extensive pelvic inflammatory disease (PID) caused by a long history of sexually transmitted disease.

PATIENT’S CLAIM If the ectopic pregnancy had been diagnosed earlier, one of her ovaries could have been preserved, saving her from the symptoms of surgical menopause.

PHYSICIAN’S DEFENSE PID had caused the ovaries, numerous fibroid tumors, and the uterus to fuse into one mass. That was why the first two imaging studies appeared to show an intrauterine pregnancy. It was not possible to diagnose the extent of the problem until surgery. The patient did not have a true ectopic pregnancy.

The patient’s difficulties occurred during a 2-week time period in which she had one visit with him and another visit to an ED where two other physicians examined her and missed the diagnosis.

VERDICT A Michigan defense verdict was returned. 

ILIAC ARTERY INJURED DURING LAPAROSCOPIC SURGERY; PATIENT DIES
A 40-year-old woman underwent laparoscopic gynecologic surgery performed by her ObGyn. During the procedure, the patient’s left internal iliac artery was punctured, but the injury was not recognized at the time. She was discharged the same day. The next morning, she went into hypovolemic shock due to internal bleeding. She was taken to the ED, where she died.

ESTATE’S CLAIM The ObGyn, anesthesiologist, and hospital staff were negligent in their postoperative care. The anesthesiologist prescribed pain medication that masked the injury; the patient was discharged from the postanesthesia unit too early and without proper examination. The nursing staff did not react to the patient’s reports of abdominal pain, nor did they properly assess her condition prior to discharge. The ObGyn failed to return a phone call the evening after the procedure.

DEFENDANTS’ DEFENSE The ObGyn settled before trial. The anesthesiologist and hospital denied negligence: care was proper and followed all protocols.

VERDICT A confidential California settlement was reached with the ObGyn. A defense verdict was returned for the anesthesiologist and hospital. 

Related article: Anatomy for the laparoscopic surgeon Emad Mikhail, MD; Lauren Scott, MD; Stuart Hart, MD, MS (April 2014)

GENETIC TESTING MISSED A KEY DIAGNOSIS
A 40-year-old woman underwent genetic testing after she became pregnant. She was assured that there were no abnormalities that would impact her child.

The baby was born with Wolf-Hirschhorn syndrome, characterized by facial deformities, intellectual disabilities, delayed growth, and seizures. The child is nonverbal, deaf, and blind. She uses a feeding tube and requires 24-hour care.

PARENTS’ CLAIM The genetic testing was improperly conducted. The mother would have had an abortion if she’d known that the child was so disabled.

DEFENDANTS’ DEFENSE Settlements were mediated.

VERDICT A $6.15 million New Jersey settlement was reached on behalf of the hospital and two laboratory technicians, and a $1 million settlement was reached with the director of the genetic laboratory. 

HEAT INJURY TO COLON: ABSCESSES, PERITONITIS
A 43-year-old patient had a history of symptomatic uterine fibroids and infertility. Her ObGyn performed a hysteroscopy because he suspected endometriosis, but found none. He then successfully removed a large uterine fibroid during laparoscopic myomectomy. The patient was discharged the same day.

Two days later, the patient developed abdominal pain, nausea, and fever. She went to the ED and was taken into emergency surgery after a CT scan showed free air and fluid in her abdomen. She suffered multiple abscesses and peritonitis.

PATIENT’S CLAIM The ObGyn was negligent in performing the surgery: the sigmoid colon sustained a thermal injury, which caused the abscesses and peritonitis.

PHYSICIAN’S DEFENSE There was no evidence of thermal injury during the original operation; heat damage can and does occur in the absence of negligence. The patient’s previously unknown diverticulitis contributed to the development of the recurrent abscesses and peritonitis.

VERDICT A Florida defense verdict was returned.

RUPTURED UTERUS IS UNDETECTED
During labor and delivery, a declining fetal heart rate was observed, but there was an hour’s delay before cesarean delivery was started. The child suffered a hypoxic brain injury. He has spastic quadriplegia, cannot speak, and requires a respirator and feeding tube.

PARENTS’ CLAIM The mother suffered a ruptured uterus during labor that was not recognized by the ObGyn or nursing staff.

DEFENDANTS’ DEFENSE A settlement was reached during trial.

VERDICT A $7.5 million New Jersey settlement was reached.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Tell us what you think!
Drop us a line and let us know what you think about this or other current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected] Please include your name, city and state.
Stay in touch! Your feedback is important to us!

PLACENTA FAILS TO DELIVER: MOTHER DIES OF HEMORRHAGE

After a 38-year-old woman gave birth, the placenta did not deliver. The ObGyn was unable remove the entire placenta and the mother began to hemorrhage. After an hour, the patient was given a blood transfusion. She could not be stabilized and died.

ESTATE’S CLAIM The ObGyn was negligent. He failed to remove the entire placenta and did not treat the hemorrhage in a timely manner. The hospital staff was negligent in failing to properly address the massive hemorrhage. A prompt transfusion would have saved the woman’s life, but the anesthesiologist who had to approve the procedure could not be located. Other procedures, including a hysterectomy, could have saved the mother’s life.

DEFENDANTS’ DEFENSE The ObGyn claimed that incomplete delivery of the placenta and postpartum hemorrhage are known complications of a delivery. The hospital claimed that the staff had acted appropriately and that it was not responsible for the actions of the anesthesiologist, an independent contractor. The anesthesiologist denied negligence.

VERDICT A $2 million New York settlement was reached that included $200,000 from the hospital and $1.8 million from the physicians’ insurers.

Related Article: Postpartum hemorrhage: 11 critical questions, answered by an expert  Haywood L. Brown, MD (January 2011)

DECREASED FETAL MOVEMENT OVERLOOKED; SEVERE INJURY TO BABY
At her 39th-week prenatal visit at a clinic, the mother reported decreased fetal movement. Acoustic stimulation of the fetus was attempted twice without response. The fetal heart-rate monitor identified a normal heart rate without variability or accelerations. The mother was taken by wheelchair to the hospital next door. A note explaining the nonreassuring findings allegedly accompanied her.

The mother waited to be admitted. When a fetal heart-rate monitor was connected 30 minutes after admission, results were still nonreassuring.

A resident examined the mother 45 minutes later. He called the attending ObGyn, and they decided to postpone cesarean delivery because the mother had eaten breakfast.

When the fetal heart rate crashed 4 hours later, a second-year resident began emergency cesarean delivery. The ObGyn, who had never examined the patient, observed some of the procedure in the OR.

The baby was born with catastrophic brain damage, and has spastic quadriplegia cerebral palsy, feeding problems, and significant cognitive and developmental delays.

PARENTS’ CLAIM A cesarean delivery should have been performed immediately after the mother’s admission. Even if the cesarean had been begun 15 to 20 minutes earlier, the injury could have been avoided. The ObGyn never examined the mother nor did he participate in the cesarean delivery.

DEFENDANTS’ DEFENSE The ObGyn and hospital denied negligence. The note was not attached to the patient’s chart. At trial, the ObGyn admitted that a delivery 15 to 20 minutes earlier might have avoided the injury.

VERDICT A $33,591,900 Tennessee verdict was returned.

WOMAN BECOMES PREGNANT AFTER TUBAL LIGATION
A 32-year-old woman requested sterilization after the birth of her third child. A Falope ring tubal ligation procedure was performed by a gynecologist in April 2006. During surgery, the device used by the gynecologist ejected 2 silastic bands on the right side instead of one.

The patient learned she was pregnant in March 2007. Her high-risk pregnancy ended with cesarean delivery in September 2007. The delivering ObGyn found the patient’s right fallopian tube in its natural, unscarred state. A silastic band was applied to the right ovarian ligament, not the right fallopian tube.

PATIENT’S CLAIM The gynecologist banded the ovarian ligament instead of the fallopian tube.

PHYSICIAN’S DEFENSE The procedure was properly performed. The rings initially enclosed the fallopian tube and ovarian ligament, but the top ring subsequently migrated off the structures, allowing the fallopian tube to slip out of the attachment. Failure to sterilize is a known risk of the procedure.

VERDICT An Illinois defense verdict was returned.

ABORTION ATTEMPTED BUT PREGNANCY IS ECTOPIC
A 14-year-old patient went to a clinic for elective abortion at 8 weeks’ gestation. Ultrasonography (US) prior to the procedure showed an intrauterine pregnancy. After dilating the cervix, the ObGyn inserted a semi-rigid vacuum aspiration curette to suction the uterine contents, but received nothing. A second US confirmed an intrauterine pregnancy. The ObGyn was able to locate the pregnancy and indent the gestational sac with 3 different dilators and the curette. The pregnancy decreased in size on US after the suction was applied. However, the patient’s vital signs dropped dramatically, and she was rushed to the hospital. During emergency surgery, severe pelvic adhesive disease complicated the ability to stop the hemorrhage. Four physicians concurred that supracervical hysterectomy was needed to save the patient’s life. Postoperative pathology identified a cornual or interstitial ectopic pregnancy.

PATIENT’S CLAIM The ObGyn failed to heed several warning signs of ectopic pregnancy. Further testing should have been done before the second round of vacuum. If ectopic pregnancy had been discovered earlier, the patient could have undergone surgery that would have preserved her uterus and allowed her to bear children. The ObGyn tore the uterus multiple times when he turned on the suction, causing massive hemorrhage.

PHYSICIAN’S DEFENSE Ultrasonography clearly showed an intrauterine pregnancy. There was nothing to cause suspicion that the pregnancy was ectopic. She might be able to have a child through surrogacy.  

VERDICT A $950,000 Illinois verdict was returned.

Related Article: Is the hCG discriminatory zone a reliable indicator of intrauterine or ectopic pregnancy? Andrew M. Kaunitz, MD (Examining the Evidence, February 2012)

MACROSOMIC FETUS: MOTHER AND BABY BOTH INJURED
When prenatal ultrasonography indicated the fetal weight was 10 lbs, the patient and her mother expressed concern over delivery of such a large baby. The ObGyn reassured them that it would not be a problem.

Four days later, the mother went into labor. She was 9-cm dilated 4.5 hours later, but only progressed to 9.5 cm over the next 7 hours. She was told to begin to push, but, after 2 hours, birth had not occurred. The ObGyn used forceps to deliver the head 45 minutes later. Shoulder dystocia was encountered and there was a 3.5-minute delivery delay. The baby suffered oxygen deprivation and the mother experienced a 4th-degree perineal tear.

After the NICU team resuscitated the baby, she was transferred to another hospital, where she underwent “head cooling” in an attempt to mitigate her injuries. The child has mild cerebral palsy, with right hemiparesis, speech delay, and additional neurologic injuries. 

PARENTS' CLAIM Cesarean delivery was unnecessarily delayed. The ObGyn was negligent in not performing an emergency cesarean delivery after 2 hours of pushing was not effective. The ObGyn never suggested a cesarean delivery, it was not noted in the chart, and no one else present at the time remembered the option being offered.

PHYSICIAN’S DEFENSE There was nothing during labor to contraindicate a vaginal birth. The ObGyn claimed that he offered a cesarean delivery after 2 hours of pushing. The baby’s blood gas reading at delivery was normal. Any brain injuries to the baby were from resuscitation.  

VERDICT A $4,080,500 Pennsylvania verdict was returned.

Related Articles:
When macrosomia is suspected at term, does induction of labor lower the risk of cesarean delivery? Jennifer T. Ahn, MD (Examining the Evidence, May 2012)
Develop and use a checklist for 3rd- and 4th-degree perinatal lacerations  Robert L. Barbieri, MD (Editorial, August 2013)

BOWEL INJURY DURING CESAREAN DELIVERY
During cesarean delivery, the mother suffered a bowel injury that led to infection and several abdominal abscesses. She required two procedures for drain placement plus two additional operations.

PATIENT’S CLAIM The ObGyn was negligent in how he performed the cesarean delivery and for not treating the injury and subsequent infection in a timely manner. The abscesses took 3 years to resolve; additional procedures left scarring and aggravated a spinal injury.

PHYSICIAN’S DEFENSE Bowel perforation is a known complication of cesarean delivery. It probably occurred during manipulation of the uterus in an area that was not visible.

VERDICT A $750,000 New Jersey verdict was returned.  

Related Article: How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy Michael Baggish, MD (Surgical Technique, October 2012)

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts  and awards.

TELL US WHAT YOU THINK!
Share your thoughts on this article or on any topic relevant to ObGyns and women’s health practitioners. Tell us which topics you’d like to see covered in future issues, and what challenges you face in daily practice. We will consider publishing your letter and in a future issue.
Send your letter to: [email protected] Please include the city and state in which you practice.
Stay in touch! Your feedback is important to us!

PLACENTA FAILS TO DELIVER: MOTHER DIES OF HEMORRHAGE

After a 38-year-old woman gave birth, the placenta did not deliver. The ObGyn was unable remove the entire placenta and the mother began to hemorrhage. After an hour, the patient was given a blood transfusion. She could not be stabilized and died.

ESTATE’S CLAIM The ObGyn was negligent. He failed to remove the entire placenta and did not treat the hemorrhage in a timely manner. The hospital staff was negligent in failing to properly address the massive hemorrhage. A prompt transfusion would have saved the woman’s life, but the anesthesiologist who had to approve the procedure could not be located. Other procedures, including a hysterectomy, could have saved the mother’s life.

DEFENDANTS’ DEFENSE The ObGyn claimed that incomplete delivery of the placenta and postpartum hemorrhage are known complications of a delivery. The hospital claimed that the staff had acted appropriately and that it was not responsible for the actions of the anesthesiologist, an independent contractor. The anesthesiologist denied negligence.

VERDICT A $2 million New York settlement was reached that included $200,000 from the hospital and $1.8 million from the physicians’ insurers.

Related Article: Postpartum hemorrhage: 11 critical questions, answered by an expert  Haywood L. Brown, MD (January 2011)

DECREASED FETAL MOVEMENT OVERLOOKED; SEVERE INJURY TO BABY
At her 39th-week prenatal visit at a clinic, the mother reported decreased fetal movement. Acoustic stimulation of the fetus was attempted twice without response. The fetal heart-rate monitor identified a normal heart rate without variability or accelerations. The mother was taken by wheelchair to the hospital next door. A note explaining the nonreassuring findings allegedly accompanied her.

The mother waited to be admitted. When a fetal heart-rate monitor was connected 30 minutes after admission, results were still nonreassuring.

A resident examined the mother 45 minutes later. He called the attending ObGyn, and they decided to postpone cesarean delivery because the mother had eaten breakfast.

When the fetal heart rate crashed 4 hours later, a second-year resident began emergency cesarean delivery. The ObGyn, who had never examined the patient, observed some of the procedure in the OR.

The baby was born with catastrophic brain damage, and has spastic quadriplegia cerebral palsy, feeding problems, and significant cognitive and developmental delays.

PARENTS’ CLAIM A cesarean delivery should have been performed immediately after the mother’s admission. Even if the cesarean had been begun 15 to 20 minutes earlier, the injury could have been avoided. The ObGyn never examined the mother nor did he participate in the cesarean delivery.

DEFENDANTS’ DEFENSE The ObGyn and hospital denied negligence. The note was not attached to the patient’s chart. At trial, the ObGyn admitted that a delivery 15 to 20 minutes earlier might have avoided the injury.

VERDICT A $33,591,900 Tennessee verdict was returned.

WOMAN BECOMES PREGNANT AFTER TUBAL LIGATION
A 32-year-old woman requested sterilization after the birth of her third child. A Falope ring tubal ligation procedure was performed by a gynecologist in April 2006. During surgery, the device used by the gynecologist ejected 2 silastic bands on the right side instead of one.

The patient learned she was pregnant in March 2007. Her high-risk pregnancy ended with cesarean delivery in September 2007. The delivering ObGyn found the patient’s right fallopian tube in its natural, unscarred state. A silastic band was applied to the right ovarian ligament, not the right fallopian tube.

PATIENT’S CLAIM The gynecologist banded the ovarian ligament instead of the fallopian tube.

PHYSICIAN’S DEFENSE The procedure was properly performed. The rings initially enclosed the fallopian tube and ovarian ligament, but the top ring subsequently migrated off the structures, allowing the fallopian tube to slip out of the attachment. Failure to sterilize is a known risk of the procedure.

VERDICT An Illinois defense verdict was returned.

ABORTION ATTEMPTED BUT PREGNANCY IS ECTOPIC
A 14-year-old patient went to a clinic for elective abortion at 8 weeks’ gestation. Ultrasonography (US) prior to the procedure showed an intrauterine pregnancy. After dilating the cervix, the ObGyn inserted a semi-rigid vacuum aspiration curette to suction the uterine contents, but received nothing. A second US confirmed an intrauterine pregnancy. The ObGyn was able to locate the pregnancy and indent the gestational sac with 3 different dilators and the curette. The pregnancy decreased in size on US after the suction was applied. However, the patient’s vital signs dropped dramatically, and she was rushed to the hospital. During emergency surgery, severe pelvic adhesive disease complicated the ability to stop the hemorrhage. Four physicians concurred that supracervical hysterectomy was needed to save the patient’s life. Postoperative pathology identified a cornual or interstitial ectopic pregnancy.

PATIENT’S CLAIM The ObGyn failed to heed several warning signs of ectopic pregnancy. Further testing should have been done before the second round of vacuum. If ectopic pregnancy had been discovered earlier, the patient could have undergone surgery that would have preserved her uterus and allowed her to bear children. The ObGyn tore the uterus multiple times when he turned on the suction, causing massive hemorrhage.

PHYSICIAN’S DEFENSE Ultrasonography clearly showed an intrauterine pregnancy. There was nothing to cause suspicion that the pregnancy was ectopic. She might be able to have a child through surrogacy.  

VERDICT A $950,000 Illinois verdict was returned.

Related Article: Is the hCG discriminatory zone a reliable indicator of intrauterine or ectopic pregnancy? Andrew M. Kaunitz, MD (Examining the Evidence, February 2012)

MACROSOMIC FETUS: MOTHER AND BABY BOTH INJURED
When prenatal ultrasonography indicated the fetal weight was 10 lbs, the patient and her mother expressed concern over delivery of such a large baby. The ObGyn reassured them that it would not be a problem.

Four days later, the mother went into labor. She was 9-cm dilated 4.5 hours later, but only progressed to 9.5 cm over the next 7 hours. She was told to begin to push, but, after 2 hours, birth had not occurred. The ObGyn used forceps to deliver the head 45 minutes later. Shoulder dystocia was encountered and there was a 3.5-minute delivery delay. The baby suffered oxygen deprivation and the mother experienced a 4th-degree perineal tear.

After the NICU team resuscitated the baby, she was transferred to another hospital, where she underwent “head cooling” in an attempt to mitigate her injuries. The child has mild cerebral palsy, with right hemiparesis, speech delay, and additional neurologic injuries. 

PARENTS' CLAIM Cesarean delivery was unnecessarily delayed. The ObGyn was negligent in not performing an emergency cesarean delivery after 2 hours of pushing was not effective. The ObGyn never suggested a cesarean delivery, it was not noted in the chart, and no one else present at the time remembered the option being offered.

PHYSICIAN’S DEFENSE There was nothing during labor to contraindicate a vaginal birth. The ObGyn claimed that he offered a cesarean delivery after 2 hours of pushing. The baby’s blood gas reading at delivery was normal. Any brain injuries to the baby were from resuscitation.  

VERDICT A $4,080,500 Pennsylvania verdict was returned.

Related Articles:
When macrosomia is suspected at term, does induction of labor lower the risk of cesarean delivery? Jennifer T. Ahn, MD (Examining the Evidence, May 2012)
Develop and use a checklist for 3rd- and 4th-degree perinatal lacerations  Robert L. Barbieri, MD (Editorial, August 2013)

BOWEL INJURY DURING CESAREAN DELIVERY
During cesarean delivery, the mother suffered a bowel injury that led to infection and several abdominal abscesses. She required two procedures for drain placement plus two additional operations.

PATIENT’S CLAIM The ObGyn was negligent in how he performed the cesarean delivery and for not treating the injury and subsequent infection in a timely manner. The abscesses took 3 years to resolve; additional procedures left scarring and aggravated a spinal injury.

PHYSICIAN’S DEFENSE Bowel perforation is a known complication of cesarean delivery. It probably occurred during manipulation of the uterus in an area that was not visible.

VERDICT A $750,000 New Jersey verdict was returned.  

Related Article: How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy Michael Baggish, MD (Surgical Technique, October 2012)

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts  and awards.

TELL US WHAT YOU THINK!
Share your thoughts on this article or on any topic relevant to ObGyns and women’s health practitioners. Tell us which topics you’d like to see covered in future issues, and what challenges you face in daily practice. We will consider publishing your letter and in a future issue.
Send your letter to: [email protected] Please include the city and state in which you practice.
Stay in touch! Your feedback is important to us!

PLACENTA FAILS TO DELIVER: MOTHER DIES OF HEMORRHAGE

After a 38-year-old woman gave birth, the placenta did not deliver. The ObGyn was unable remove the entire placenta and the mother began to hemorrhage. After an hour, the patient was given a blood transfusion. She could not be stabilized and died.

ESTATE’S CLAIM The ObGyn was negligent. He failed to remove the entire placenta and did not treat the hemorrhage in a timely manner. The hospital staff was negligent in failing to properly address the massive hemorrhage. A prompt transfusion would have saved the woman’s life, but the anesthesiologist who had to approve the procedure could not be located. Other procedures, including a hysterectomy, could have saved the mother’s life.

DEFENDANTS’ DEFENSE The ObGyn claimed that incomplete delivery of the placenta and postpartum hemorrhage are known complications of a delivery. The hospital claimed that the staff had acted appropriately and that it was not responsible for the actions of the anesthesiologist, an independent contractor. The anesthesiologist denied negligence.

VERDICT A $2 million New York settlement was reached that included $200,000 from the hospital and $1.8 million from the physicians’ insurers.

Related Article: Postpartum hemorrhage: 11 critical questions, answered by an expert  Haywood L. Brown, MD (January 2011)

DECREASED FETAL MOVEMENT OVERLOOKED; SEVERE INJURY TO BABY
At her 39th-week prenatal visit at a clinic, the mother reported decreased fetal movement. Acoustic stimulation of the fetus was attempted twice without response. The fetal heart-rate monitor identified a normal heart rate without variability or accelerations. The mother was taken by wheelchair to the hospital next door. A note explaining the nonreassuring findings allegedly accompanied her.

The mother waited to be admitted. When a fetal heart-rate monitor was connected 30 minutes after admission, results were still nonreassuring.

A resident examined the mother 45 minutes later. He called the attending ObGyn, and they decided to postpone cesarean delivery because the mother had eaten breakfast.

When the fetal heart rate crashed 4 hours later, a second-year resident began emergency cesarean delivery. The ObGyn, who had never examined the patient, observed some of the procedure in the OR.

The baby was born with catastrophic brain damage, and has spastic quadriplegia cerebral palsy, feeding problems, and significant cognitive and developmental delays.

PARENTS’ CLAIM A cesarean delivery should have been performed immediately after the mother’s admission. Even if the cesarean had been begun 15 to 20 minutes earlier, the injury could have been avoided. The ObGyn never examined the mother nor did he participate in the cesarean delivery.

DEFENDANTS’ DEFENSE The ObGyn and hospital denied negligence. The note was not attached to the patient’s chart. At trial, the ObGyn admitted that a delivery 15 to 20 minutes earlier might have avoided the injury.

VERDICT A $33,591,900 Tennessee verdict was returned.

WOMAN BECOMES PREGNANT AFTER TUBAL LIGATION
A 32-year-old woman requested sterilization after the birth of her third child. A Falope ring tubal ligation procedure was performed by a gynecologist in April 2006. During surgery, the device used by the gynecologist ejected 2 silastic bands on the right side instead of one.

The patient learned she was pregnant in March 2007. Her high-risk pregnancy ended with cesarean delivery in September 2007. The delivering ObGyn found the patient’s right fallopian tube in its natural, unscarred state. A silastic band was applied to the right ovarian ligament, not the right fallopian tube.

PATIENT’S CLAIM The gynecologist banded the ovarian ligament instead of the fallopian tube.

PHYSICIAN’S DEFENSE The procedure was properly performed. The rings initially enclosed the fallopian tube and ovarian ligament, but the top ring subsequently migrated off the structures, allowing the fallopian tube to slip out of the attachment. Failure to sterilize is a known risk of the procedure.

VERDICT An Illinois defense verdict was returned.

ABORTION ATTEMPTED BUT PREGNANCY IS ECTOPIC
A 14-year-old patient went to a clinic for elective abortion at 8 weeks’ gestation. Ultrasonography (US) prior to the procedure showed an intrauterine pregnancy. After dilating the cervix, the ObGyn inserted a semi-rigid vacuum aspiration curette to suction the uterine contents, but received nothing. A second US confirmed an intrauterine pregnancy. The ObGyn was able to locate the pregnancy and indent the gestational sac with 3 different dilators and the curette. The pregnancy decreased in size on US after the suction was applied. However, the patient’s vital signs dropped dramatically, and she was rushed to the hospital. During emergency surgery, severe pelvic adhesive disease complicated the ability to stop the hemorrhage. Four physicians concurred that supracervical hysterectomy was needed to save the patient’s life. Postoperative pathology identified a cornual or interstitial ectopic pregnancy.

PATIENT’S CLAIM The ObGyn failed to heed several warning signs of ectopic pregnancy. Further testing should have been done before the second round of vacuum. If ectopic pregnancy had been discovered earlier, the patient could have undergone surgery that would have preserved her uterus and allowed her to bear children. The ObGyn tore the uterus multiple times when he turned on the suction, causing massive hemorrhage.

PHYSICIAN’S DEFENSE Ultrasonography clearly showed an intrauterine pregnancy. There was nothing to cause suspicion that the pregnancy was ectopic. She might be able to have a child through surrogacy.  

VERDICT A $950,000 Illinois verdict was returned.

Related Article: Is the hCG discriminatory zone a reliable indicator of intrauterine or ectopic pregnancy? Andrew M. Kaunitz, MD (Examining the Evidence, February 2012)

MACROSOMIC FETUS: MOTHER AND BABY BOTH INJURED
When prenatal ultrasonography indicated the fetal weight was 10 lbs, the patient and her mother expressed concern over delivery of such a large baby. The ObGyn reassured them that it would not be a problem.

Four days later, the mother went into labor. She was 9-cm dilated 4.5 hours later, but only progressed to 9.5 cm over the next 7 hours. She was told to begin to push, but, after 2 hours, birth had not occurred. The ObGyn used forceps to deliver the head 45 minutes later. Shoulder dystocia was encountered and there was a 3.5-minute delivery delay. The baby suffered oxygen deprivation and the mother experienced a 4th-degree perineal tear.

After the NICU team resuscitated the baby, she was transferred to another hospital, where she underwent “head cooling” in an attempt to mitigate her injuries. The child has mild cerebral palsy, with right hemiparesis, speech delay, and additional neurologic injuries. 

PARENTS' CLAIM Cesarean delivery was unnecessarily delayed. The ObGyn was negligent in not performing an emergency cesarean delivery after 2 hours of pushing was not effective. The ObGyn never suggested a cesarean delivery, it was not noted in the chart, and no one else present at the time remembered the option being offered.

PHYSICIAN’S DEFENSE There was nothing during labor to contraindicate a vaginal birth. The ObGyn claimed that he offered a cesarean delivery after 2 hours of pushing. The baby’s blood gas reading at delivery was normal. Any brain injuries to the baby were from resuscitation.  

VERDICT A $4,080,500 Pennsylvania verdict was returned.

Related Articles:
When macrosomia is suspected at term, does induction of labor lower the risk of cesarean delivery? Jennifer T. Ahn, MD (Examining the Evidence, May 2012)
Develop and use a checklist for 3rd- and 4th-degree perinatal lacerations  Robert L. Barbieri, MD (Editorial, August 2013)

BOWEL INJURY DURING CESAREAN DELIVERY
During cesarean delivery, the mother suffered a bowel injury that led to infection and several abdominal abscesses. She required two procedures for drain placement plus two additional operations.

PATIENT’S CLAIM The ObGyn was negligent in how he performed the cesarean delivery and for not treating the injury and subsequent infection in a timely manner. The abscesses took 3 years to resolve; additional procedures left scarring and aggravated a spinal injury.

PHYSICIAN’S DEFENSE Bowel perforation is a known complication of cesarean delivery. It probably occurred during manipulation of the uterus in an area that was not visible.

VERDICT A $750,000 New Jersey verdict was returned.  

Related Article: How to avoid intestinal and urinary tract injuries during gynecologic laparoscopy Michael Baggish, MD (Surgical Technique, October 2012)

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts  and awards.

TELL US WHAT YOU THINK!
Share your thoughts on this article or on any topic relevant to ObGyns and women’s health practitioners. Tell us which topics you’d like to see covered in future issues, and what challenges you face in daily practice. We will consider publishing your letter and in a future issue.
Send your letter to: [email protected] Please include the city and state in which you practice.
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Vasovagal syncope, or something far worse?

A 48-YEAR-OLD WOMAN with a history of syncopal events was brought to the emergency department (ED) by her daughter, following an episode in which the mother lost consciousness and vomited while driving. (The daughter was able to get the car safely to the shoulder of the road.) The episode occurred after the woman had eaten, and followed a week in which she’d experienced several episodes in which her left arm and chin briefly went numb. In fact, she experienced another chin/arm numbing episode while in the ED. The ED physician gave her a diagnosis of vasovagal syncope, instructed her to follow up with her primary care physician, and included “rule out transient ischemic attack (TIA)” on the discharge note.

The primary care physician subsequently established a differential diagnosis of “vasovagal vs hypoglycemia vs both or neurocardiogenic syncope” and referred the patient to an electrophysiologist, who concluded that she’d had a vasovagal syncope episode triggered by a gastrointestinal cause.

The patient continued to have arm/chin numbness but was unconcerned because her physicians didn’t seem worried. Months later, she sought treatment for low back pain, for which her primary care physician prescribed celecoxib; her numbness was not discussed with her physician. The next day, she suffered a stroke from an occluded right carotid artery. She had hemiparesis with little to no movement of her left shoulder, elbow, hand, hip, and ankle.

PLAINTIFF’S CLAIM The numbness and fainting were TIAs and an ultrasound should have been performed, which would have revealed the carotid artery occlusion and helped avoid the stroke.

THE DEFENSE The events the plaintiff experienced were not TIAs and there was no way to show whether, or to what degree, the carotid artery was occluded before the stroke. The plaintiff should have reported the continuing symptoms. Given that the patient had a long history of syncopal events—and a history of smoking—the diagnosis was reasonable.

VERDICT $1.6 million Wisconsin verdict.

COMMENT I think the lesson here is that physicians need to take focal neurological findings seriously and continue the evaluation until one has a reasonably certain diagnosis. The cause of this patient’s recurrent arm and chin numbness should have been pursued.

Failure to take full sexual history has devastating consequences

A MAN WITH A HISTORY OF ABNORMAL BLOOD TEST RESULTS sought treatment in the emergency department for extreme leg pain. He was given a diagnosis of sepsis and renal failure. A positive human immunodeficiency virus (HIV) test led to a diagnosis of acquired immunodeficiency syndrome (AIDS). The patient had been seeing his primary care physician for 10 years, but the doctor never asked about his sexual history. The patient survived, but suffers from AIDS-related kidney disease and must undergo peritoneal dialysis for the rest of his life.

PLAINTIFF’S CLAIM The physician should have tested for HIV much sooner to prevent the loss of kidney function. The physician’s questions were not specific enough to obtain proper information on whether the patient was having unprotected sex, if he had multiple partners, and what gender his partners were.

THE DEFENSE No information about the defense is available.

VERDICT $5.2 million Illinois verdict.

COMMENT I’m not sure the jury got this one right. Nonetheless, the Centers for Disease Control and Prevention now recommends HIV screening for all adults so it is worthwhile to offer it to all patients and to document refusal if a patient doesn’t want to be tested.

Vasovagal syncope, or something far worse?

A 48-YEAR-OLD WOMAN with a history of syncopal events was brought to the emergency department (ED) by her daughter, following an episode in which the mother lost consciousness and vomited while driving. (The daughter was able to get the car safely to the shoulder of the road.) The episode occurred after the woman had eaten, and followed a week in which she’d experienced several episodes in which her left arm and chin briefly went numb. In fact, she experienced another chin/arm numbing episode while in the ED. The ED physician gave her a diagnosis of vasovagal syncope, instructed her to follow up with her primary care physician, and included “rule out transient ischemic attack (TIA)” on the discharge note.

The primary care physician subsequently established a differential diagnosis of “vasovagal vs hypoglycemia vs both or neurocardiogenic syncope” and referred the patient to an electrophysiologist, who concluded that she’d had a vasovagal syncope episode triggered by a gastrointestinal cause.

The patient continued to have arm/chin numbness but was unconcerned because her physicians didn’t seem worried. Months later, she sought treatment for low back pain, for which her primary care physician prescribed celecoxib; her numbness was not discussed with her physician. The next day, she suffered a stroke from an occluded right carotid artery. She had hemiparesis with little to no movement of her left shoulder, elbow, hand, hip, and ankle.

PLAINTIFF’S CLAIM The numbness and fainting were TIAs and an ultrasound should have been performed, which would have revealed the carotid artery occlusion and helped avoid the stroke.

THE DEFENSE The events the plaintiff experienced were not TIAs and there was no way to show whether, or to what degree, the carotid artery was occluded before the stroke. The plaintiff should have reported the continuing symptoms. Given that the patient had a long history of syncopal events—and a history of smoking—the diagnosis was reasonable.

VERDICT $1.6 million Wisconsin verdict.

COMMENT I think the lesson here is that physicians need to take focal neurological findings seriously and continue the evaluation until one has a reasonably certain diagnosis. The cause of this patient’s recurrent arm and chin numbness should have been pursued.

Failure to take full sexual history has devastating consequences

A MAN WITH A HISTORY OF ABNORMAL BLOOD TEST RESULTS sought treatment in the emergency department for extreme leg pain. He was given a diagnosis of sepsis and renal failure. A positive human immunodeficiency virus (HIV) test led to a diagnosis of acquired immunodeficiency syndrome (AIDS). The patient had been seeing his primary care physician for 10 years, but the doctor never asked about his sexual history. The patient survived, but suffers from AIDS-related kidney disease and must undergo peritoneal dialysis for the rest of his life.

PLAINTIFF’S CLAIM The physician should have tested for HIV much sooner to prevent the loss of kidney function. The physician’s questions were not specific enough to obtain proper information on whether the patient was having unprotected sex, if he had multiple partners, and what gender his partners were.

THE DEFENSE No information about the defense is available.

VERDICT $5.2 million Illinois verdict.

COMMENT I’m not sure the jury got this one right. Nonetheless, the Centers for Disease Control and Prevention now recommends HIV screening for all adults so it is worthwhile to offer it to all patients and to document refusal if a patient doesn’t want to be tested.

Vasovagal syncope, or something far worse?

A 48-YEAR-OLD WOMAN with a history of syncopal events was brought to the emergency department (ED) by her daughter, following an episode in which the mother lost consciousness and vomited while driving. (The daughter was able to get the car safely to the shoulder of the road.) The episode occurred after the woman had eaten, and followed a week in which she’d experienced several episodes in which her left arm and chin briefly went numb. In fact, she experienced another chin/arm numbing episode while in the ED. The ED physician gave her a diagnosis of vasovagal syncope, instructed her to follow up with her primary care physician, and included “rule out transient ischemic attack (TIA)” on the discharge note.

The primary care physician subsequently established a differential diagnosis of “vasovagal vs hypoglycemia vs both or neurocardiogenic syncope” and referred the patient to an electrophysiologist, who concluded that she’d had a vasovagal syncope episode triggered by a gastrointestinal cause.

The patient continued to have arm/chin numbness but was unconcerned because her physicians didn’t seem worried. Months later, she sought treatment for low back pain, for which her primary care physician prescribed celecoxib; her numbness was not discussed with her physician. The next day, she suffered a stroke from an occluded right carotid artery. She had hemiparesis with little to no movement of her left shoulder, elbow, hand, hip, and ankle.

PLAINTIFF’S CLAIM The numbness and fainting were TIAs and an ultrasound should have been performed, which would have revealed the carotid artery occlusion and helped avoid the stroke.

THE DEFENSE The events the plaintiff experienced were not TIAs and there was no way to show whether, or to what degree, the carotid artery was occluded before the stroke. The plaintiff should have reported the continuing symptoms. Given that the patient had a long history of syncopal events—and a history of smoking—the diagnosis was reasonable.

VERDICT $1.6 million Wisconsin verdict.

COMMENT I think the lesson here is that physicians need to take focal neurological findings seriously and continue the evaluation until one has a reasonably certain diagnosis. The cause of this patient’s recurrent arm and chin numbness should have been pursued.

Failure to take full sexual history has devastating consequences

A MAN WITH A HISTORY OF ABNORMAL BLOOD TEST RESULTS sought treatment in the emergency department for extreme leg pain. He was given a diagnosis of sepsis and renal failure. A positive human immunodeficiency virus (HIV) test led to a diagnosis of acquired immunodeficiency syndrome (AIDS). The patient had been seeing his primary care physician for 10 years, but the doctor never asked about his sexual history. The patient survived, but suffers from AIDS-related kidney disease and must undergo peritoneal dialysis for the rest of his life.

PLAINTIFF’S CLAIM The physician should have tested for HIV much sooner to prevent the loss of kidney function. The physician’s questions were not specific enough to obtain proper information on whether the patient was having unprotected sex, if he had multiple partners, and what gender his partners were.

THE DEFENSE No information about the defense is available.

VERDICT $5.2 million Illinois verdict.

COMMENT I’m not sure the jury got this one right. Nonetheless, the Centers for Disease Control and Prevention now recommends HIV screening for all adults so it is worthwhile to offer it to all patients and to document refusal if a patient doesn’t want to be tested.

CIRCUMCISION ACCIDENT: $1.3M VERDICT
A newborn underwent circumcision when 12 hours old. The ObGyn removed adhesions present between the foreskin and glans. After locking the Mogen clamp, the ObGyn amputated a 9-mm by 8-mm portion of the top of the penis along with the foreskin. The newborn was rushed to a children’s hospital where a pediatric urologist surgically reattached the amputated glans. The child’s penis is not cosmetically normal, with permanent scars and disfigurement. He has altered nerve sensation at and above the area of the amputation.
PARENTS’ CLAIM The ObGyn improperly performed the circumcision. He failed to remove a sufficient amount of adhesions, pulled too much into the clamp, and amputated 30% of the distal portion of the glans.
PHYSICIAN’S DEFENSE The ObGyn circumcised this child the same way he had performed more than 1,000 circumcisions. Multiple dense adhesions between the glans and foreskin caused the top of the penis to be inadvertently pulled through the clamp. Amputation is a known risk of the procedure.
VERDICT A $1,357,901 Illinois verdict was returned.

WHAT CAUSED CHILD’S KIDNEY DISEASE?
At 36 weeks’ gestation, a mother came to the emergency department (ED) with abdominal pain. She had proteinuria, elevated liver enzymes, and a low-normal platelet count. An ObGyn determined that the fetus was normal, and discharged her.
The patient returned 2 days later with internal bleeding and placental abruption. She was diagnosed with hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). The child, born by cesarean delivery, had kidney failure that caused growth retardation. The child has received a kidney transplant.
PARENTS’ CLAIM The mother should not have been discharged from the hospital with abnormal findings.
DEFENDANTS’ DEFENSE The case was settled during trial.
VERDICT A $1 million New Jersey settlement was reached, of which $100,000 was provided to the mother.

Related Article: A stepwise approach to managing eclampsia and other hypertensive emergencies Baha M. Sibai, MD (October 2013)

EXCESSIVE FORCE BLAMED FOR ERB’S PALSY
Shoulder dystocia was encountered during delivery. The child suffered a brachial plexus injury with Erb’s palsy. She received botulinum toxin injections and underwent nerve-graft surgery to restore some function. She has limited use of her right arm and a protruding right elbow.
PARENTS’ CLAIM The ObGyn used excessive force in response to shoulder dystocia.
PHYSICIAN’S DEFENSE The case was settled at trial.
VERDICT A $1 million New Jersey settlement was placed in a structured payment fund to provide a net $1.78 million over the child’s lifetime. 

Related Article: You are the second responder to a shoulder dystocia emergency. What do you do first? Robert L. Barbieri, MD (Editorial, May 2013)

WAS WOMAN UNLAWFULLY SEEKING DRUGS?
A 30-year-old woman went to an ED with pelvic pain and vaginal discharge. An ED physician conducted a physical exam. Blood tests indicated the patient had taken barbiturates, but the patient could not explain the findings. Determining no cause for her symptoms, the ED physician discharged the patient.
Just after she left, the ED physician found that the patient had several narcotics prescriptions and called the police. The patient was arrested and charged with unlawfully seeking drugs at the hospital. Criminal charges were later dismissed.
PATIENT’S CLAIM The ED physician did not properly examine her; she was found to have endometriosis and underwent surgery a few weeks later. The ED physician was negligent for divulging her personal information to police.
The ED physician had had his physician’s license suspended due to substance abuse and had also been arrested for driving under the influence after his license was restored.
PHYSICIAN’S DEFENSE The ED physician’s examination and treatment were proper. The phone call to police was not part of treatment. The patient had a malicious prosecution basis for any claims.
VERDICT A $125,000 Kentucky verdict was returned.

CASCADING PROBLEMS: MOTHER AND BABY DIE
A pregnant woman was admitted to an ED, where the on-call physician determined that she had pneumonia. The patient’s ObGyn, 45 miles away, refused to come to the hospital or arrange for another ObGyn to take the case.
Several hours later, after the mother was found to have fulminant preeclampsia, the ObGyn demanded the patient be moved to the hospital’s internal medicine (IM) service. However, the IM service refused to admit the patient because she needed obstetric care. The ObGyn tried to transfer the patient to a maternal-fetal medicine (MFM) specialist at a tertiary care center; transfer was refused because the patient was too unstable and needed an emergency cesarean delivery. The ObGyn continued to refuse to relinquish care to another ObGyn.
The ED physician decided to transfer the patient to another hospital 50 miles away even though she was now in active labor. An MFM specialist accepted transfer. After 5 hours in the ED, the mother left by ambulance, but, during transport, she suffered placental abruption and internal hemorrhaging. She was in critical condition upon arrival. An emergency cesarean delivery was performed, but the mother died. The baby, born with severe brain damage, also died.
ESTATES’ CLAIM The ED physician failed to properly and timely determine that the mother had preeclampsia; no treatment for hypertension was provided. The ED physician withheld critical information, including the patient’s severe hypertension, proteinurea, and edema, when speaking to the MFM specialist who accepted transfer. The ED physician did not evaluate the mother before departure and certified the transfer although the patient was highly unstable.
The ObGyn was negligent in not transferring care to another ObGyn and not coming to the hospital. The ObGyn did not inform the ED physician of the rejected attempt to transfer the patient or of the first MFM specialist’s recommendation for emergency cesarean. Both mother and baby could have survived with proper treatment.
DEFENDANTS’ DEFENSE The case was settled at trial. 
VERDICT A $900,000 Michigan settlement was reached.

FECAL INCONTINENCE AFTER EPISIOTOMY
A 26-year-old woman gave birth after her ObGyn created an episiotomy to facilitate delivery. The incision was repaired and the ObGyn prescribed docusate (Colace) to soften her stools.
A month later, the patient report-ed fecal incontinence. The ObGyn determined that the incontinence was related to the episiotomy, but did not feel that immediate attention was needed. When the condition did not improve, the patient saw a colorectal surgeon, who diagnosed a significant sphincter defect. The patient underwent a sphincteroplasty, with minor improvement.
PATIENT’S CLAIM The ObGyn failed to properly manage episiotomy healing. The patient remembers being told to stop docusate after she had passed one stool after delivery. A 10-day regimen of docusate and a diet to reduce defecation frequency should have been prescribed. Incontinence should have prompted an immediate referral to a colorectal surgeon.
PHYSICIAN’S DEFENSE Prompt surgical intervention was not necessary. Sphincteroplasty can be delayed until conservative methods have been tried. Episiotomy healing was properly addressed. Permanent incontinence is a known risk of the procedure.
VERDICT A $6 million New York verdict was returned.

Related Article: Does mediolateral episiotomy reduce the risk of anal sphincter injury in operative vaginal delivery? Errol R. Norwitz, MD, PhD (Examining the Evidence, August 2012)

MECONIUM ASPIRATION SYNDROME
A baby stayed in hospital for 3 weeks postdelivery due to meconium aspiration syndrome.
PARENTS’ CLAIM The resident who followed the mother during her pregnancy was negligent in allowing the pregnancy to progress to 46 weeks’ gestation before delivery.
DEFENDANTS’ DEFENSE The estimated date of conception was disputed. The resident claimed that the baby was born at 42 weeks’ gestation. An attending physician reviewed all prenatal visits with the resident. The mother’s cervix was never ripe before induction of labor. Aspiration occurred despite aggressive suctioning. The child has had no further respiratory issues since her neonatal discharge.
VERDICT An Illinois defense verdict was returned.  

BOWEL INJURY AFTER HYSTERECTOMY
A woman underwent laparoscopic-assisted vaginal hysterectomy and was discharged the following day. Two days later, she went to an ED in acute distress. A bowel perforation was found during emergency surgery, and her colon was repaired. She made a full recovery.
PATIENT’S CLAIM The ObGyn was negligent in failing to properly evaluate the patient after surgery. The ObGyn also failed to explain the signs of a possible perforation to the patient before she left the hospital.
PHYSICIAN’S DEFENSE The patient’s postoperative course was normal while she was hospitalized. Bowel perforation is a known complication of the procedure. The patient had been informed of all the signs and symptoms of a bowel perforation and had been instructed to call the ObGyn or return to the hospital if she began to have any symptoms.
VERDICT A South Carolina defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected]

CIRCUMCISION ACCIDENT: $1.3M VERDICT
A newborn underwent circumcision when 12 hours old. The ObGyn removed adhesions present between the foreskin and glans. After locking the Mogen clamp, the ObGyn amputated a 9-mm by 8-mm portion of the top of the penis along with the foreskin. The newborn was rushed to a children’s hospital where a pediatric urologist surgically reattached the amputated glans. The child’s penis is not cosmetically normal, with permanent scars and disfigurement. He has altered nerve sensation at and above the area of the amputation.
PARENTS’ CLAIM The ObGyn improperly performed the circumcision. He failed to remove a sufficient amount of adhesions, pulled too much into the clamp, and amputated 30% of the distal portion of the glans.
PHYSICIAN’S DEFENSE The ObGyn circumcised this child the same way he had performed more than 1,000 circumcisions. Multiple dense adhesions between the glans and foreskin caused the top of the penis to be inadvertently pulled through the clamp. Amputation is a known risk of the procedure.
VERDICT A $1,357,901 Illinois verdict was returned.

WHAT CAUSED CHILD’S KIDNEY DISEASE?
At 36 weeks’ gestation, a mother came to the emergency department (ED) with abdominal pain. She had proteinuria, elevated liver enzymes, and a low-normal platelet count. An ObGyn determined that the fetus was normal, and discharged her.
The patient returned 2 days later with internal bleeding and placental abruption. She was diagnosed with hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). The child, born by cesarean delivery, had kidney failure that caused growth retardation. The child has received a kidney transplant.
PARENTS’ CLAIM The mother should not have been discharged from the hospital with abnormal findings.
DEFENDANTS’ DEFENSE The case was settled during trial.
VERDICT A $1 million New Jersey settlement was reached, of which $100,000 was provided to the mother.

Related Article: A stepwise approach to managing eclampsia and other hypertensive emergencies Baha M. Sibai, MD (October 2013)

EXCESSIVE FORCE BLAMED FOR ERB’S PALSY
Shoulder dystocia was encountered during delivery. The child suffered a brachial plexus injury with Erb’s palsy. She received botulinum toxin injections and underwent nerve-graft surgery to restore some function. She has limited use of her right arm and a protruding right elbow.
PARENTS’ CLAIM The ObGyn used excessive force in response to shoulder dystocia.
PHYSICIAN’S DEFENSE The case was settled at trial.
VERDICT A $1 million New Jersey settlement was placed in a structured payment fund to provide a net $1.78 million over the child’s lifetime. 

Related Article: You are the second responder to a shoulder dystocia emergency. What do you do first? Robert L. Barbieri, MD (Editorial, May 2013)

WAS WOMAN UNLAWFULLY SEEKING DRUGS?
A 30-year-old woman went to an ED with pelvic pain and vaginal discharge. An ED physician conducted a physical exam. Blood tests indicated the patient had taken barbiturates, but the patient could not explain the findings. Determining no cause for her symptoms, the ED physician discharged the patient.
Just after she left, the ED physician found that the patient had several narcotics prescriptions and called the police. The patient was arrested and charged with unlawfully seeking drugs at the hospital. Criminal charges were later dismissed.
PATIENT’S CLAIM The ED physician did not properly examine her; she was found to have endometriosis and underwent surgery a few weeks later. The ED physician was negligent for divulging her personal information to police.
The ED physician had had his physician’s license suspended due to substance abuse and had also been arrested for driving under the influence after his license was restored.
PHYSICIAN’S DEFENSE The ED physician’s examination and treatment were proper. The phone call to police was not part of treatment. The patient had a malicious prosecution basis for any claims.
VERDICT A $125,000 Kentucky verdict was returned.

CASCADING PROBLEMS: MOTHER AND BABY DIE
A pregnant woman was admitted to an ED, where the on-call physician determined that she had pneumonia. The patient’s ObGyn, 45 miles away, refused to come to the hospital or arrange for another ObGyn to take the case.
Several hours later, after the mother was found to have fulminant preeclampsia, the ObGyn demanded the patient be moved to the hospital’s internal medicine (IM) service. However, the IM service refused to admit the patient because she needed obstetric care. The ObGyn tried to transfer the patient to a maternal-fetal medicine (MFM) specialist at a tertiary care center; transfer was refused because the patient was too unstable and needed an emergency cesarean delivery. The ObGyn continued to refuse to relinquish care to another ObGyn.
The ED physician decided to transfer the patient to another hospital 50 miles away even though she was now in active labor. An MFM specialist accepted transfer. After 5 hours in the ED, the mother left by ambulance, but, during transport, she suffered placental abruption and internal hemorrhaging. She was in critical condition upon arrival. An emergency cesarean delivery was performed, but the mother died. The baby, born with severe brain damage, also died.
ESTATES’ CLAIM The ED physician failed to properly and timely determine that the mother had preeclampsia; no treatment for hypertension was provided. The ED physician withheld critical information, including the patient’s severe hypertension, proteinurea, and edema, when speaking to the MFM specialist who accepted transfer. The ED physician did not evaluate the mother before departure and certified the transfer although the patient was highly unstable.
The ObGyn was negligent in not transferring care to another ObGyn and not coming to the hospital. The ObGyn did not inform the ED physician of the rejected attempt to transfer the patient or of the first MFM specialist’s recommendation for emergency cesarean. Both mother and baby could have survived with proper treatment.
DEFENDANTS’ DEFENSE The case was settled at trial. 
VERDICT A $900,000 Michigan settlement was reached.

FECAL INCONTINENCE AFTER EPISIOTOMY
A 26-year-old woman gave birth after her ObGyn created an episiotomy to facilitate delivery. The incision was repaired and the ObGyn prescribed docusate (Colace) to soften her stools.
A month later, the patient report-ed fecal incontinence. The ObGyn determined that the incontinence was related to the episiotomy, but did not feel that immediate attention was needed. When the condition did not improve, the patient saw a colorectal surgeon, who diagnosed a significant sphincter defect. The patient underwent a sphincteroplasty, with minor improvement.
PATIENT’S CLAIM The ObGyn failed to properly manage episiotomy healing. The patient remembers being told to stop docusate after she had passed one stool after delivery. A 10-day regimen of docusate and a diet to reduce defecation frequency should have been prescribed. Incontinence should have prompted an immediate referral to a colorectal surgeon.
PHYSICIAN’S DEFENSE Prompt surgical intervention was not necessary. Sphincteroplasty can be delayed until conservative methods have been tried. Episiotomy healing was properly addressed. Permanent incontinence is a known risk of the procedure.
VERDICT A $6 million New York verdict was returned.

Related Article: Does mediolateral episiotomy reduce the risk of anal sphincter injury in operative vaginal delivery? Errol R. Norwitz, MD, PhD (Examining the Evidence, August 2012)

MECONIUM ASPIRATION SYNDROME
A baby stayed in hospital for 3 weeks postdelivery due to meconium aspiration syndrome.
PARENTS’ CLAIM The resident who followed the mother during her pregnancy was negligent in allowing the pregnancy to progress to 46 weeks’ gestation before delivery.
DEFENDANTS’ DEFENSE The estimated date of conception was disputed. The resident claimed that the baby was born at 42 weeks’ gestation. An attending physician reviewed all prenatal visits with the resident. The mother’s cervix was never ripe before induction of labor. Aspiration occurred despite aggressive suctioning. The child has had no further respiratory issues since her neonatal discharge.
VERDICT An Illinois defense verdict was returned.  

BOWEL INJURY AFTER HYSTERECTOMY
A woman underwent laparoscopic-assisted vaginal hysterectomy and was discharged the following day. Two days later, she went to an ED in acute distress. A bowel perforation was found during emergency surgery, and her colon was repaired. She made a full recovery.
PATIENT’S CLAIM The ObGyn was negligent in failing to properly evaluate the patient after surgery. The ObGyn also failed to explain the signs of a possible perforation to the patient before she left the hospital.
PHYSICIAN’S DEFENSE The patient’s postoperative course was normal while she was hospitalized. Bowel perforation is a known complication of the procedure. The patient had been informed of all the signs and symptoms of a bowel perforation and had been instructed to call the ObGyn or return to the hospital if she began to have any symptoms.
VERDICT A South Carolina defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

WE WANT TO HEAR FROM YOU!
Drop us a line and let us know what you think about current articles, which topics you'd like to see covered in future issues, and what challenges you face in daily practice. Tell us what you think by emailing us at: [email protected]

CIRCUMCISION ACCIDENT: $1.3M VERDICT
A newborn underwent circumcision when 12 hours old. The ObGyn removed adhesions present between the foreskin and glans. After locking the Mogen clamp, the ObGyn amputated a 9-mm by 8-mm portion of the top of the penis along with the foreskin. The newborn was rushed to a children’s hospital where a pediatric urologist surgically reattached the amputated glans. The child’s penis is not cosmetically normal, with permanent scars and disfigurement. He has altered nerve sensation at and above the area of the amputation.
PARENTS’ CLAIM The ObGyn improperly performed the circumcision. He failed to remove a sufficient amount of adhesions, pulled too much into the clamp, and amputated 30% of the distal portion of the glans.
PHYSICIAN’S DEFENSE The ObGyn circumcised this child the same way he had performed more than 1,000 circumcisions. Multiple dense adhesions between the glans and foreskin caused the top of the penis to be inadvertently pulled through the clamp. Amputation is a known risk of the procedure.
VERDICT A $1,357,901 Illinois verdict was returned.

WHAT CAUSED CHILD’S KIDNEY DISEASE?
At 36 weeks’ gestation, a mother came to the emergency department (ED) with abdominal pain. She had proteinuria, elevated liver enzymes, and a low-normal platelet count. An ObGyn determined that the fetus was normal, and discharged her.
The patient returned 2 days later with internal bleeding and placental abruption. She was diagnosed with hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). The child, born by cesarean delivery, had kidney failure that caused growth retardation. The child has received a kidney transplant.
PARENTS’ CLAIM The mother should not have been discharged from the hospital with abnormal findings.
DEFENDANTS’ DEFENSE The case was settled during trial.
VERDICT A $1 million New Jersey settlement was reached, of which $100,000 was provided to the mother.

Related Article: A stepwise approach to managing eclampsia and other hypertensive emergencies Baha M. Sibai, MD (October 2013)

EXCESSIVE FORCE BLAMED FOR ERB’S PALSY
Shoulder dystocia was encountered during delivery. The child suffered a brachial plexus injury with Erb’s palsy. She received botulinum toxin injections and underwent nerve-graft surgery to restore some function. She has limited use of her right arm and a protruding right elbow.
PARENTS’ CLAIM The ObGyn used excessive force in response to shoulder dystocia.
PHYSICIAN’S DEFENSE The case was settled at trial.
VERDICT A $1 million New Jersey settlement was placed in a structured payment fund to provide a net $1.78 million over the child’s lifetime. 

Related Article: You are the second responder to a shoulder dystocia emergency. What do you do first? Robert L. Barbieri, MD (Editorial, May 2013)

WAS WOMAN UNLAWFULLY SEEKING DRUGS?
A 30-year-old woman went to an ED with pelvic pain and vaginal discharge. An ED physician conducted a physical exam. Blood tests indicated the patient had taken barbiturates, but the patient could not explain the findings. Determining no cause for her symptoms, the ED physician discharged the patient.
Just after she left, the ED physician found that the patient had several narcotics prescriptions and called the police. The patient was arrested and charged with unlawfully seeking drugs at the hospital. Criminal charges were later dismissed.
PATIENT’S CLAIM The ED physician did not properly examine her; she was found to have endometriosis and underwent surgery a few weeks later. The ED physician was negligent for divulging her personal information to police.
The ED physician had had his physician’s license suspended due to substance abuse and had also been arrested for driving under the influence after his license was restored.
PHYSICIAN’S DEFENSE The ED physician’s examination and treatment were proper. The phone call to police was not part of treatment. The patient had a malicious prosecution basis for any claims.
VERDICT A $125,000 Kentucky verdict was returned.

CASCADING PROBLEMS: MOTHER AND BABY DIE
A pregnant woman was admitted to an ED, where the on-call physician determined that she had pneumonia. The patient’s ObGyn, 45 miles away, refused to come to the hospital or arrange for another ObGyn to take the case.
Several hours later, after the mother was found to have fulminant preeclampsia, the ObGyn demanded the patient be moved to the hospital’s internal medicine (IM) service. However, the IM service refused to admit the patient because she needed obstetric care. The ObGyn tried to transfer the patient to a maternal-fetal medicine (MFM) specialist at a tertiary care center; transfer was refused because the patient was too unstable and needed an emergency cesarean delivery. The ObGyn continued to refuse to relinquish care to another ObGyn.
The ED physician decided to transfer the patient to another hospital 50 miles away even though she was now in active labor. An MFM specialist accepted transfer. After 5 hours in the ED, the mother left by ambulance, but, during transport, she suffered placental abruption and internal hemorrhaging. She was in critical condition upon arrival. An emergency cesarean delivery was performed, but the mother died. The baby, born with severe brain damage, also died.
ESTATES’ CLAIM The ED physician failed to properly and timely determine that the mother had preeclampsia; no treatment for hypertension was provided. The ED physician withheld critical information, including the patient’s severe hypertension, proteinurea, and edema, when speaking to the MFM specialist who accepted transfer. The ED physician did not evaluate the mother before departure and certified the transfer although the patient was highly unstable.
The ObGyn was negligent in not transferring care to another ObGyn and not coming to the hospital. The ObGyn did not inform the ED physician of the rejected attempt to transfer the patient or of the first MFM specialist’s recommendation for emergency cesarean. Both mother and baby could have survived with proper treatment.
DEFENDANTS’ DEFENSE The case was settled at trial. 
VERDICT A $900,000 Michigan settlement was reached.

FECAL INCONTINENCE AFTER EPISIOTOMY
A 26-year-old woman gave birth after her ObGyn created an episiotomy to facilitate delivery. The incision was repaired and the ObGyn prescribed docusate (Colace) to soften her stools.
A month later, the patient report-ed fecal incontinence. The ObGyn determined that the incontinence was related to the episiotomy, but did not feel that immediate attention was needed. When the condition did not improve, the patient saw a colorectal surgeon, who diagnosed a significant sphincter defect. The patient underwent a sphincteroplasty, with minor improvement.
PATIENT’S CLAIM The ObGyn failed to properly manage episiotomy healing. The patient remembers being told to stop docusate after she had passed one stool after delivery. A 10-day regimen of docusate and a diet to reduce defecation frequency should have been prescribed. Incontinence should have prompted an immediate referral to a colorectal surgeon.
PHYSICIAN’S DEFENSE Prompt surgical intervention was not necessary. Sphincteroplasty can be delayed until conservative methods have been tried. Episiotomy healing was properly addressed. Permanent incontinence is a known risk of the procedure.
VERDICT A $6 million New York verdict was returned.

Related Article: Does mediolateral episiotomy reduce the risk of anal sphincter injury in operative vaginal delivery? Errol R. Norwitz, MD, PhD (Examining the Evidence, August 2012)

MECONIUM ASPIRATION SYNDROME
A baby stayed in hospital for 3 weeks postdelivery due to meconium aspiration syndrome.
PARENTS’ CLAIM The resident who followed the mother during her pregnancy was negligent in allowing the pregnancy to progress to 46 weeks’ gestation before delivery.
DEFENDANTS’ DEFENSE The estimated date of conception was disputed. The resident claimed that the baby was born at 42 weeks’ gestation. An attending physician reviewed all prenatal visits with the resident. The mother’s cervix was never ripe before induction of labor. Aspiration occurred despite aggressive suctioning. The child has had no further respiratory issues since her neonatal discharge.
VERDICT An Illinois defense verdict was returned.  

BOWEL INJURY AFTER HYSTERECTOMY
A woman underwent laparoscopic-assisted vaginal hysterectomy and was discharged the following day. Two days later, she went to an ED in acute distress. A bowel perforation was found during emergency surgery, and her colon was repaired. She made a full recovery.
PATIENT’S CLAIM The ObGyn was negligent in failing to properly evaluate the patient after surgery. The ObGyn also failed to explain the signs of a possible perforation to the patient before she left the hospital.
PHYSICIAN’S DEFENSE The patient’s postoperative course was normal while she was hospitalized. Bowel perforation is a known complication of the procedure. The patient had been informed of all the signs and symptoms of a bowel perforation and had been instructed to call the ObGyn or return to the hospital if she began to have any symptoms.
VERDICT A South Carolina defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

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Lung cancer found belatedly despite multiple chest radiographs

DURING AN ANNUAL PHYSICAL EXAMINATION by her primary care physician, a 68-year-old woman with a history of smoking for more than 30 years had an in-house chest x-ray. The physician didn’t have a radiologist read the radiograph or order follow-up imaging. The chest film was repeated the following year. A year after that, the patient developed pulmonary symptoms. A chest x-ray showed an abnormality. The doctor prescribed antibiotics for presumed bronchitis or pneumonia. When the antibiotics didn’t relieve her symptoms, he referred her to a radiologist, who reported a large lesion suggestive of advanced lung cancer. Subsequent films confirmed stage IIIB lung cancer. After 16 rounds of chemotherapy, the patient died at age 73.

PLAINTIFF'S CLAIM The doctor missed an obvious lung lesion on the first radiograph; missed the lesion, which had grown and metastasized, on the second x-ray; and misinterpreted late-stage metastatic cancer on the third radiograph as bronchitis or pneumonia. The chest radiographs should have been over-read, especially when they showed an abnormality. A cancer diagnosis at the time of the first chest radiograph would have allowed a 75% possibility of cure with surgery alone. By the time of the diagnosis 2 years later, a surgical cure wasn’t possible. 

THE DEFENSE The lesion could be seen only on retrospective review of the radiographs. The first and second radiographs were consistent with pulmonary hypertension and didn’t necessitate referral to a radiologist or additional imaging. The patient had many comorbid conditions, including obesity, hypertension, and stenosis of the carotid arteries. She also had a family history of heart disease and COPD.

VERDICT $2 million Virginia verdict.

COMMENT This case illustrates that a simple test, a chest x-ray in this instance, has the potential for litigation if it isn’t interpreted accurately and followed up. Failure to appropriately follow up on test results is one of the 2 major patient safety issues for family medicine; the other is medication errors/drug interactions.

Otitis media? Not likely

A 3-MONTH-OLD INFANT was taken to the emergency department with a fever of 103°F. The ED physician discharged her with a diagnosis of otitis media and a prescription for amoxicillin. He didn’t document which ear was infected or what he observed in the affected ear. The following day, the infant was pale, cool to the touch, and lethargic. She was brought to her pediatrician, then transferred immediately to a local medical center, where she was diagnosed with pneumococcal meningitis, hypoxic brain injury, and hydrocephalus and hospitalized for nearly a month. She was subsequently taken to the hospital 10 times and evaluated by several specialists. The child died of respiratory complications linked to the infection almost 2 years after her initial hospitalization.

PLAINTIFF'S CLAIM The ED physician should have ordered a blood count and urinalysis to rule out bacteremia and meningitis. He should have scheduled a follow-up within 24 to 48 hours of the ED visit.

THE DEFENSE The doctor wasn’t negligent; he couldn’t have anticipated the infant’s clinical course. The bacteremia and meningitis developed after the baby left the hospital, and the causative pneumococcal strain was resistant to amoxicillin.

VERDICT $1.72 million Pennsylvania verdict.

COMMENT Does otitis media ever cause a fever of 103°F in a 3-month-old? Although no definitive studies exist, I doubt it. Otitis media is a closed-space infection like an abscess, and abscesses rarely cause fever. Furthermore, the physical findings of otitis media, although not recorded in this case, are highly unreliable in a 3-month-old. Attributing a fever of 103°F in a 3-month-old to otitis media is always a bad idea.

Lung cancer found belatedly despite multiple chest radiographs

DURING AN ANNUAL PHYSICAL EXAMINATION by her primary care physician, a 68-year-old woman with a history of smoking for more than 30 years had an in-house chest x-ray. The physician didn’t have a radiologist read the radiograph or order follow-up imaging. The chest film was repeated the following year. A year after that, the patient developed pulmonary symptoms. A chest x-ray showed an abnormality. The doctor prescribed antibiotics for presumed bronchitis or pneumonia. When the antibiotics didn’t relieve her symptoms, he referred her to a radiologist, who reported a large lesion suggestive of advanced lung cancer. Subsequent films confirmed stage IIIB lung cancer. After 16 rounds of chemotherapy, the patient died at age 73.

PLAINTIFF'S CLAIM The doctor missed an obvious lung lesion on the first radiograph; missed the lesion, which had grown and metastasized, on the second x-ray; and misinterpreted late-stage metastatic cancer on the third radiograph as bronchitis or pneumonia. The chest radiographs should have been over-read, especially when they showed an abnormality. A cancer diagnosis at the time of the first chest radiograph would have allowed a 75% possibility of cure with surgery alone. By the time of the diagnosis 2 years later, a surgical cure wasn’t possible. 

THE DEFENSE The lesion could be seen only on retrospective review of the radiographs. The first and second radiographs were consistent with pulmonary hypertension and didn’t necessitate referral to a radiologist or additional imaging. The patient had many comorbid conditions, including obesity, hypertension, and stenosis of the carotid arteries. She also had a family history of heart disease and COPD.

VERDICT $2 million Virginia verdict.

COMMENT This case illustrates that a simple test, a chest x-ray in this instance, has the potential for litigation if it isn’t interpreted accurately and followed up. Failure to appropriately follow up on test results is one of the 2 major patient safety issues for family medicine; the other is medication errors/drug interactions.

Otitis media? Not likely

A 3-MONTH-OLD INFANT was taken to the emergency department with a fever of 103°F. The ED physician discharged her with a diagnosis of otitis media and a prescription for amoxicillin. He didn’t document which ear was infected or what he observed in the affected ear. The following day, the infant was pale, cool to the touch, and lethargic. She was brought to her pediatrician, then transferred immediately to a local medical center, where she was diagnosed with pneumococcal meningitis, hypoxic brain injury, and hydrocephalus and hospitalized for nearly a month. She was subsequently taken to the hospital 10 times and evaluated by several specialists. The child died of respiratory complications linked to the infection almost 2 years after her initial hospitalization.

PLAINTIFF'S CLAIM The ED physician should have ordered a blood count and urinalysis to rule out bacteremia and meningitis. He should have scheduled a follow-up within 24 to 48 hours of the ED visit.

THE DEFENSE The doctor wasn’t negligent; he couldn’t have anticipated the infant’s clinical course. The bacteremia and meningitis developed after the baby left the hospital, and the causative pneumococcal strain was resistant to amoxicillin.

VERDICT $1.72 million Pennsylvania verdict.

COMMENT Does otitis media ever cause a fever of 103°F in a 3-month-old? Although no definitive studies exist, I doubt it. Otitis media is a closed-space infection like an abscess, and abscesses rarely cause fever. Furthermore, the physical findings of otitis media, although not recorded in this case, are highly unreliable in a 3-month-old. Attributing a fever of 103°F in a 3-month-old to otitis media is always a bad idea.

Lung cancer found belatedly despite multiple chest radiographs

DURING AN ANNUAL PHYSICAL EXAMINATION by her primary care physician, a 68-year-old woman with a history of smoking for more than 30 years had an in-house chest x-ray. The physician didn’t have a radiologist read the radiograph or order follow-up imaging. The chest film was repeated the following year. A year after that, the patient developed pulmonary symptoms. A chest x-ray showed an abnormality. The doctor prescribed antibiotics for presumed bronchitis or pneumonia. When the antibiotics didn’t relieve her symptoms, he referred her to a radiologist, who reported a large lesion suggestive of advanced lung cancer. Subsequent films confirmed stage IIIB lung cancer. After 16 rounds of chemotherapy, the patient died at age 73.

PLAINTIFF'S CLAIM The doctor missed an obvious lung lesion on the first radiograph; missed the lesion, which had grown and metastasized, on the second x-ray; and misinterpreted late-stage metastatic cancer on the third radiograph as bronchitis or pneumonia. The chest radiographs should have been over-read, especially when they showed an abnormality. A cancer diagnosis at the time of the first chest radiograph would have allowed a 75% possibility of cure with surgery alone. By the time of the diagnosis 2 years later, a surgical cure wasn’t possible. 

THE DEFENSE The lesion could be seen only on retrospective review of the radiographs. The first and second radiographs were consistent with pulmonary hypertension and didn’t necessitate referral to a radiologist or additional imaging. The patient had many comorbid conditions, including obesity, hypertension, and stenosis of the carotid arteries. She also had a family history of heart disease and COPD.

VERDICT $2 million Virginia verdict.

COMMENT This case illustrates that a simple test, a chest x-ray in this instance, has the potential for litigation if it isn’t interpreted accurately and followed up. Failure to appropriately follow up on test results is one of the 2 major patient safety issues for family medicine; the other is medication errors/drug interactions.

Otitis media? Not likely

A 3-MONTH-OLD INFANT was taken to the emergency department with a fever of 103°F. The ED physician discharged her with a diagnosis of otitis media and a prescription for amoxicillin. He didn’t document which ear was infected or what he observed in the affected ear. The following day, the infant was pale, cool to the touch, and lethargic. She was brought to her pediatrician, then transferred immediately to a local medical center, where she was diagnosed with pneumococcal meningitis, hypoxic brain injury, and hydrocephalus and hospitalized for nearly a month. She was subsequently taken to the hospital 10 times and evaluated by several specialists. The child died of respiratory complications linked to the infection almost 2 years after her initial hospitalization.

PLAINTIFF'S CLAIM The ED physician should have ordered a blood count and urinalysis to rule out bacteremia and meningitis. He should have scheduled a follow-up within 24 to 48 hours of the ED visit.

THE DEFENSE The doctor wasn’t negligent; he couldn’t have anticipated the infant’s clinical course. The bacteremia and meningitis developed after the baby left the hospital, and the causative pneumococcal strain was resistant to amoxicillin.

VERDICT $1.72 million Pennsylvania verdict.

COMMENT Does otitis media ever cause a fever of 103°F in a 3-month-old? Although no definitive studies exist, I doubt it. Otitis media is a closed-space infection like an abscess, and abscesses rarely cause fever. Furthermore, the physical findings of otitis media, although not recorded in this case, are highly unreliable in a 3-month-old. Attributing a fever of 103°F in a 3-month-old to otitis media is always a bad idea.

When pain persists, so should investigation

TWO WEEKS OF ABDOMINAL PAIN brought a 63-year- old man to a group medical practice where an internist attributed the pain to gastritis and prescribed an over-the-counter medication.

The internist examined the man several times over the next 4 years, during which time the man complained periodically of nausea and abdominal pain and the doctor prescribed antacids. A different physician who examined the patient during this period recommended referral to a gastroenterologist. Although the internist was told of the recommendation, he didn’t make the referral.

Four years after the patient first reported abdominal pain to the internist, he was diagnosed with stage IV colon cancer. He died the following year at 68 years of age.

The physician's initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach.

PLAINTIFF'S CLAIM The colon cancer should have been diagnosed when the patient initially complained of pain. His symptoms and age called for an immediate colonoscopy (which would have detected the cancer) or referral to a gastroenterologist.

THE DEFENSE The internist maintained that the pa- tient had been advised several times to undergo a colonoscopy and had refused to do so, although records didn’t support that claim. Earlier treatment wouldn’t have changed the outcome.

VERDICT $950,000 New York settlement.

COMMENT I do a fair amount of malpractice case reviews and find that most cases arise from diagnostic delays and missed diagnoses. This physician’s initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach, and early referral is necessary in the absence of a definitive diagnosis.

Failure to reconsider the initial evaluation

A 29-YEAR-OLD MAN complained of chronic constipation (3 years) and recent rectal bleeding at his first visit to an internist. The doctor performed a rectal examination and ordered a colonoscopy, which was negative and didn’t reveal the cause of the bleeding.

The following year, the patient returned to the internist, reporting new rectal bleeding. After a digital rectal examination, the doctor diagnosed internal hemorrhoids. She continued to treat the patient for the next 3 years. During that time, the patient reported rectal bleeding on 2 occasions; the physician diagnosed external hemorrhoids.

Almost 5 years after his first visit to the internist, the patient requested another colonoscopy, which revealed rectal cancer. After receiving radiation and chemotherapy, the patient underwent abdominoperineal resection with removal of the sphincter muscle, resulting in a permanent colostomy.

PLAINTIFF'S CLAIM The internist couldn’t have diagnosed internal hemorrhoids by digital exam alone unless the hemorrhoids were prolapsing. She was negligent in failing to perform an anoscopy or refer the patient to a gastroenterologist to confirm the cause of the rectal bleeding. Proper management would have enabled diagnosis of the cancer at a stage when radical surgery could have been avoided and the sphincter muscle preserved, eliminating the need for a permanent colostomy.

THE DEFENSE The internist claimed she had diagnosed prolapsing internal hemorrhoids, although the chart noted only internal hemorrhoids. Reliance on the initial negative colonoscopy was proper; earlier diagnosis wouldn’t have changed the patient’s treatment and outcome.

VERDICT $934,779 Illinois bench verdict.

COMMENT This is a difficult case. Colon and rectal cancer are very rare in 29-year-olds, and the initial evaluation was appropriate. At what point should the physician have re-evaluated with colonoscopy or anoscopy and biopsy? I don’t think any retrospectoscope will provide a definitive answer. If this case offers a take-away lesson, it is to reevaluate when potentially serious symptoms persist.

When pain persists, so should investigation

TWO WEEKS OF ABDOMINAL PAIN brought a 63-year- old man to a group medical practice where an internist attributed the pain to gastritis and prescribed an over-the-counter medication.

The internist examined the man several times over the next 4 years, during which time the man complained periodically of nausea and abdominal pain and the doctor prescribed antacids. A different physician who examined the patient during this period recommended referral to a gastroenterologist. Although the internist was told of the recommendation, he didn’t make the referral.

Four years after the patient first reported abdominal pain to the internist, he was diagnosed with stage IV colon cancer. He died the following year at 68 years of age.

The physician's initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach.

PLAINTIFF'S CLAIM The colon cancer should have been diagnosed when the patient initially complained of pain. His symptoms and age called for an immediate colonoscopy (which would have detected the cancer) or referral to a gastroenterologist.

THE DEFENSE The internist maintained that the pa- tient had been advised several times to undergo a colonoscopy and had refused to do so, although records didn’t support that claim. Earlier treatment wouldn’t have changed the outcome.

VERDICT $950,000 New York settlement.

COMMENT I do a fair amount of malpractice case reviews and find that most cases arise from diagnostic delays and missed diagnoses. This physician’s initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach, and early referral is necessary in the absence of a definitive diagnosis.

Failure to reconsider the initial evaluation

A 29-YEAR-OLD MAN complained of chronic constipation (3 years) and recent rectal bleeding at his first visit to an internist. The doctor performed a rectal examination and ordered a colonoscopy, which was negative and didn’t reveal the cause of the bleeding.

The following year, the patient returned to the internist, reporting new rectal bleeding. After a digital rectal examination, the doctor diagnosed internal hemorrhoids. She continued to treat the patient for the next 3 years. During that time, the patient reported rectal bleeding on 2 occasions; the physician diagnosed external hemorrhoids.

Almost 5 years after his first visit to the internist, the patient requested another colonoscopy, which revealed rectal cancer. After receiving radiation and chemotherapy, the patient underwent abdominoperineal resection with removal of the sphincter muscle, resulting in a permanent colostomy.

PLAINTIFF'S CLAIM The internist couldn’t have diagnosed internal hemorrhoids by digital exam alone unless the hemorrhoids were prolapsing. She was negligent in failing to perform an anoscopy or refer the patient to a gastroenterologist to confirm the cause of the rectal bleeding. Proper management would have enabled diagnosis of the cancer at a stage when radical surgery could have been avoided and the sphincter muscle preserved, eliminating the need for a permanent colostomy.

THE DEFENSE The internist claimed she had diagnosed prolapsing internal hemorrhoids, although the chart noted only internal hemorrhoids. Reliance on the initial negative colonoscopy was proper; earlier diagnosis wouldn’t have changed the patient’s treatment and outcome.

VERDICT $934,779 Illinois bench verdict.

COMMENT This is a difficult case. Colon and rectal cancer are very rare in 29-year-olds, and the initial evaluation was appropriate. At what point should the physician have re-evaluated with colonoscopy or anoscopy and biopsy? I don’t think any retrospectoscope will provide a definitive answer. If this case offers a take-away lesson, it is to reevaluate when potentially serious symptoms persist.

When pain persists, so should investigation

TWO WEEKS OF ABDOMINAL PAIN brought a 63-year- old man to a group medical practice where an internist attributed the pain to gastritis and prescribed an over-the-counter medication.

The internist examined the man several times over the next 4 years, during which time the man complained periodically of nausea and abdominal pain and the doctor prescribed antacids. A different physician who examined the patient during this period recommended referral to a gastroenterologist. Although the internist was told of the recommendation, he didn’t make the referral.

Four years after the patient first reported abdominal pain to the internist, he was diagnosed with stage IV colon cancer. He died the following year at 68 years of age.

The physician's initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach.

PLAINTIFF'S CLAIM The colon cancer should have been diagnosed when the patient initially complained of pain. His symptoms and age called for an immediate colonoscopy (which would have detected the cancer) or referral to a gastroenterologist.

THE DEFENSE The internist maintained that the pa- tient had been advised several times to undergo a colonoscopy and had refused to do so, although records didn’t support that claim. Earlier treatment wouldn’t have changed the outcome.

VERDICT $950,000 New York settlement.

COMMENT I do a fair amount of malpractice case reviews and find that most cases arise from diagnostic delays and missed diagnoses. This physician’s initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach, and early referral is necessary in the absence of a definitive diagnosis.

Failure to reconsider the initial evaluation

A 29-YEAR-OLD MAN complained of chronic constipation (3 years) and recent rectal bleeding at his first visit to an internist. The doctor performed a rectal examination and ordered a colonoscopy, which was negative and didn’t reveal the cause of the bleeding.

The following year, the patient returned to the internist, reporting new rectal bleeding. After a digital rectal examination, the doctor diagnosed internal hemorrhoids. She continued to treat the patient for the next 3 years. During that time, the patient reported rectal bleeding on 2 occasions; the physician diagnosed external hemorrhoids.

Almost 5 years after his first visit to the internist, the patient requested another colonoscopy, which revealed rectal cancer. After receiving radiation and chemotherapy, the patient underwent abdominoperineal resection with removal of the sphincter muscle, resulting in a permanent colostomy.

PLAINTIFF'S CLAIM The internist couldn’t have diagnosed internal hemorrhoids by digital exam alone unless the hemorrhoids were prolapsing. She was negligent in failing to perform an anoscopy or refer the patient to a gastroenterologist to confirm the cause of the rectal bleeding. Proper management would have enabled diagnosis of the cancer at a stage when radical surgery could have been avoided and the sphincter muscle preserved, eliminating the need for a permanent colostomy.

THE DEFENSE The internist claimed she had diagnosed prolapsing internal hemorrhoids, although the chart noted only internal hemorrhoids. Reliance on the initial negative colonoscopy was proper; earlier diagnosis wouldn’t have changed the patient’s treatment and outcome.

VERDICT $934,779 Illinois bench verdict.

COMMENT This is a difficult case. Colon and rectal cancer are very rare in 29-year-olds, and the initial evaluation was appropriate. At what point should the physician have re-evaluated with colonoscopy or anoscopy and biopsy? I don’t think any retrospectoscope will provide a definitive answer. If this case offers a take-away lesson, it is to reevaluate when potentially serious symptoms persist.

During a routine mammogram, an enlarged lymph node was found in the patient’s armpit. The patient’s primary care physician (PCP) ordered follow-up imaging and referred the patient to a surgeon for possible excisional biopsy. The surgeon suggested that the biopsy could be delayed until additional imaging studies were completed.

The patient transferred her care to another surgeon, who immediately performed the biopsy and found stage IV inoperable breast cancer. The patient underwent aggressive chemotherapy for 3 years, but died 39 months after diagnosis.

ESTATE’S CLAIM The first surgeon was negligent for not immediately performing the biopsy.

DEFENDANTS’ DEFENSE There was no negligence. An earlier biopsy would not have changed the outcome.

VERDICT A $1.5 million Massachusetts verdict was returned.

Treating bowel injury after uterine ablation
Following uterine ablation performed by a gynecologist, a 35-year-old woman suffered severe abdominal pain. Six days later, the gynecologist and a surgeon performed a hysterectomy.

Three days after discharge, the patient returned to the hospital with an abdominal infection and sepsis. During a third operation, a burn hole was found; the injured portion of bowel was resected. The patient has chronic abdominal pain.

PATIENT’S CLAIM Sepsis and infection could have been avoided if either physician had identified the injury during the second hospitalization and surgery. The patient developed psychological issues as a result of chronic pain.

DEFENDANTS’ DEFENSE A settlement was reached with the gynecologist during the trial. The surgeon denied negligence. During the second surgery, he examined her bowel for a possible injury but found none.

VERDICT A $3.5 million Illinois verdict was returned. It included
$1.5 million for past pain and suffering that was reduced by $100,000 due to the patient’s failure to report for psychological counseling. The jury found the gynecologist 65% at fault and the surgeon 35% at fault.

Mother in permanent vegetative state
When a 30-year-old woman went to a hospital in labor, she had gestational hypertension. The next morning, she suffered cardiopulmonary arrest. A healthy baby was born by emergency cesarean delivery, but the mother was left in a permanent vegetative state.

PATIENT’S CLAIM The nurses failed to ensure that the ObGyn came to the hospital and did not report blood pressure data to the ObGyn. Gestational hypertension progressed to preeclampsia. Early delivery should have been induced or magnesium sulfate should have been administered.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial.

The nurses were right to rely on the ObGyn to make decisions regarding the patient’s care. They provided appropriate treatment.

VERDICT A New Jersey defense verdict was returned for the hospital.

What caused the child’s brain injuries?
After vaginal delivery, the baby was not breathing and required intubation. He had a seizure and displayed signs of oxygen deprivation, hypoxic ischemic injury, and brain damage. The child uses a special walker and can only communicate using a computer that speaks for him.

PARENTS’ CLAIM The nurses and ObGyn failed to properly assess the baby. The fetal heart-rate monitor electrode should have been placed on the fetal scalp. A cesarean delivery should have been performed.

DEFENDANTS’ DEFENSE The fetal monitor was properly placed. The child’s injury occurred 24 to 72 hours prior to birth due to an umbilical cord accident. A cesarean delivery would have not changed the outcome.  

VERDICT A Georgia defense verdict was returned.

Did a woman’s vaginal infection cause her baby’s death?
At 22 weeks’ gestation, a 26-year-old woman began to leak amniotic fluid and went to the hospital. She was in premature labor. The newborn died 19 minutes after birth.

PARENTS’ CLAIM The ObGyn and nurse midwife who provided prenatal care failed to diagnose and treat a vaginal infection. The infection resulted in premature rupture of membranes, leading to premature birth and the baby’s death.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial. The nurse midwife claimed the patient did not have a vaginal infection; she never reported symptoms of a foul-smelling vaginal odor or discharge. Premature rupture of membranes was not caused by a vaginal infection. The newborn’s death was related to an umbilical cord defect, the patient’s delay in coming to the hospital, and the multiple obstetric procedures the mother had undergone before this pregnancy.   

VERDICT A $456,024 New Jersey verdict was returned.

Inadvertent ligation, ureteral obstruction
A 41-year-old woman suffered pelvic pain and had a history of endometriosis. In January 2007, a CT scan revealed a ruptured ovarian cyst; her ObGyn performed laparotomy for a hysterectomy and oophorectomy.

During surgery, a resident working under the supervision of the ObGyn inadvertently ligated the left ureter. The injury was close to the bladder near the ureteral vesicle junction. A few days later, cystoscopy showed ureteral obstruction. The patient underwent operative repair with nephrostomy tube placement. In May 2007, the patient had a third operation to reimplant the ureter. She has chronic flank pain.

PATIENT’S CLAIM The resident and, therefore, the ObGyn, were negligent in the performance of the procedure. Proper bladder dissection would have moved the ureter to a position where it could not have been ligated.

DEFENDANTS’ DEFENSE Ureter injury is a known risk of the procedure.

VERDICT An Illinois defense verdict was returned.

Foot drop after tubal ligatioN?
During tubal ligation, a woman in her 30s was restrained by a belt. Venodyne boots were applied to promote blood circulation.

PATIENT’S CLAIM The belt and/or boot damaged the perineal and tibial nerves in her left leg, causing foot drop. When asked to definitely identify what caused the nerve damage, the patient invoked the doctrine of res ipsa loquitur (presumed negligence during surgery).

DEFENDANTS’ DEFENSE A $400,000 settlement was reached with the hospital before the trial.

The gynecologist and anesthesiologist denied negligence. The Venodyne boots could not have caused the injury, nor could the belt, which was applied in an area that did not involve the perineal or tibial nerves. The patient did not complain of pain after surgery.  

VERDICT A New York defense verdict was returned for the physicians.

Avoid surgical menopause?
After a 10-year history of endometriosis and chronic pelvic pain, a 38-year-old woman underwent bilateral salpingo-oophorectomy. Postoperatively, she suffered surgical menopause that exacerbated pre-existing anxiety and depression.

PATIENT’S CLAIM It was unnecessary to remove the healthy right ovary; having it remain would have avoided early menopause. She would not have consented to the removal of both ovaries had she been properly advised. Alternative treatment was not offered. Her marriage dissolved, her children went to live with their grandparents, and she was unable to work because of complications.

PHYSICIAN’S DEFENSE Proper consent was obtained, including alternatives to surgery. Evidence of ovarian cancer or other medical necessity was not required because full consent was obtained. Removal of the ovaries was proper due to dense pelvic and bowel adhesions, cystic adnexal masses with questionable pathology, and her chronic pelvic pain. The patient’s appendix was adhesed, causing an unreasonable risk of ovarian torsion.

VERDICT A Michigan defense verdict was returned.

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Persistent voiding problems
A 52-year-old woman was given a diagnosis of stage II anterior pelvic organ prolapse, a high transverse fascial defect, stress urinary incontinence, and distal rectocele.

A gynecologist performed robotic supracervical hysterectomy and colposacropexy, with tension-free vaginal tape and perineal repair.

While in the hospital, she required a catheter to void, and was still unable to void 5 days after discharge. The gynecologist identified persistent urinary retention, released the tension-free vaginal tape, and performed a midurethral sling procedure, but the patient continued to have voiding problems.

The gynecologist suspected a neurogenic problem and referred the patient to a neuro-urologist. Continued intermittent catheterization was recommended by the neuro-urologist, but the patient had continued voiding problems and developed a urinary tract infection.

She went to her ObGyn, who performed a sling revision and cysto­scopy and removed all the mesh that could be found. The patient underwent additional treatment, with some improvement.

PATIENT’S CLAIM The gynecologist was negligent for failing to offer further surgery to improve the patient’s condition. 

PHYSICIAN’S DEFENSE There was no negligence. Further dissection in the presence of a neurogenic bladder carried a high risk of incontinence. The patient was told of the risk of urinary retention prior to the first procedure and signed an informed consent.   

VERDICT A Virginia defense verdict was returned.

Did pathologists fail to diagnose early breast cancer?
After A 45-year-old woman underwent mammography in May 2008 at a local hospital, an oncologist noted a suspicious finding in the right breast. The patient had an incisional biopsy interpreted by Dr. A, a pathologist, and a core biopsy interpreted by Dr. B, another pathologist from the same diagnostic medical group. Both pathologists interpreted the mass as atypia, a benign abnormality.

In 2010, the patient went to a university medical center, where the mass was biopsied and the patient was found to have cancer. She underwent a right mastectomy.

PATIENT’S CLAIM The pathologists failed to diagnose her breast cancer at an early stage. Dr. A should have interpreted the 2008 incisional biopsy as malignant. A diagnosis in 2008 would have avoided the need for a mastectomy, allowing her to have a lumpectomy with chemotherapy.

DEFENDANTS’ DEFENSE The 2010 review of the 2008 data was an over-interpretation with hindsight bias; the diagnosis in 2008 was correct.  

VERDICT The case against the local hospital and Dr. B were dismissed. The matter continued against Dr. A and the diagnostic medical group. A California defense verdict was returned.

Brachial plexus injury occurs after admitting physician leaves
A woman sought prenatal care from her family practitioner (FP). The FP admitted the mother to a hospital for induction of labor at 38 weeks’ gestation with concerns of increased uric acid, possible gestational hypertension, and leaking amniotic fluid. Labor progressed and the mother began pushing about 4 pm. After 30 minutes, the FP attempted vacu­um extraction three times; the device popped off during one of the attempts.

The FP then left for a planned trip, and an ObGyn assumed her care. The ObGyn chose to allow the mother to rest. At 6 pm, the mother began to feel the urge to push. The ObGyn attempted vacu­um extraction. Shoulder dystocia was encountered, and McRoberts and corkscrew maneuvers were used to deliver the fetus.

The child has C5–C6 brachial plexus injury with scapular winging and internal shoulder rotation.

PARENTS’ CLAIM A cesarean delivery should have been performed. The ObGyn applied excessive lateral traction, leading to the injury.

DEFENDANTS’ DEFENSE The FP and ObGyn argued that a cesarean ­delivery was not indicated because the fetus was not in distress. Fetal heart-rate monitoring strips were reassuring. The ObGyn denied using excessive lateral traction when freeing the shoulder dystocia. 

VERDICT The hospital settled before trial for $300,000. An Illinois defense verdict was returned for the FP. The jury deadlocked as to the ObGyn’s negligence.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

During a routine mammogram, an enlarged lymph node was found in the patient’s armpit. The patient’s primary care physician (PCP) ordered follow-up imaging and referred the patient to a surgeon for possible excisional biopsy. The surgeon suggested that the biopsy could be delayed until additional imaging studies were completed.

The patient transferred her care to another surgeon, who immediately performed the biopsy and found stage IV inoperable breast cancer. The patient underwent aggressive chemotherapy for 3 years, but died 39 months after diagnosis.

ESTATE’S CLAIM The first surgeon was negligent for not immediately performing the biopsy.

DEFENDANTS’ DEFENSE There was no negligence. An earlier biopsy would not have changed the outcome.

VERDICT A $1.5 million Massachusetts verdict was returned.

Treating bowel injury after uterine ablation
Following uterine ablation performed by a gynecologist, a 35-year-old woman suffered severe abdominal pain. Six days later, the gynecologist and a surgeon performed a hysterectomy.

Three days after discharge, the patient returned to the hospital with an abdominal infection and sepsis. During a third operation, a burn hole was found; the injured portion of bowel was resected. The patient has chronic abdominal pain.

PATIENT’S CLAIM Sepsis and infection could have been avoided if either physician had identified the injury during the second hospitalization and surgery. The patient developed psychological issues as a result of chronic pain.

DEFENDANTS’ DEFENSE A settlement was reached with the gynecologist during the trial. The surgeon denied negligence. During the second surgery, he examined her bowel for a possible injury but found none.

VERDICT A $3.5 million Illinois verdict was returned. It included
$1.5 million for past pain and suffering that was reduced by $100,000 due to the patient’s failure to report for psychological counseling. The jury found the gynecologist 65% at fault and the surgeon 35% at fault.

Mother in permanent vegetative state
When a 30-year-old woman went to a hospital in labor, she had gestational hypertension. The next morning, she suffered cardiopulmonary arrest. A healthy baby was born by emergency cesarean delivery, but the mother was left in a permanent vegetative state.

PATIENT’S CLAIM The nurses failed to ensure that the ObGyn came to the hospital and did not report blood pressure data to the ObGyn. Gestational hypertension progressed to preeclampsia. Early delivery should have been induced or magnesium sulfate should have been administered.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial.

The nurses were right to rely on the ObGyn to make decisions regarding the patient’s care. They provided appropriate treatment.

VERDICT A New Jersey defense verdict was returned for the hospital.

What caused the child’s brain injuries?
After vaginal delivery, the baby was not breathing and required intubation. He had a seizure and displayed signs of oxygen deprivation, hypoxic ischemic injury, and brain damage. The child uses a special walker and can only communicate using a computer that speaks for him.

PARENTS’ CLAIM The nurses and ObGyn failed to properly assess the baby. The fetal heart-rate monitor electrode should have been placed on the fetal scalp. A cesarean delivery should have been performed.

DEFENDANTS’ DEFENSE The fetal monitor was properly placed. The child’s injury occurred 24 to 72 hours prior to birth due to an umbilical cord accident. A cesarean delivery would have not changed the outcome.  

VERDICT A Georgia defense verdict was returned.

Did a woman’s vaginal infection cause her baby’s death?
At 22 weeks’ gestation, a 26-year-old woman began to leak amniotic fluid and went to the hospital. She was in premature labor. The newborn died 19 minutes after birth.

PARENTS’ CLAIM The ObGyn and nurse midwife who provided prenatal care failed to diagnose and treat a vaginal infection. The infection resulted in premature rupture of membranes, leading to premature birth and the baby’s death.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial. The nurse midwife claimed the patient did not have a vaginal infection; she never reported symptoms of a foul-smelling vaginal odor or discharge. Premature rupture of membranes was not caused by a vaginal infection. The newborn’s death was related to an umbilical cord defect, the patient’s delay in coming to the hospital, and the multiple obstetric procedures the mother had undergone before this pregnancy.   

VERDICT A $456,024 New Jersey verdict was returned.

Inadvertent ligation, ureteral obstruction
A 41-year-old woman suffered pelvic pain and had a history of endometriosis. In January 2007, a CT scan revealed a ruptured ovarian cyst; her ObGyn performed laparotomy for a hysterectomy and oophorectomy.

During surgery, a resident working under the supervision of the ObGyn inadvertently ligated the left ureter. The injury was close to the bladder near the ureteral vesicle junction. A few days later, cystoscopy showed ureteral obstruction. The patient underwent operative repair with nephrostomy tube placement. In May 2007, the patient had a third operation to reimplant the ureter. She has chronic flank pain.

PATIENT’S CLAIM The resident and, therefore, the ObGyn, were negligent in the performance of the procedure. Proper bladder dissection would have moved the ureter to a position where it could not have been ligated.

DEFENDANTS’ DEFENSE Ureter injury is a known risk of the procedure.

VERDICT An Illinois defense verdict was returned.

Foot drop after tubal ligatioN?
During tubal ligation, a woman in her 30s was restrained by a belt. Venodyne boots were applied to promote blood circulation.

PATIENT’S CLAIM The belt and/or boot damaged the perineal and tibial nerves in her left leg, causing foot drop. When asked to definitely identify what caused the nerve damage, the patient invoked the doctrine of res ipsa loquitur (presumed negligence during surgery).

DEFENDANTS’ DEFENSE A $400,000 settlement was reached with the hospital before the trial.

The gynecologist and anesthesiologist denied negligence. The Venodyne boots could not have caused the injury, nor could the belt, which was applied in an area that did not involve the perineal or tibial nerves. The patient did not complain of pain after surgery.  

VERDICT A New York defense verdict was returned for the physicians.

Avoid surgical menopause?
After a 10-year history of endometriosis and chronic pelvic pain, a 38-year-old woman underwent bilateral salpingo-oophorectomy. Postoperatively, she suffered surgical menopause that exacerbated pre-existing anxiety and depression.

PATIENT’S CLAIM It was unnecessary to remove the healthy right ovary; having it remain would have avoided early menopause. She would not have consented to the removal of both ovaries had she been properly advised. Alternative treatment was not offered. Her marriage dissolved, her children went to live with their grandparents, and she was unable to work because of complications.

PHYSICIAN’S DEFENSE Proper consent was obtained, including alternatives to surgery. Evidence of ovarian cancer or other medical necessity was not required because full consent was obtained. Removal of the ovaries was proper due to dense pelvic and bowel adhesions, cystic adnexal masses with questionable pathology, and her chronic pelvic pain. The patient’s appendix was adhesed, causing an unreasonable risk of ovarian torsion.

VERDICT A Michigan defense verdict was returned.

Do you enjoy reading Medical Verdicts?
Find more in the PROFESSIONAL LIABILITY Topic Collection.

Persistent voiding problems
A 52-year-old woman was given a diagnosis of stage II anterior pelvic organ prolapse, a high transverse fascial defect, stress urinary incontinence, and distal rectocele.

A gynecologist performed robotic supracervical hysterectomy and colposacropexy, with tension-free vaginal tape and perineal repair.

While in the hospital, she required a catheter to void, and was still unable to void 5 days after discharge. The gynecologist identified persistent urinary retention, released the tension-free vaginal tape, and performed a midurethral sling procedure, but the patient continued to have voiding problems.

The gynecologist suspected a neurogenic problem and referred the patient to a neuro-urologist. Continued intermittent catheterization was recommended by the neuro-urologist, but the patient had continued voiding problems and developed a urinary tract infection.

She went to her ObGyn, who performed a sling revision and cysto­scopy and removed all the mesh that could be found. The patient underwent additional treatment, with some improvement.

PATIENT’S CLAIM The gynecologist was negligent for failing to offer further surgery to improve the patient’s condition. 

PHYSICIAN’S DEFENSE There was no negligence. Further dissection in the presence of a neurogenic bladder carried a high risk of incontinence. The patient was told of the risk of urinary retention prior to the first procedure and signed an informed consent.   

VERDICT A Virginia defense verdict was returned.

Did pathologists fail to diagnose early breast cancer?
After A 45-year-old woman underwent mammography in May 2008 at a local hospital, an oncologist noted a suspicious finding in the right breast. The patient had an incisional biopsy interpreted by Dr. A, a pathologist, and a core biopsy interpreted by Dr. B, another pathologist from the same diagnostic medical group. Both pathologists interpreted the mass as atypia, a benign abnormality.

In 2010, the patient went to a university medical center, where the mass was biopsied and the patient was found to have cancer. She underwent a right mastectomy.

PATIENT’S CLAIM The pathologists failed to diagnose her breast cancer at an early stage. Dr. A should have interpreted the 2008 incisional biopsy as malignant. A diagnosis in 2008 would have avoided the need for a mastectomy, allowing her to have a lumpectomy with chemotherapy.

DEFENDANTS’ DEFENSE The 2010 review of the 2008 data was an over-interpretation with hindsight bias; the diagnosis in 2008 was correct.  

VERDICT The case against the local hospital and Dr. B were dismissed. The matter continued against Dr. A and the diagnostic medical group. A California defense verdict was returned.

Brachial plexus injury occurs after admitting physician leaves
A woman sought prenatal care from her family practitioner (FP). The FP admitted the mother to a hospital for induction of labor at 38 weeks’ gestation with concerns of increased uric acid, possible gestational hypertension, and leaking amniotic fluid. Labor progressed and the mother began pushing about 4 pm. After 30 minutes, the FP attempted vacu­um extraction three times; the device popped off during one of the attempts.

The FP then left for a planned trip, and an ObGyn assumed her care. The ObGyn chose to allow the mother to rest. At 6 pm, the mother began to feel the urge to push. The ObGyn attempted vacu­um extraction. Shoulder dystocia was encountered, and McRoberts and corkscrew maneuvers were used to deliver the fetus.

The child has C5–C6 brachial plexus injury with scapular winging and internal shoulder rotation.

PARENTS’ CLAIM A cesarean delivery should have been performed. The ObGyn applied excessive lateral traction, leading to the injury.

DEFENDANTS’ DEFENSE The FP and ObGyn argued that a cesarean ­delivery was not indicated because the fetus was not in distress. Fetal heart-rate monitoring strips were reassuring. The ObGyn denied using excessive lateral traction when freeing the shoulder dystocia. 

VERDICT The hospital settled before trial for $300,000. An Illinois defense verdict was returned for the FP. The jury deadlocked as to the ObGyn’s negligence.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

During a routine mammogram, an enlarged lymph node was found in the patient’s armpit. The patient’s primary care physician (PCP) ordered follow-up imaging and referred the patient to a surgeon for possible excisional biopsy. The surgeon suggested that the biopsy could be delayed until additional imaging studies were completed.

The patient transferred her care to another surgeon, who immediately performed the biopsy and found stage IV inoperable breast cancer. The patient underwent aggressive chemotherapy for 3 years, but died 39 months after diagnosis.

ESTATE’S CLAIM The first surgeon was negligent for not immediately performing the biopsy.

DEFENDANTS’ DEFENSE There was no negligence. An earlier biopsy would not have changed the outcome.

VERDICT A $1.5 million Massachusetts verdict was returned.

Treating bowel injury after uterine ablation
Following uterine ablation performed by a gynecologist, a 35-year-old woman suffered severe abdominal pain. Six days later, the gynecologist and a surgeon performed a hysterectomy.

Three days after discharge, the patient returned to the hospital with an abdominal infection and sepsis. During a third operation, a burn hole was found; the injured portion of bowel was resected. The patient has chronic abdominal pain.

PATIENT’S CLAIM Sepsis and infection could have been avoided if either physician had identified the injury during the second hospitalization and surgery. The patient developed psychological issues as a result of chronic pain.

DEFENDANTS’ DEFENSE A settlement was reached with the gynecologist during the trial. The surgeon denied negligence. During the second surgery, he examined her bowel for a possible injury but found none.

VERDICT A $3.5 million Illinois verdict was returned. It included
$1.5 million for past pain and suffering that was reduced by $100,000 due to the patient’s failure to report for psychological counseling. The jury found the gynecologist 65% at fault and the surgeon 35% at fault.

Mother in permanent vegetative state
When a 30-year-old woman went to a hospital in labor, she had gestational hypertension. The next morning, she suffered cardiopulmonary arrest. A healthy baby was born by emergency cesarean delivery, but the mother was left in a permanent vegetative state.

PATIENT’S CLAIM The nurses failed to ensure that the ObGyn came to the hospital and did not report blood pressure data to the ObGyn. Gestational hypertension progressed to preeclampsia. Early delivery should have been induced or magnesium sulfate should have been administered.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial.

The nurses were right to rely on the ObGyn to make decisions regarding the patient’s care. They provided appropriate treatment.

VERDICT A New Jersey defense verdict was returned for the hospital.

What caused the child’s brain injuries?
After vaginal delivery, the baby was not breathing and required intubation. He had a seizure and displayed signs of oxygen deprivation, hypoxic ischemic injury, and brain damage. The child uses a special walker and can only communicate using a computer that speaks for him.

PARENTS’ CLAIM The nurses and ObGyn failed to properly assess the baby. The fetal heart-rate monitor electrode should have been placed on the fetal scalp. A cesarean delivery should have been performed.

DEFENDANTS’ DEFENSE The fetal monitor was properly placed. The child’s injury occurred 24 to 72 hours prior to birth due to an umbilical cord accident. A cesarean delivery would have not changed the outcome.  

VERDICT A Georgia defense verdict was returned.

Did a woman’s vaginal infection cause her baby’s death?
At 22 weeks’ gestation, a 26-year-old woman began to leak amniotic fluid and went to the hospital. She was in premature labor. The newborn died 19 minutes after birth.

PARENTS’ CLAIM The ObGyn and nurse midwife who provided prenatal care failed to diagnose and treat a vaginal infection. The infection resulted in premature rupture of membranes, leading to premature birth and the baby’s death.

DEFENDANTS’ DEFENSE A confidential settlement was reached with the ObGyn before trial. The nurse midwife claimed the patient did not have a vaginal infection; she never reported symptoms of a foul-smelling vaginal odor or discharge. Premature rupture of membranes was not caused by a vaginal infection. The newborn’s death was related to an umbilical cord defect, the patient’s delay in coming to the hospital, and the multiple obstetric procedures the mother had undergone before this pregnancy.   

VERDICT A $456,024 New Jersey verdict was returned.

Inadvertent ligation, ureteral obstruction
A 41-year-old woman suffered pelvic pain and had a history of endometriosis. In January 2007, a CT scan revealed a ruptured ovarian cyst; her ObGyn performed laparotomy for a hysterectomy and oophorectomy.

During surgery, a resident working under the supervision of the ObGyn inadvertently ligated the left ureter. The injury was close to the bladder near the ureteral vesicle junction. A few days later, cystoscopy showed ureteral obstruction. The patient underwent operative repair with nephrostomy tube placement. In May 2007, the patient had a third operation to reimplant the ureter. She has chronic flank pain.

PATIENT’S CLAIM The resident and, therefore, the ObGyn, were negligent in the performance of the procedure. Proper bladder dissection would have moved the ureter to a position where it could not have been ligated.

DEFENDANTS’ DEFENSE Ureter injury is a known risk of the procedure.

VERDICT An Illinois defense verdict was returned.

Foot drop after tubal ligatioN?
During tubal ligation, a woman in her 30s was restrained by a belt. Venodyne boots were applied to promote blood circulation.

PATIENT’S CLAIM The belt and/or boot damaged the perineal and tibial nerves in her left leg, causing foot drop. When asked to definitely identify what caused the nerve damage, the patient invoked the doctrine of res ipsa loquitur (presumed negligence during surgery).

DEFENDANTS’ DEFENSE A $400,000 settlement was reached with the hospital before the trial.

The gynecologist and anesthesiologist denied negligence. The Venodyne boots could not have caused the injury, nor could the belt, which was applied in an area that did not involve the perineal or tibial nerves. The patient did not complain of pain after surgery.  

VERDICT A New York defense verdict was returned for the physicians.

Avoid surgical menopause?
After a 10-year history of endometriosis and chronic pelvic pain, a 38-year-old woman underwent bilateral salpingo-oophorectomy. Postoperatively, she suffered surgical menopause that exacerbated pre-existing anxiety and depression.

PATIENT’S CLAIM It was unnecessary to remove the healthy right ovary; having it remain would have avoided early menopause. She would not have consented to the removal of both ovaries had she been properly advised. Alternative treatment was not offered. Her marriage dissolved, her children went to live with their grandparents, and she was unable to work because of complications.

PHYSICIAN’S DEFENSE Proper consent was obtained, including alternatives to surgery. Evidence of ovarian cancer or other medical necessity was not required because full consent was obtained. Removal of the ovaries was proper due to dense pelvic and bowel adhesions, cystic adnexal masses with questionable pathology, and her chronic pelvic pain. The patient’s appendix was adhesed, causing an unreasonable risk of ovarian torsion.

VERDICT A Michigan defense verdict was returned.

Do you enjoy reading Medical Verdicts?
Find more in the PROFESSIONAL LIABILITY Topic Collection.

Persistent voiding problems
A 52-year-old woman was given a diagnosis of stage II anterior pelvic organ prolapse, a high transverse fascial defect, stress urinary incontinence, and distal rectocele.

A gynecologist performed robotic supracervical hysterectomy and colposacropexy, with tension-free vaginal tape and perineal repair.

While in the hospital, she required a catheter to void, and was still unable to void 5 days after discharge. The gynecologist identified persistent urinary retention, released the tension-free vaginal tape, and performed a midurethral sling procedure, but the patient continued to have voiding problems.

The gynecologist suspected a neurogenic problem and referred the patient to a neuro-urologist. Continued intermittent catheterization was recommended by the neuro-urologist, but the patient had continued voiding problems and developed a urinary tract infection.

She went to her ObGyn, who performed a sling revision and cysto­scopy and removed all the mesh that could be found. The patient underwent additional treatment, with some improvement.

PATIENT’S CLAIM The gynecologist was negligent for failing to offer further surgery to improve the patient’s condition. 

PHYSICIAN’S DEFENSE There was no negligence. Further dissection in the presence of a neurogenic bladder carried a high risk of incontinence. The patient was told of the risk of urinary retention prior to the first procedure and signed an informed consent.   

VERDICT A Virginia defense verdict was returned.

Did pathologists fail to diagnose early breast cancer?
After A 45-year-old woman underwent mammography in May 2008 at a local hospital, an oncologist noted a suspicious finding in the right breast. The patient had an incisional biopsy interpreted by Dr. A, a pathologist, and a core biopsy interpreted by Dr. B, another pathologist from the same diagnostic medical group. Both pathologists interpreted the mass as atypia, a benign abnormality.

In 2010, the patient went to a university medical center, where the mass was biopsied and the patient was found to have cancer. She underwent a right mastectomy.

PATIENT’S CLAIM The pathologists failed to diagnose her breast cancer at an early stage. Dr. A should have interpreted the 2008 incisional biopsy as malignant. A diagnosis in 2008 would have avoided the need for a mastectomy, allowing her to have a lumpectomy with chemotherapy.

DEFENDANTS’ DEFENSE The 2010 review of the 2008 data was an over-interpretation with hindsight bias; the diagnosis in 2008 was correct.  

VERDICT The case against the local hospital and Dr. B were dismissed. The matter continued against Dr. A and the diagnostic medical group. A California defense verdict was returned.

Brachial plexus injury occurs after admitting physician leaves
A woman sought prenatal care from her family practitioner (FP). The FP admitted the mother to a hospital for induction of labor at 38 weeks’ gestation with concerns of increased uric acid, possible gestational hypertension, and leaking amniotic fluid. Labor progressed and the mother began pushing about 4 pm. After 30 minutes, the FP attempted vacu­um extraction three times; the device popped off during one of the attempts.

The FP then left for a planned trip, and an ObGyn assumed her care. The ObGyn chose to allow the mother to rest. At 6 pm, the mother began to feel the urge to push. The ObGyn attempted vacu­um extraction. Shoulder dystocia was encountered, and McRoberts and corkscrew maneuvers were used to deliver the fetus.

The child has C5–C6 brachial plexus injury with scapular winging and internal shoulder rotation.

PARENTS’ CLAIM A cesarean delivery should have been performed. The ObGyn applied excessive lateral traction, leading to the injury.

DEFENDANTS’ DEFENSE The FP and ObGyn argued that a cesarean ­delivery was not indicated because the fetus was not in distress. Fetal heart-rate monitoring strips were reassuring. The ObGyn denied using excessive lateral traction when freeing the shoulder dystocia. 

VERDICT The hospital settled before trial for $300,000. An Illinois defense verdict was returned for the FP. The jury deadlocked as to the ObGyn’s negligence.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Delayed Dx leads to blindness

A WOMAN WITH DISABLING RHEUMATOID ARTHRITIS visited her long-time internist with pulmonary symptoms. Shortly thereafter the 59-year-old patient was diagnosed with lung cancer with a moderate prognosis and underwent surgery.

The following month, the woman complained of jaw pain to her internist. She also reported an “achy” temple to the nurse who saw her initially. The internist surmised that the cause of the pain might be an allergic reaction to dye used in a CT scan the patient had undergone because the patient said the pain had begun immediately after the scan. She was treated with methylprednisolone and the symptoms improved temporarily.

Within a few weeks, the patient complained of vision problems in her left eye. An ophthalmologist to whom she was referred thought the cause might be metastasis of the lung cancer. After an MRI of the optic area, a neuroradiologist reported to the ophthalmologist that the findings were consistent with metastatic cancer.

Before the patient could keep a follow-up appointment with the ophthalmologist, she lost all vision in her left eye. When she called the internist’s office for the results of the MRI, she told the person who answered the phone about the vision loss. Her call wasn’t returned.

The patient also told the ophthalmologist’s office about her loss of vision when she received a call to remind her of her follow-up appointment. The person she spoke to claimed the patient was offered an appointment that same day with another doctor, but declined it.

On the day before the follow-up appointment, the patient lost all sight in her right eye, as well. She received emergency treatment with corticosteroids the next day, but her vision didn’t return, leaving her completely blind. A temporal artery biopsy confirmed giant cell arteritis.

PLAINTIFF'S CLAIM The patient had classic symptoms of giant cell arteritis when she saw both the internist and ophthalmologist.

THE DEFENSE No negligence occurred because the patient had additional medical conditions; the patient didn’t describe her symptoms effectively and was negligent in failing to seek emergency medical care when she lost vision in her left eye.

VERDICT $1.4 million Washington settlement.

COMMENT This is a tough case with plenty of blame to go around, but it provides a good reminder to think of temporal arteritis whenever an older patient complains of jaw pain. Sedimentation rate measurements are cheap.

Lack of vigilance ends badly

SHORTNESS OF BREATH, FATIGUE, AND DIARRHEA prompted a 36-year-old man with diabetes and hypothyroidism to consult his primary care physician. The doctor prescribed levofloxacin and told the patient to return in 4 weeks.

Three days later, the man went back to the physician, reporting weakness, diarrhea, and a fever of 103°F. The physician diagnosed bronchitis and prescribed extended-release amoxicillin tablets. Two days later, the patient went to the emergency department; a chest radiograph showed advanced bilateral pneumonia. He died about 2 weeks later.

PLAINTIFF'S CLAIM The physician was negligent in failing to order a radiograph, admit the patient to the hospital, and prescribe proper medication.

THE DEFENSE No information about the defense is available.

VERDICT $1 million New Jersey settlement.

COMMENT Shortness of breath, fatigue, and diarrhea in a 36-year-old patient with diabetes sounds potentially serious to me. Presumably the physician diagnosed pneumonia on the initial exam, and one cannot fault him for that diagnosis or the treatment he prescribed. But return in 4 weeks? No way. Such patients require close follow-up and escalation of evaluation and treatment if they’re not doing well.

Delayed Dx leads to blindness

A WOMAN WITH DISABLING RHEUMATOID ARTHRITIS visited her long-time internist with pulmonary symptoms. Shortly thereafter the 59-year-old patient was diagnosed with lung cancer with a moderate prognosis and underwent surgery.

The following month, the woman complained of jaw pain to her internist. She also reported an “achy” temple to the nurse who saw her initially. The internist surmised that the cause of the pain might be an allergic reaction to dye used in a CT scan the patient had undergone because the patient said the pain had begun immediately after the scan. She was treated with methylprednisolone and the symptoms improved temporarily.

Within a few weeks, the patient complained of vision problems in her left eye. An ophthalmologist to whom she was referred thought the cause might be metastasis of the lung cancer. After an MRI of the optic area, a neuroradiologist reported to the ophthalmologist that the findings were consistent with metastatic cancer.

Before the patient could keep a follow-up appointment with the ophthalmologist, she lost all vision in her left eye. When she called the internist’s office for the results of the MRI, she told the person who answered the phone about the vision loss. Her call wasn’t returned.

The patient also told the ophthalmologist’s office about her loss of vision when she received a call to remind her of her follow-up appointment. The person she spoke to claimed the patient was offered an appointment that same day with another doctor, but declined it.

On the day before the follow-up appointment, the patient lost all sight in her right eye, as well. She received emergency treatment with corticosteroids the next day, but her vision didn’t return, leaving her completely blind. A temporal artery biopsy confirmed giant cell arteritis.

PLAINTIFF'S CLAIM The patient had classic symptoms of giant cell arteritis when she saw both the internist and ophthalmologist.

THE DEFENSE No negligence occurred because the patient had additional medical conditions; the patient didn’t describe her symptoms effectively and was negligent in failing to seek emergency medical care when she lost vision in her left eye.

VERDICT $1.4 million Washington settlement.

COMMENT This is a tough case with plenty of blame to go around, but it provides a good reminder to think of temporal arteritis whenever an older patient complains of jaw pain. Sedimentation rate measurements are cheap.

Lack of vigilance ends badly

SHORTNESS OF BREATH, FATIGUE, AND DIARRHEA prompted a 36-year-old man with diabetes and hypothyroidism to consult his primary care physician. The doctor prescribed levofloxacin and told the patient to return in 4 weeks.

Three days later, the man went back to the physician, reporting weakness, diarrhea, and a fever of 103°F. The physician diagnosed bronchitis and prescribed extended-release amoxicillin tablets. Two days later, the patient went to the emergency department; a chest radiograph showed advanced bilateral pneumonia. He died about 2 weeks later.

PLAINTIFF'S CLAIM The physician was negligent in failing to order a radiograph, admit the patient to the hospital, and prescribe proper medication.

THE DEFENSE No information about the defense is available.

VERDICT $1 million New Jersey settlement.

COMMENT Shortness of breath, fatigue, and diarrhea in a 36-year-old patient with diabetes sounds potentially serious to me. Presumably the physician diagnosed pneumonia on the initial exam, and one cannot fault him for that diagnosis or the treatment he prescribed. But return in 4 weeks? No way. Such patients require close follow-up and escalation of evaluation and treatment if they’re not doing well.

Delayed Dx leads to blindness

A WOMAN WITH DISABLING RHEUMATOID ARTHRITIS visited her long-time internist with pulmonary symptoms. Shortly thereafter the 59-year-old patient was diagnosed with lung cancer with a moderate prognosis and underwent surgery.

The following month, the woman complained of jaw pain to her internist. She also reported an “achy” temple to the nurse who saw her initially. The internist surmised that the cause of the pain might be an allergic reaction to dye used in a CT scan the patient had undergone because the patient said the pain had begun immediately after the scan. She was treated with methylprednisolone and the symptoms improved temporarily.

Within a few weeks, the patient complained of vision problems in her left eye. An ophthalmologist to whom she was referred thought the cause might be metastasis of the lung cancer. After an MRI of the optic area, a neuroradiologist reported to the ophthalmologist that the findings were consistent with metastatic cancer.

Before the patient could keep a follow-up appointment with the ophthalmologist, she lost all vision in her left eye. When she called the internist’s office for the results of the MRI, she told the person who answered the phone about the vision loss. Her call wasn’t returned.

The patient also told the ophthalmologist’s office about her loss of vision when she received a call to remind her of her follow-up appointment. The person she spoke to claimed the patient was offered an appointment that same day with another doctor, but declined it.

On the day before the follow-up appointment, the patient lost all sight in her right eye, as well. She received emergency treatment with corticosteroids the next day, but her vision didn’t return, leaving her completely blind. A temporal artery biopsy confirmed giant cell arteritis.

PLAINTIFF'S CLAIM The patient had classic symptoms of giant cell arteritis when she saw both the internist and ophthalmologist.

THE DEFENSE No negligence occurred because the patient had additional medical conditions; the patient didn’t describe her symptoms effectively and was negligent in failing to seek emergency medical care when she lost vision in her left eye.

VERDICT $1.4 million Washington settlement.

COMMENT This is a tough case with plenty of blame to go around, but it provides a good reminder to think of temporal arteritis whenever an older patient complains of jaw pain. Sedimentation rate measurements are cheap.

Lack of vigilance ends badly

SHORTNESS OF BREATH, FATIGUE, AND DIARRHEA prompted a 36-year-old man with diabetes and hypothyroidism to consult his primary care physician. The doctor prescribed levofloxacin and told the patient to return in 4 weeks.

Three days later, the man went back to the physician, reporting weakness, diarrhea, and a fever of 103°F. The physician diagnosed bronchitis and prescribed extended-release amoxicillin tablets. Two days later, the patient went to the emergency department; a chest radiograph showed advanced bilateral pneumonia. He died about 2 weeks later.

PLAINTIFF'S CLAIM The physician was negligent in failing to order a radiograph, admit the patient to the hospital, and prescribe proper medication.

THE DEFENSE No information about the defense is available.

VERDICT $1 million New Jersey settlement.

COMMENT Shortness of breath, fatigue, and diarrhea in a 36-year-old patient with diabetes sounds potentially serious to me. Presumably the physician diagnosed pneumonia on the initial exam, and one cannot fault him for that diagnosis or the treatment he prescribed. But return in 4 weeks? No way. Such patients require close follow-up and escalation of evaluation and treatment if they’re not doing well.

A woman in her 50s underwent hysterectomy performed by a surgeon, who then assigned an ObGyn to her follow-up care. The day after surgery, the patient had severe abdominal pain with decreased blood pressure and increased heart and respiration rates. The ObGyn admitted the patient to the intensive care unit (ICU), and then designated Dr. A, the patient’s family practitioner to continue her care. Dr. A was not available, so his associate, Dr. B, took over. Over the phone, Dr. B requested pulmonary, cardiology, and infectious disease consults. In the ICU the next day, the patient suffered respiratory arrest and was intubated. When her abdomen became rigid and swollen, emergency surgery revealed that a colon perforation had allowed fecal matter to reach the abdominal cavity. The woman died the next day from complications of sepsis, peritonitis, and multiple organ failure.

ESTATE’S CLAIM None of the physicians assigned to her care ever saw the patient in the ICU. Earlier surgery could have prevented her death. The physicians involved in her care failed to communicate with each other properly.

DEFENDANTS’ DEFENSE The case was settled during the trial.

VERDICT A $3.2 million Illinois settlement was reached with the hospital.

BOTH PARENTS HAD PLATELET ANTIBODIES
When a 32-year-old woman became pregnant with her third child, she sought treatment at a clinic. The mother informed the nurse practi-tioner that her two other children had been diagnosed with low platelets at birth, but they were now healthy and had no further problems.

The woman gave birth vaginally to her third child at term. The newborn had Apgar scores of 8 and 8, at 1 and 5 minutes, respectively. However, the child’s platelet level was 26 x 103/µL. The baby was transferred to another hospital the next day, where he was diagnosed with hydrocephalus and neonatal alloimmune thrombocytopenia. He suffered a massive intracranial hemorrhage, which caused severe neurologic injuries and brain damage. A shunt was placed. The child has significant cognitive deficits as well as cerebral palsy with mild developmental delays. Testing showed that each parent had a different genotype for platelet antibodies.

PARENTS’ CLAIM The parents should have been tested for platelet antibodies prior to this birth due to the family’s history. A prenatal diagnosis of neonatal alloimmune thrombocytopenia would have allowed for treatment with gamma globulin, which could have avoided the intracranial hemorrhage.

DEFENDANTS’ DEFENSE The case was settled during the trial.  

VERDICT A $4.8 million California settlement was reached.

CORD PROLAPSE NOT CARED FOR IN AMBULANCE
At 36 weeks’ gestation, a mother called an ambulance when her membranes ruptured and she noticed an umbilical cord prolapse.

The child was in a breech presentation, experienced oxygen deprivation, and sustained severe neurologic damage.

PARENTS’ CLAIM The ambulance service was negligent in its care. The ambulance service dispatcher advised the mother to stand, squat, and push before the ambulance arrived. The ambulance attendants failed to take basic actions to relieve pressure on the prolapsed umbilical cord. The ambulance did not stop at two closer hospitals, which delayed arrival for an additional 20 minutes.

DEFENDANTS’ DEFENSE The case was settled during the trial.

VERDICT A $2.7 million settlement was reached, but before it was submitted to the court for approval, the child died. The defendants then sought to revoke the settlement, but the parents claimed breach of contract. The defendants claimed that the agreement was orally negotiated independent of defense counsel and was unenforceable due to the child’s death and lack of court approval. A Texas judge issued summary judgment on breach of contract and awarded $2.7 million plus $40,000 in attorney fees to the parents.    

SECOND- AND THIRD-DEGREE BURNS TO PERINEUM
A mother received an epidural injection during vaginal delivery. Six hours later, the patient asked a nurse for a warm compress to place on her perineum. The nurse heated the compress in a microwave and then applied it to the perineal area. The compress caused second- and third-degree burns to the patient’s labia and inner left thigh. She underwent surgical repair of the burned area, and, a year later, had plastic surgery.

PATIENT’S CLAIM The nurse was negligent in overheating the compress.

DEFENDANTS’ DEFENSE The hospital agreed that the nurse who heated and applied the compress had been negligent. The hospital paid all medical expenses relating to the burns, including follow-up surgeries. 

VERDICT A $190,000 Utah verdict was returned for noneconomic damages.

DOCUMENTATION MAKES A DIFFERENCE FOR OBGYN AFTER CHILD DIES
A 30-year-old physician was pregnant with her first child. Due to a low amniotic fluid index and lagging fetal growth, she saw a maternal-fetal medicine specialist, who suggested labor induction at 39 weeks.

Labor progressed slowly. After three attempts at vacuum-assisted delivery, the ObGyn recommended cesarean delivery. The parents eventually consented to cesarean delivery after another failed vacuum-assisted attempt. Although the ObGyn had recommended cesarean 2 hours earlier, surgery was not ordered on an emergent basis.

At birth, the baby’s resuscitation took more than 20 minutes. The child lost nearly one-third of her blood volume; she had a subgaleal hemorrhage. Both parties agreed that the vacuum device probably caused the bleeding.

The child had hypoxic ischemic encephalopathy and disseminated intravascular coagulation. She suffered a myocardial infarction at 3 days of age. Without electrical brain activity, life support was removed, and the child died at 5 days of age. An autopsy found possible hypereosinophilic syndrome as the concurrent cause of death.

PARENTS’ CLAIM The mother claimed she was not informed of the risks, benefits, and alternatives to vacuum extraction; she would not have consented had she known the risks. The mother, her husband, and two family members maintained that the ObGyn offered the possibility of cesarean delivery as a question, but did not insist on it. The mother claimed she wanted what was best for the baby, and never refused a cesarean. The resuscitation efforts caused eosinophilic infiltration into several organs.

PHYSICIAN’S DEFENSE The ObGyn charted that the parents were “adamant about having a vaginal delivery,” and said she told the parents what she charted. The obstetric nurse testified that the mother delayed consent because she felt vaginal delivery was imminent. The ObGyn acted properly; eosinophilia caused the baby’s death.  

VERDICT An Illinois defense verdict was returned.

HIGH BP TO BLAME FOR DEATHS OF BOTH MOTHER AND CHILD
A 23-year-old woman’s pregnancy was at high risk because of very high blood pressure (BP). At 34 weeks’ gestation, she went to a county hospital with symptoms of high BP; she was treated and discharged 3 days later. She returned to the hospital to be checked twice more within a month. The day after the third visit, she suffered a seizure and was taken to a university hospital, where emergency cesarean delivery was performed. The mother died from an aortic rupture during delivery.

The child was born with brain injuries and died at age 4 years due to neurologic complications.

ESTATE’S CLAIM The mother was not properly treated at the county hospital, resulting in both deaths; she should not have been discharged. Under monitoring, she would have undergone delivery before the aortic rupture occurred, avoiding the baby’s brain injury.

DEFENDANTS’ DEFENSE The mother was stable when released; aortic rupture is unpredictable and unpreventable, and would have occurred under any circumstances. It is highly unusual that a woman of her age would have an aortic rupture.

VERDICT A $3,062,803 California verdict was returned. The parties then settled for $1,782,000 (with the county assuming the medical lien).

NECROTIZING FASCIITIS FROM PERFORATED COLON
A woman underwent laparoscopic-assisted vaginal hysterectomy performed by her ObGyn, and was discharged after 3 days. The next day, she went to another hospital’s emergency department (ED) with abdominal distention and rigidity, severe abdominal pain, and vomiting. She had a toxic appearance, rapid pulse rate, and hypotension. In emergency surgery, several liters of dark brown, foul-smelling fluid were found in her abdomen, and feculent peritonitis and necrotizing fasciitis were diagnosed due to a perforated sigmoid colon. She required multiple hospitalizations and operations.

PATIENT’S CLAIM Perforation occur­red during hysterectomy. The ObGyn failed to recognize the injury prior to discharge. The hospital staff did not properly assess her or communicate her symptoms to the ObGyn.

DEFENDANTS’ DEFENSE There was no negligence; proper care was given.

VERDICT A $2,922,503 Florida verdict was returned, with the jury finding the ObGyn 30% at fault and the hospital 70% at fault.

FAILURE TO REACT TO FETAL DISTRESS: $15.6M
After delivery at full term, a child suffered convulsions and seizures on her second day of life. A CT scan showed brain injuries. At age 11 years, she has severe learning and developmental delays, and requires 24-hour care.

PARENTS’ CLAIM Severe decelerations with slow return to baseline occurred several times during labor and delivery. The nurse midwife failed to recognize and react to fetal distress. A cesarean delivery should have been performed instead of a vaginal delivery. The delay in delivery caused the child’s injuries.

DEFENDANTS’ DEFENSE A prenatal neurogenetic disorder caused the child’s injuries. 

VERDICT A $15.6 million Maryland verdict was returned. It will not be automatically reduced; the awarded noneconomic damages do not exceed the state cap.

LATE DELIVERY; SEVERE INJURY TO CHILD
At 40 weeks’ gestation, a woman was admitted to the hospital in labor. When the mother’s membranes were ruptured, a small amount of meconium was noted, but the fetal monitor strips were reassuring. Two hours later, the nurse and midwife noted a pattern of decelerations, but they felt the pattern was nonrepetitive and reactive. Thirty minutes later, the nurse and midwife noted decelerations to 90 bpm with pushing, but did not call a physician.

Another midwife arrived to assist the first midwife who was new to practice. The mother was given oxygen, her position was changed, and an IV fluid bolus was administered. Thirty minutes later, the nurses recognized late decelerations and called a Code White twice while the fetal heart rate continued to decelerate. After the attending physician unsuccessfully attempted vacuum extraction, an emergency cesarean delivery was performed.

The child’s Apgar scores were 2, 3, and 3, at 1, 5, and 10 minutes, respectively. The cord blood pH was 6.66, indicating severe metabolic acidosis. She developed seizures within the first few minutes of life. Imaging studies showed global hypoxic ischemic encephalopathy. The child cannot walk, talk, or sit up unsupported at age 8, and requires a G-tube. She is cortically blind and requires antiseizure medication.

PARENTS’ CLAIM The nurse, two midwives, and physician were negligent in their care of the mother and child.

DEFENDANTS’ DEFENSE The case was settled during the trial.  

VERDICT A $5 million Massachusetts settlement was reached.

WHAT CAUSED INFECTION AFTER ABORTION?
A 20-year-old woman underwent a surgical termination of pregnancy performed by an ObGyn. After discharge, the patient developed pain and other complications requiring rehospitalization and additional surgery for a pelvic infection.

PATIENT’S CLAIM Complications were due to a uterine perforation that spontaneously sealed before it could be detected. The ObGyn was negligent in the performance of the elective abortion. The patient has a large scar on her abdomen because of the additional operation.

PHYSICIAN’S DEFENSE Perforation of the uterus is a known complication of the procedure. However, no perforation occurred; it was not found on imaging, and spontaneous sealing of a perforation cannot occur. The patient’s complications were due to a subclinical infection that was activated by the surgery.  

VERDICT A New York defense verdict was returned.

We want to hear from you. Tell us what you think!

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

A woman in her 50s underwent hysterectomy performed by a surgeon, who then assigned an ObGyn to her follow-up care. The day after surgery, the patient had severe abdominal pain with decreased blood pressure and increased heart and respiration rates. The ObGyn admitted the patient to the intensive care unit (ICU), and then designated Dr. A, the patient’s family practitioner to continue her care. Dr. A was not available, so his associate, Dr. B, took over. Over the phone, Dr. B requested pulmonary, cardiology, and infectious disease consults. In the ICU the next day, the patient suffered respiratory arrest and was intubated. When her abdomen became rigid and swollen, emergency surgery revealed that a colon perforation had allowed fecal matter to reach the abdominal cavity. The woman died the next day from complications of sepsis, peritonitis, and multiple organ failure.

ESTATE’S CLAIM None of the physicians assigned to her care ever saw the patient in the ICU. Earlier surgery could have prevented her death. The physicians involved in her care failed to communicate with each other properly.

DEFENDANTS’ DEFENSE The case was settled during the trial.

VERDICT A $3.2 million Illinois settlement was reached with the hospital.

BOTH PARENTS HAD PLATELET ANTIBODIES
When a 32-year-old woman became pregnant with her third child, she sought treatment at a clinic. The mother informed the nurse practi-tioner that her two other children had been diagnosed with low platelets at birth, but they were now healthy and had no further problems.

The woman gave birth vaginally to her third child at term. The newborn had Apgar scores of 8 and 8, at 1 and 5 minutes, respectively. However, the child’s platelet level was 26 x 103/µL. The baby was transferred to another hospital the next day, where he was diagnosed with hydrocephalus and neonatal alloimmune thrombocytopenia. He suffered a massive intracranial hemorrhage, which caused severe neurologic injuries and brain damage. A shunt was placed. The child has significant cognitive deficits as well as cerebral palsy with mild developmental delays. Testing showed that each parent had a different genotype for platelet antibodies.

PARENTS’ CLAIM The parents should have been tested for platelet antibodies prior to this birth due to the family’s history. A prenatal diagnosis of neonatal alloimmune thrombocytopenia would have allowed for treatment with gamma globulin, which could have avoided the intracranial hemorrhage.

DEFENDANTS’ DEFENSE The case was settled during the trial.  

VERDICT A $4.8 million California settlement was reached.

CORD PROLAPSE NOT CARED FOR IN AMBULANCE
At 36 weeks’ gestation, a mother called an ambulance when her membranes ruptured and she noticed an umbilical cord prolapse.

The child was in a breech presentation, experienced oxygen deprivation, and sustained severe neurologic damage.

PARENTS’ CLAIM The ambulance service was negligent in its care. The ambulance service dispatcher advised the mother to stand, squat, and push before the ambulance arrived. The ambulance attendants failed to take basic actions to relieve pressure on the prolapsed umbilical cord. The ambulance did not stop at two closer hospitals, which delayed arrival for an additional 20 minutes.

DEFENDANTS’ DEFENSE The case was settled during the trial.

VERDICT A $2.7 million settlement was reached, but before it was submitted to the court for approval, the child died. The defendants then sought to revoke the settlement, but the parents claimed breach of contract. The defendants claimed that the agreement was orally negotiated independent of defense counsel and was unenforceable due to the child’s death and lack of court approval. A Texas judge issued summary judgment on breach of contract and awarded $2.7 million plus $40,000 in attorney fees to the parents.    

SECOND- AND THIRD-DEGREE BURNS TO PERINEUM
A mother received an epidural injection during vaginal delivery. Six hours later, the patient asked a nurse for a warm compress to place on her perineum. The nurse heated the compress in a microwave and then applied it to the perineal area. The compress caused second- and third-degree burns to the patient’s labia and inner left thigh. She underwent surgical repair of the burned area, and, a year later, had plastic surgery.

PATIENT’S CLAIM The nurse was negligent in overheating the compress.

DEFENDANTS’ DEFENSE The hospital agreed that the nurse who heated and applied the compress had been negligent. The hospital paid all medical expenses relating to the burns, including follow-up surgeries. 

VERDICT A $190,000 Utah verdict was returned for noneconomic damages.

DOCUMENTATION MAKES A DIFFERENCE FOR OBGYN AFTER CHILD DIES
A 30-year-old physician was pregnant with her first child. Due to a low amniotic fluid index and lagging fetal growth, she saw a maternal-fetal medicine specialist, who suggested labor induction at 39 weeks.

Labor progressed slowly. After three attempts at vacuum-assisted delivery, the ObGyn recommended cesarean delivery. The parents eventually consented to cesarean delivery after another failed vacuum-assisted attempt. Although the ObGyn had recommended cesarean 2 hours earlier, surgery was not ordered on an emergent basis.

At birth, the baby’s resuscitation took more than 20 minutes. The child lost nearly one-third of her blood volume; she had a subgaleal hemorrhage. Both parties agreed that the vacuum device probably caused the bleeding.

The child had hypoxic ischemic encephalopathy and disseminated intravascular coagulation. She suffered a myocardial infarction at 3 days of age. Without electrical brain activity, life support was removed, and the child died at 5 days of age. An autopsy found possible hypereosinophilic syndrome as the concurrent cause of death.

PARENTS’ CLAIM The mother claimed she was not informed of the risks, benefits, and alternatives to vacuum extraction; she would not have consented had she known the risks. The mother, her husband, and two family members maintained that the ObGyn offered the possibility of cesarean delivery as a question, but did not insist on it. The mother claimed she wanted what was best for the baby, and never refused a cesarean. The resuscitation efforts caused eosinophilic infiltration into several organs.

PHYSICIAN’S DEFENSE The ObGyn charted that the parents were “adamant about having a vaginal delivery,” and said she told the parents what she charted. The obstetric nurse testified that the mother delayed consent because she felt vaginal delivery was imminent. The ObGyn acted properly; eosinophilia caused the baby’s death.  

VERDICT An Illinois defense verdict was returned.

HIGH BP TO BLAME FOR DEATHS OF BOTH MOTHER AND CHILD
A 23-year-old woman’s pregnancy was at high risk because of very high blood pressure (BP). At 34 weeks’ gestation, she went to a county hospital with symptoms of high BP; she was treated and discharged 3 days later. She returned to the hospital to be checked twice more within a month. The day after the third visit, she suffered a seizure and was taken to a university hospital, where emergency cesarean delivery was performed. The mother died from an aortic rupture during delivery.

The child was born with brain injuries and died at age 4 years due to neurologic complications.

ESTATE’S CLAIM The mother was not properly treated at the county hospital, resulting in both deaths; she should not have been discharged. Under monitoring, she would have undergone delivery before the aortic rupture occurred, avoiding the baby’s brain injury.

DEFENDANTS’ DEFENSE The mother was stable when released; aortic rupture is unpredictable and unpreventable, and would have occurred under any circumstances. It is highly unusual that a woman of her age would have an aortic rupture.

VERDICT A $3,062,803 California verdict was returned. The parties then settled for $1,782,000 (with the county assuming the medical lien).

NECROTIZING FASCIITIS FROM PERFORATED COLON
A woman underwent laparoscopic-assisted vaginal hysterectomy performed by her ObGyn, and was discharged after 3 days. The next day, she went to another hospital’s emergency department (ED) with abdominal distention and rigidity, severe abdominal pain, and vomiting. She had a toxic appearance, rapid pulse rate, and hypotension. In emergency surgery, several liters of dark brown, foul-smelling fluid were found in her abdomen, and feculent peritonitis and necrotizing fasciitis were diagnosed due to a perforated sigmoid colon. She required multiple hospitalizations and operations.

PATIENT’S CLAIM Perforation occur­red during hysterectomy. The ObGyn failed to recognize the injury prior to discharge. The hospital staff did not properly assess her or communicate her symptoms to the ObGyn.

DEFENDANTS’ DEFENSE There was no negligence; proper care was given.

VERDICT A $2,922,503 Florida verdict was returned, with the jury finding the ObGyn 30% at fault and the hospital 70% at fault.

FAILURE TO REACT TO FETAL DISTRESS: $15.6M
After delivery at full term, a child suffered convulsions and seizures on her second day of life. A CT scan showed brain injuries. At age 11 years, she has severe learning and developmental delays, and requires 24-hour care.

PARENTS’ CLAIM Severe decelerations with slow return to baseline occurred several times during labor and delivery. The nurse midwife failed to recognize and react to fetal distress. A cesarean delivery should have been performed instead of a vaginal delivery. The delay in delivery caused the child’s injuries.

DEFENDANTS’ DEFENSE A prenatal neurogenetic disorder caused the child’s injuries. 

VERDICT A $15.6 million Maryland verdict was returned. It will not be automatically reduced; the awarded noneconomic damages do not exceed the state cap.

LATE DELIVERY; SEVERE INJURY TO CHILD
At 40 weeks’ gestation, a woman was admitted to the hospital in labor. When the mother’s membranes were ruptured, a small amount of meconium was noted, but the fetal monitor strips were reassuring. Two hours later, the nurse and midwife noted a pattern of decelerations, but they felt the pattern was nonrepetitive and reactive. Thirty minutes later, the nurse and midwife noted decelerations to 90 bpm with pushing, but did not call a physician.

Another midwife arrived to assist the first midwife who was new to practice. The mother was given oxygen, her position was changed, and an IV fluid bolus was administered. Thirty minutes later, the nurses recognized late decelerations and called a Code White twice while the fetal heart rate continued to decelerate. After the attending physician unsuccessfully attempted vacuum extraction, an emergency cesarean delivery was performed.

The child’s Apgar scores were 2, 3, and 3, at 1, 5, and 10 minutes, respectively. The cord blood pH was 6.66, indicating severe metabolic acidosis. She developed seizures within the first few minutes of life. Imaging studies showed global hypoxic ischemic encephalopathy. The child cannot walk, talk, or sit up unsupported at age 8, and requires a G-tube. She is cortically blind and requires antiseizure medication.

PARENTS’ CLAIM The nurse, two midwives, and physician were negligent in their care of the mother and child.

DEFENDANTS’ DEFENSE The case was settled during the trial.  

VERDICT A $5 million Massachusetts settlement was reached.

WHAT CAUSED INFECTION AFTER ABORTION?
A 20-year-old woman underwent a surgical termination of pregnancy performed by an ObGyn. After discharge, the patient developed pain and other complications requiring rehospitalization and additional surgery for a pelvic infection.

PATIENT’S CLAIM Complications were due to a uterine perforation that spontaneously sealed before it could be detected. The ObGyn was negligent in the performance of the elective abortion. The patient has a large scar on her abdomen because of the additional operation.

PHYSICIAN’S DEFENSE Perforation of the uterus is a known complication of the procedure. However, no perforation occurred; it was not found on imaging, and spontaneous sealing of a perforation cannot occur. The patient’s complications were due to a subclinical infection that was activated by the surgery.  

VERDICT A New York defense verdict was returned.

We want to hear from you. Tell us what you think!

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

A woman in her 50s underwent hysterectomy performed by a surgeon, who then assigned an ObGyn to her follow-up care. The day after surgery, the patient had severe abdominal pain with decreased blood pressure and increased heart and respiration rates. The ObGyn admitted the patient to the intensive care unit (ICU), and then designated Dr. A, the patient’s family practitioner to continue her care. Dr. A was not available, so his associate, Dr. B, took over. Over the phone, Dr. B requested pulmonary, cardiology, and infectious disease consults. In the ICU the next day, the patient suffered respiratory arrest and was intubated. When her abdomen became rigid and swollen, emergency surgery revealed that a colon perforation had allowed fecal matter to reach the abdominal cavity. The woman died the next day from complications of sepsis, peritonitis, and multiple organ failure.

ESTATE’S CLAIM None of the physicians assigned to her care ever saw the patient in the ICU. Earlier surgery could have prevented her death. The physicians involved in her care failed to communicate with each other properly.

DEFENDANTS’ DEFENSE The case was settled during the trial.

VERDICT A $3.2 million Illinois settlement was reached with the hospital.

BOTH PARENTS HAD PLATELET ANTIBODIES
When a 32-year-old woman became pregnant with her third child, she sought treatment at a clinic. The mother informed the nurse practi-tioner that her two other children had been diagnosed with low platelets at birth, but they were now healthy and had no further problems.

The woman gave birth vaginally to her third child at term. The newborn had Apgar scores of 8 and 8, at 1 and 5 minutes, respectively. However, the child’s platelet level was 26 x 103/µL. The baby was transferred to another hospital the next day, where he was diagnosed with hydrocephalus and neonatal alloimmune thrombocytopenia. He suffered a massive intracranial hemorrhage, which caused severe neurologic injuries and brain damage. A shunt was placed. The child has significant cognitive deficits as well as cerebral palsy with mild developmental delays. Testing showed that each parent had a different genotype for platelet antibodies.

PARENTS’ CLAIM The parents should have been tested for platelet antibodies prior to this birth due to the family’s history. A prenatal diagnosis of neonatal alloimmune thrombocytopenia would have allowed for treatment with gamma globulin, which could have avoided the intracranial hemorrhage.

DEFENDANTS’ DEFENSE The case was settled during the trial.  

VERDICT A $4.8 million California settlement was reached.

CORD PROLAPSE NOT CARED FOR IN AMBULANCE
At 36 weeks’ gestation, a mother called an ambulance when her membranes ruptured and she noticed an umbilical cord prolapse.

The child was in a breech presentation, experienced oxygen deprivation, and sustained severe neurologic damage.

PARENTS’ CLAIM The ambulance service was negligent in its care. The ambulance service dispatcher advised the mother to stand, squat, and push before the ambulance arrived. The ambulance attendants failed to take basic actions to relieve pressure on the prolapsed umbilical cord. The ambulance did not stop at two closer hospitals, which delayed arrival for an additional 20 minutes.

DEFENDANTS’ DEFENSE The case was settled during the trial.

VERDICT A $2.7 million settlement was reached, but before it was submitted to the court for approval, the child died. The defendants then sought to revoke the settlement, but the parents claimed breach of contract. The defendants claimed that the agreement was orally negotiated independent of defense counsel and was unenforceable due to the child’s death and lack of court approval. A Texas judge issued summary judgment on breach of contract and awarded $2.7 million plus $40,000 in attorney fees to the parents.    

SECOND- AND THIRD-DEGREE BURNS TO PERINEUM
A mother received an epidural injection during vaginal delivery. Six hours later, the patient asked a nurse for a warm compress to place on her perineum. The nurse heated the compress in a microwave and then applied it to the perineal area. The compress caused second- and third-degree burns to the patient’s labia and inner left thigh. She underwent surgical repair of the burned area, and, a year later, had plastic surgery.

PATIENT’S CLAIM The nurse was negligent in overheating the compress.

DEFENDANTS’ DEFENSE The hospital agreed that the nurse who heated and applied the compress had been negligent. The hospital paid all medical expenses relating to the burns, including follow-up surgeries. 

VERDICT A $190,000 Utah verdict was returned for noneconomic damages.

DOCUMENTATION MAKES A DIFFERENCE FOR OBGYN AFTER CHILD DIES
A 30-year-old physician was pregnant with her first child. Due to a low amniotic fluid index and lagging fetal growth, she saw a maternal-fetal medicine specialist, who suggested labor induction at 39 weeks.

Labor progressed slowly. After three attempts at vacuum-assisted delivery, the ObGyn recommended cesarean delivery. The parents eventually consented to cesarean delivery after another failed vacuum-assisted attempt. Although the ObGyn had recommended cesarean 2 hours earlier, surgery was not ordered on an emergent basis.

At birth, the baby’s resuscitation took more than 20 minutes. The child lost nearly one-third of her blood volume; she had a subgaleal hemorrhage. Both parties agreed that the vacuum device probably caused the bleeding.

The child had hypoxic ischemic encephalopathy and disseminated intravascular coagulation. She suffered a myocardial infarction at 3 days of age. Without electrical brain activity, life support was removed, and the child died at 5 days of age. An autopsy found possible hypereosinophilic syndrome as the concurrent cause of death.

PARENTS’ CLAIM The mother claimed she was not informed of the risks, benefits, and alternatives to vacuum extraction; she would not have consented had she known the risks. The mother, her husband, and two family members maintained that the ObGyn offered the possibility of cesarean delivery as a question, but did not insist on it. The mother claimed she wanted what was best for the baby, and never refused a cesarean. The resuscitation efforts caused eosinophilic infiltration into several organs.

PHYSICIAN’S DEFENSE The ObGyn charted that the parents were “adamant about having a vaginal delivery,” and said she told the parents what she charted. The obstetric nurse testified that the mother delayed consent because she felt vaginal delivery was imminent. The ObGyn acted properly; eosinophilia caused the baby’s death.  

VERDICT An Illinois defense verdict was returned.

HIGH BP TO BLAME FOR DEATHS OF BOTH MOTHER AND CHILD
A 23-year-old woman’s pregnancy was at high risk because of very high blood pressure (BP). At 34 weeks’ gestation, she went to a county hospital with symptoms of high BP; she was treated and discharged 3 days later. She returned to the hospital to be checked twice more within a month. The day after the third visit, she suffered a seizure and was taken to a university hospital, where emergency cesarean delivery was performed. The mother died from an aortic rupture during delivery.

The child was born with brain injuries and died at age 4 years due to neurologic complications.

ESTATE’S CLAIM The mother was not properly treated at the county hospital, resulting in both deaths; she should not have been discharged. Under monitoring, she would have undergone delivery before the aortic rupture occurred, avoiding the baby’s brain injury.

DEFENDANTS’ DEFENSE The mother was stable when released; aortic rupture is unpredictable and unpreventable, and would have occurred under any circumstances. It is highly unusual that a woman of her age would have an aortic rupture.

VERDICT A $3,062,803 California verdict was returned. The parties then settled for $1,782,000 (with the county assuming the medical lien).

NECROTIZING FASCIITIS FROM PERFORATED COLON
A woman underwent laparoscopic-assisted vaginal hysterectomy performed by her ObGyn, and was discharged after 3 days. The next day, she went to another hospital’s emergency department (ED) with abdominal distention and rigidity, severe abdominal pain, and vomiting. She had a toxic appearance, rapid pulse rate, and hypotension. In emergency surgery, several liters of dark brown, foul-smelling fluid were found in her abdomen, and feculent peritonitis and necrotizing fasciitis were diagnosed due to a perforated sigmoid colon. She required multiple hospitalizations and operations.

PATIENT’S CLAIM Perforation occur­red during hysterectomy. The ObGyn failed to recognize the injury prior to discharge. The hospital staff did not properly assess her or communicate her symptoms to the ObGyn.

DEFENDANTS’ DEFENSE There was no negligence; proper care was given.

VERDICT A $2,922,503 Florida verdict was returned, with the jury finding the ObGyn 30% at fault and the hospital 70% at fault.

FAILURE TO REACT TO FETAL DISTRESS: $15.6M
After delivery at full term, a child suffered convulsions and seizures on her second day of life. A CT scan showed brain injuries. At age 11 years, she has severe learning and developmental delays, and requires 24-hour care.

PARENTS’ CLAIM Severe decelerations with slow return to baseline occurred several times during labor and delivery. The nurse midwife failed to recognize and react to fetal distress. A cesarean delivery should have been performed instead of a vaginal delivery. The delay in delivery caused the child’s injuries.

DEFENDANTS’ DEFENSE A prenatal neurogenetic disorder caused the child’s injuries. 

VERDICT A $15.6 million Maryland verdict was returned. It will not be automatically reduced; the awarded noneconomic damages do not exceed the state cap.

LATE DELIVERY; SEVERE INJURY TO CHILD
At 40 weeks’ gestation, a woman was admitted to the hospital in labor. When the mother’s membranes were ruptured, a small amount of meconium was noted, but the fetal monitor strips were reassuring. Two hours later, the nurse and midwife noted a pattern of decelerations, but they felt the pattern was nonrepetitive and reactive. Thirty minutes later, the nurse and midwife noted decelerations to 90 bpm with pushing, but did not call a physician.

Another midwife arrived to assist the first midwife who was new to practice. The mother was given oxygen, her position was changed, and an IV fluid bolus was administered. Thirty minutes later, the nurses recognized late decelerations and called a Code White twice while the fetal heart rate continued to decelerate. After the attending physician unsuccessfully attempted vacuum extraction, an emergency cesarean delivery was performed.

The child’s Apgar scores were 2, 3, and 3, at 1, 5, and 10 minutes, respectively. The cord blood pH was 6.66, indicating severe metabolic acidosis. She developed seizures within the first few minutes of life. Imaging studies showed global hypoxic ischemic encephalopathy. The child cannot walk, talk, or sit up unsupported at age 8, and requires a G-tube. She is cortically blind and requires antiseizure medication.

PARENTS’ CLAIM The nurse, two midwives, and physician were negligent in their care of the mother and child.

DEFENDANTS’ DEFENSE The case was settled during the trial.  

VERDICT A $5 million Massachusetts settlement was reached.

WHAT CAUSED INFECTION AFTER ABORTION?
A 20-year-old woman underwent a surgical termination of pregnancy performed by an ObGyn. After discharge, the patient developed pain and other complications requiring rehospitalization and additional surgery for a pelvic infection.

PATIENT’S CLAIM Complications were due to a uterine perforation that spontaneously sealed before it could be detected. The ObGyn was negligent in the performance of the elective abortion. The patient has a large scar on her abdomen because of the additional operation.

PHYSICIAN’S DEFENSE Perforation of the uterus is a known complication of the procedure. However, no perforation occurred; it was not found on imaging, and spontaneous sealing of a perforation cannot occur. The patient’s complications were due to a subclinical infection that was activated by the surgery.  

VERDICT A New York defense verdict was returned.

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These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.