Misdiagnosed Ectopic Pregnancy – Another Example of Cognitive Bias?

by pregnancy journalist

Misdiagnosed Ectopic Pregnancy – Another Example of Cognitive Bias?

Posted byBill Kanich, MD on Dec 28, 2017 1:15:00 PM

A 39-year-old woman presented to the ED with a complaint of vaginal bleeding. She stated that she was 4-6 weeks pregnant and had been spotting on and off for the past two weeks without pain. She did not have an obstetrician yet. She was triaged as 3-Urgent. Her admission vital signs were: T 98.9; BP 116/57; HR 84; R 14; SaO2 of 99% on room air. Her urine pregnancy test was positive and her quantitative hCG was 7194 mIU/mL. The transvaginal ultrasound revealed “an enlarged extensively leiomyomatous uterus without evident intrauterine or ectopic pregnancy identified.” The radiologist’s impression was, “Bleeding vaginal; spontaneous abortion a possibility, other etiologies not excluded.” The ED physician reviewed the patient’s prior medical records and discussed the results from the visit with the consultant OB. The ED physician wrote he did not suspect ectopic pregnancy, but thought that the patient had likely had a spontaneous abortion. The ED physician discharged the patient in “stable” condition with instructions for threatened miscarriage and a follow-up appointment with the on-call OB the next day.

The patient didn’t make her scheduled OB appointment. Instead, three days later, she returned to the ED with severe cramping pain and still spotting blood; T 99F; BP 139/77; HR 90; R 19. Her hCG had risen to 10,953. She was seen by a different ED physician who reviewed the notes from the previous ED visit and diagnosed a spontaneous abortion. The patient was given morphine and discharged on Percocet. The second ED physician did not perform a pelvic examination, nor did he order a repeat transvaginal ultrasound. The patient’s vital signs were not documented at discharge.

Two weeks later the patient underwent a laparoscopic right salpingectomy due to a right tubal ectopic pregnancy.

Allegations: The plaintiff alleged the second ED physician misdiagnosed an ectopic pregnancy, resulting in the loss of a tube and lowering her chance of a future pregnancy. The plaintiff also named the hospital alleging that the nursing staff fell below the applicable standard of care by not checking and recording vital signs at the conclusion of the second ED visit.

To read the patient safety commentary and more on this case study please click below. 

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