Mrs B had one child and had been trying for a few years for another. She recently had a positive pregnancy test and was now about seven weeks pregnant. She suffered an abrupt onset of lower-abdominal pain one evening and telephoned the out-of-hours on-call service used by her GP practice.
She spoke to Dr M and the conversation was recorded. Mrs B made it clear that she felt very unwell and had severe lower-abdominal pain radiating down her left leg. She said she felt hot and dizzy.
Dr M thought that she was suffering from pain due to stretching of pelvic structures in early pregnancy, and sciatica unconnected to the pregnancy. He did not advise that she be visited or attend for assessment, recommending the use of a hot-water bottle and paracetamol.
The next day Mrs B asked her usual doctor, Dr N, to visit her. He noted that she was pregnant and had previously used an IUCD. Dr N saw Mrs B at lunchtime. He made the following notes: ‘Lower abdo pain, backache, frequency, shivering attacks, tender bladder, no bleeding, 6/52 pregnant, diagnosis UTI, amoxicillin 250mg tds.’ Dr N later reported that he had checked for signs of peritonism but hadn’t record this fact.
Mrs B’s husband and Dr N had differing recollections of the consultation, with Mr B saying that his wife had squealed in pain when her abdomen was palpated.
He stated that Dr N had appeared not to appreciate how much pain Mrs B was in, and had ignored the fact that she had been too dizzy and in too much pain to get to the toilet, such that she had wet herself. Mr B said that they had told Dr N that she had collapsed on occasions when she’d tried to walk.
Unfortunately Mrs B collapsed at midnight and, despite the efforts of an ambulance crew, could not be resuscitated. She was pronounced dead on arrival at her local hospital. A post-mortem revealed the cause of death as intra-abdominal haemorrhage due to a ruptured ectopic pregnancy in the left fallopian tube.
We sought expert GP advice. There was some sympathy for Dr N, in that the urinary symptoms described may have made UTI seem a reasonable diagnosis. However, his failure to record a temperature or perform urinalysis or urine culture was seen as poor practice.
Similarly, there was criticism of Dr N’s failure to record a BP or pulse in a dizzy patient.
The severity of Mrs B’s symptoms were felt to be inconsistent with a simple UTI; ‘Severe lower abdominal pain in association with rigors, vomiting and urinary incontinence are not features of a simple UTI in a young woman and suggest a more serious condition,’ commented one expert.
It was felt that the possibility of ectopic pregnancy was not given enough thought, and that if the urinary tract was suspected as the source of the symptoms, then pyelonephritis was more likely, and admission should have been considered. Dr M was criticised for not assessing Mrs B in person.
The case was settled for a significant amount, with liability shared equally between the two doctors.
- Ectopic pregnancy - this can be a difficult diagnosis to make – it has been described as like trying to spot a black cat in the dark. Where a patient is known to be in the early stages of pregnancy, or is of child-bearing age, and describes abdominal or pelvic pain, it must be considered high on the list of possible diagnoses. An absence of PV bleeding does not exclude ectopic pregnancy. One expert commented, ‘Of more concern is Dr N’s statement that “I was told that Mrs B had difficulty walking to the toilet but that this seemed to be because of pain rather than dizziness”. This would suggest a significant degree of pain, which would be compatible with peritonitis from a ruptured ectopic and could be compatible with significant pyelonephritis. There could be grounds for consideration of admission in the latter case and it would be mandatory in the former.’
- Telephone consultation - when carrying out a telephone consultation, put yourself in a position to make a sound clinical judgment before offering advice. If you are unable to do this, you should arrange for the patient to be seen.
This case also features in UK Casebook 2004 (1), February, in The acute abdomen.