David M. Lang discusses the importance of ruling out pregnancy in women of childbearing age who present with abdominal pain—even when the patient insists she cannot possibly be pregnant.
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
Ectopic Pregnancy Detected Too Late for Medical Intervention
A Michigan woman, age 37, presented to a family medical center complaining of lower abdominal pain, gas, constipation, and occasional diarrhea of one month’s duration; she was menstruating at the time of this visit. The woman was evaluated by a physician assistant, who noted no pain on palpation. The PA made a diagnosis of irritable bowel syndrome.
Six days later, the plaintiff went to a hospital-based urgent care clinic with complaints of fatigue and nausea after meals for the previous 10 days. She was diagnosed with acute gastroenteritis and prescribed anti-nausea medication.
Four days later, the plaintiff went to an emergency department complaining of intermittent abdominal pain for the previous two weeks and irregular vaginal bleeding. When a urinary pregnancy test was returned with positive results, ultrasound was performed, revealing an ectopic pregnancy. Emergent surgery was performed, during which the patient’s right fallopian tube was removed.
The plaintiff claimed that a pregnancy test should have been performed at her earlier visits. The plaintiff claimed that any woman of childbearing age with abdominal complaints should be tested for pregnancy. A positive pregnancy test, the patient argued, would have led to an earlier diagnosis of her ectopic pregnancy, allowing her to be treated with methotrexate rather than surgery.
The defendants argued that the plaintiff’s complaints were nonspecific and that the diagnoses made were reasonable. The defendants also argued that the plaintiff would have chosen surgery as a treatment even if she had been given the option of medical intervention.
According to a published account, a defense verdict was returned, and the defendants were awarded costs of $21,716.
This case illustrates the need to obtain a pregnancy test in all cases of abdominal or pelvic pain in women of childbearing age, as well as severe lower back pain or flank pain—even with apparently noncontributory symptoms. Establishing pregnancy status is often required before radiographic or pharmaceutical intervention as well.
It may be tempting to forego a formal pregnancy test when a patient states that she is taking birth control, has not engaged in sexual activity, or is menstruating—as was the case here. Don’t risk the disastrous consequences of a missed, ruptured ectopic pregnancy, or of a possible teratogenic therapeutic intervention by failing to obtain a pregnancy test. As in this case, the plaintiff, her attorney, and her expert will allege that the standard of care requires a determination of pregnancy status.
It could become a thorny issue, should a patient refuse a pregnancy test and insist that the clinician accept as fact her representation that she is not pregnant. In such cases, it is vital to respect the patient’s right to self-determination by validating your recognition that she is ultimately in charge of her body and her health care—while at the same time informing her that the standard of care requires conclusive objective proof that a similarly situated patient is not pregnant in order to proceed safely.
If this has been tactfully and thoughtfully explained but the patient insists on refusing the test, document her refusal with a witness present. Explain all the risks of refusal in clear terms (eg, missed ectopic pregnancy: loss of future fertility, internal bleeding, death) and document that the patient understands—again, with a witness.
In a woman of childbearing age who needs a medication with potential teratogenic effects but refuses the indicated pregnancy test, try to identify a second, safer choice—provided such an option is reasonable. —DML