Allegation
Failure to timely diagnose and treat ileal atresia leads to death of newborn two days after delivery
Case Details
A 25 YOF (5’4”, 188 lb, G4P2AB1) began prenatal care with the defendant family practice physician (FPP). The patient’s medical history was significant for two term deliveries, one miscarriage, pre-natal period uneventful, and an US that revealed a pregnancy with an expected EDC in approximately seven months.
About four months later, the patient had a routine US interpreted by a radiologist. The US revealed an 8-mm cystic structure cephalad to the fetal urinary bladder, of unknown clinical significance, as well as possible benign fluid distention of a bowel loop or congenital cyst. The patient had a recommended follow-up US two weeks later. A diagnostic radiologist concluded the potential etiology could be ovarian cysts, a mesenteric cyst, or an enteric duplication cyst, and recommended a follow-up US after delivery.
Two months later, the patient was admitted to the hospital at 40 weeks gestation. There was an artificial rupture of membranes with thin meconium return, and shortly after, a female infant was born via vaginal delivery. She weighed 7 lb 13 oz., measured 20” long, and reportedly without complications. The documentation at the time of delivery reflected the infant was alert, active and crying; respirations were spontaneous, and APGARS 7 and 9.
The female infant received a Hepatitis B vaccine, vitamin K injection, and erythromycin ophthalmic ointment. Doctor’s orders included breast feeding on demand or formula with iron. The defendant FPP testified that his documented plan of care included an order for follow-up US two days after delivery. The defendant FPP observed no signs or symptoms that indicated the US be done immediately after birth.
The infant’s vital signs were documented as P 141, R 88, and T 98.2°. Nasal flaring and labored respiratory effort were noted. Her O2 saturations were 94-96% on room air. The defendant FPP ordered a chest x-ray for any causes of tachypnea. The radiologist interpreted the films as hypoventilation without acute airspace consolidation. For the remainder of the first 12 hours after birth, her vital signs were documented as P 120-154, R 48-70, T 97.7-98.1°, and glucose 38-52 (75-100). The lab reported the glucose level to the nursery nurse, and the defendant FPP was immediately notified.
The nurse gave a bottle to the mother to attempt to feed the infant, but at 21:00, the mother stated she could not get her to feed because the infant was too sleepy. When the infant had her foot stimulated by tapping, she awakened enough to begin feeding from the bottle. Glucose level rose to 52. During the early morning hours of the following day, the infant patient’s vital signs and labs remained stable, and the newborn assessment was unremarkable.
The infant tolerated oral feedings from day of birth until early morning the day after. The defendant FPP performed an assessment on the newborn and noted she was fussy after feeding, had a full abdomen, but seemed to be much improved after a large belch. The FPP recorded that the infant patient had not urinated or had a stool, and again noted the meconium at delivery. The defendant FPP adjusted feedings and formula to soy, added Zantac for possible reflux, and elevated the head of the crib.
By midday, the nurse noted the infant’s O2 sat was 95%, her lungs were clear in all lobes bilaterally, and that she had good muscle tone, eyes open, and grunting respirations. Around noon, the defendant FPP was at the bedside and gave orders for ampicillin, gentamicin, labs and chest x-ray. The x-ray revealed hypoventilation with accentuation of bronchovascular markings throughout both lungs, which could obscure mild interstitial edema. The infant’s O2 saturations declined to between 84-95%, which required an oxygen hood. She had grunting, substernal retractions, R 34-60, skin dusky, tone fair, and P 158-170.
A little over an hour later, the defendant FPP initiated transfer to a medical center with a NICU. The transport team and the defendant FPP were at the bedside about two hours later. The infant’s abdomen was tense and distended. A gastric tube was placed, and formula mixed with bile was suctioned from the stomach. The newborn was transferred to the medical center’s NICU. An hour-and-a-half later, a pediatric surgeon performed an emergent exploratory abdominal laparotomy, which revealed a perforated ileal atresia that appeared to be twisted upon itself, and a portion of small bowel was removed. A subsequent surgery was completed the next day to remove additional areas of necrotic bowel. The infant’s condition deteriorated, and she was pronounced dead later that day.
Expert Testimony
An expert witness testified that ileal atresia is commonly genetic, but there was no such history in this patient’s family. The plaintiff’s expert testified there was a deviation from the standard of care by not performing an US immediately upon delivery of the infant. However, a plaintiff’s expert conceded the defendant FPP responded appropriately to the initial radiologist’s recommendation for a follow-up US, and that he responded appropriately to the newborn’s respiratory distress. Post-delivery symptoms suggesting bowel complications did not present until late in the hospital course, and the defendant FPP initiated transfer within the appropriate time in relation to the symptoms that were developing.
Resolution
The jury rendered a defense verdict within 20 minutes.
Risk Reduction Strategies
Contributing to the defensibility of the case were effective communication between healthcare providers and thorough documentation of the patient’s condition including the care provided, who was notified and when, their response, treatment plan, prenatal family history, and diagnostic reports. The medical record told the infant’s story, and the quality of documentation played an essential role in the defense of this case.
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