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The importance of being earnest

01 August 2005

Mrs G, a 35-year-old shop manager, was about seven weeks pregnant. She became unwell one evening, suffering severe pain in her lower right abdomen. She got up to go to the toilet and fainted.

She developed shooting pains over her right shoulder; her husband phoned for a doctor. Dr P, the on-call GP, visited her at home, at about five in the morning. He recorded her history and noted moderate tenderness over the lower abdomen without any definite rebound tenderness.

Dr P suspected a diagnosis of ectopic pregnancy and documented this fact. He telephoned the on-call gynaecology registrar at his local hospital. Dr P was advised to send Mrs G to the gynaecology ward at nine o’clock that morning.

Mrs G duly attended the ward and was extremely ill by the time she arrived. A ruptured ectopic pregnancy was diagnosed and she was taken urgently to theatre, undergoing a laparotomy at 10.30 am. Mrs G needed a right salpingo-oophorectomy to control her blood loss, estimated at 3 litres. In the immediate postoperative period Mrs G was cared for on the intensive care unit, after developing pulmonary oedema, possibly due to infusion of an excessive volume of intravenous fluid and blood.

Mrs G also suffered a transient coagulopathy, as a consequence of her blood loss and transfusion. She was transferred to the gynaecology ward on the second postoperative day and began to mobilise. Once there, she was given TED stockings and low-molecular-weight heparin as prophylaxis against deep venous thrombosis (DVT).Two weeks after her original admission, she was discharged home fit and well.

Unfortunately she was readmitted to the hospital a week later with a painful, swollen leg which proved to be due to a DVT. Mrs G was treated with heparin then warfarin. She had some problems with post-thrombotic syndrome, but eventually made a good recovery.

Mrs G started a legal claim against Dr P, alleging that his failure to admit her to hospital when he first assessed her had caused a long-term reduction in her fertility, and caused her to suffer a DVT. The hospital was also named as a defendant for not immediately arranging Mrs G’s admission after Dr P’s call and for delaying the start of DVT prophylaxis.

Expert opinion

A GP expert thought that Dr P should have arranged Mrs G’s immediate admission to hospital once the diagnosis of ectopic pregnancy was suspected, commenting that ‘he took an unjustifiable risk in electing to allow her to remain at home for a further three hours or so’.

It was noted that Mrs G was probably not showing signs of shock at this time, but there was no documentation of haemodynamic parameters in the notes. The presence of shoulder tip pain was thought to indicate active intraperitoneal haemorrhage and should have acted as a warning sign to both doctors to expedite Mrs G’s admission.

A gynaecology expert noted that it was impossible to know the substance of the discussion between Dr P and the registrar as this was not recorded, but felt that the registrar’s advice could not be supported. He noted that ‘a gynaecology registrar should have realised that a ruptured ectopic pregnancy is one of the few life-threatening conditions likely to come their way and demands immediate admission to hospital for assessment; some will need urgent surgery but only in the safe context of a hospital assessment can that decision be made.’

As to the link between the delay in Mrs G’s admission and any increased propensity to DVT, there was some expert haematological opinion to support the view that Mrs G’s progression to an in extremis state had had this effect.

Whilst it was felt that heparin prophylaxis was started at the correct time, given the haemorrhage and coagulopathy, it could be argued that TED stockings should have been used on the intensive care unit. Another fact to consider was that earlier admission and surgery could have reduced haemorrhage and prevented the coagulopathy, allowing earlier initiation of heparin prophylaxis.

The case was eventually settled for a sum equivalent to £250,000 plus costs, with 75% liability attributed to Dr P and the remainder to the hospital. 

Learning points

‘Dangerous’ diagnoses – There are certain conditions – and ectopic pregnancy is one of them – that demand urgent action when the merest suspicion of them crosses a doctor’s mind. We often see claims where a doctor has correctly suspected such a diagnosis, recorded the fact, but then not acted on the possibility.

Other diagnoses that often cause problems in this vein include:

  • myocardial infarction
  • pulmonary embolus
  • subarachnoid haemorrhage
  • appendicitis
  • limb ischaemia
  • intestinal obstruction or perforation
  • meningitis
  • aneurysms
  • acute psychosis/mania

If you suspect a potentially life-threatening diagnosis in a primary care setting, then act as if the diagnosis were certain and send the patient rapidly to their nearest secondary care centre. You may well get it wrong and appear to be overcautious, but this is a call it’s often impossible to make without the benefit of investigations and close observation.

Responsibilities – The GP’s failing in this case was to assume that he had relinquished his responsibility by allowing the gynaecology registrar’s assessment to prevail. Had he stressed that there were strong grounds for suspecting an ectopic pregnancy and insisted that his patient be seen immediately, the outcome may have been very different. Until the gynaecology registrar had an opportunity to examine the patient, he was not in a position to discount the GP’s concerns.