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Misdiagnosed Ectopic Pregnancy – Another Example of Cognitive Bias?

December 20, 2017

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The Case:

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.

Commentary

It appears the second ED physician relied upon the diagnosis of spontaneous abortion from the patient’s first ED visit, despite a rising hCG. The literature describes the classic triad of abdominal pain, amenorrhea, and irregular vaginal bleeding occurring in only roughly half of ectopic pregnancy cases. Early ectopic pregnancies mimic other abdominal/gynecologic problems and they are frequently misdiagnosed as spontaneous abortions. The absence of an intrauterine pregnancy on ultrasound in a symptomatic woman should be considered an ectopic pregnancy until proven otherwise.[1]

Experts who reviewed the case believed the second ED physician breached the standard of care when he did not admit the patient to the hospital given her worsening symptoms and rising hCG. The ED physician’s documentation was incomplete in that he did not mention threatened or completed abortion. It is always important to “write what you are thinking.” It was also unclear to the expert reviewers whether the physician attempted to contact the patient’s new OB physician or call in another OB consult. This could be considered a potential failure in coordination of care.

At the second ED visit the experts were most concerned that a repeat transvaginal ultrasound was not performed in light of the patient’s presentation. In addition, there was no documented pelvic exam. Repeat ED visits, especially within 72 hours, should trigger a high index of suspicion for alternative diagnoses to be considered. In this case, an ectopic pregnancy can be a difficult diagnosis to make on clinical grounds alone and there should be a low threshold for further testing or consultations.[2] 

Both expert reviewers opined there is no way to know if the tube would have been saved if the ectopic pregnancy was diagnosed during the second ED visit. If the tube was saved there would still be a potential for high risk pregnancy with a 30% chance that an ectopic pregnancy would occur again. The ED nurses did not document the patient’s vital signs and pain level at discharge, which was problematic for the hospital’s defense.

Disposition: The hospital and ED physician both agreed to a settlement with the plaintiff.

[1] Diagnosis and Management of Ectopic Pregnancy. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3213855/

[2] Topics in Primary Care Medicine: Early Diagnosis of Ectopic Pregnancy, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022234/pdf/westjmed00072-0089.pdf 

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Footnotes