An article for physicians by physicians
Originally published June 2009
Delays in the diagnosis of ectopic pregnancies may lead to poor patient outcomes and medico-legal difficulties for physicians.
Of interest to all physicians caring for women of reproductive age
Ectopic pregnancy is a potentially life-threatening emergency. Therefore, early diagnosis and treatment become vital in reducing the risk of serious maternal clinical outcomes that may occur with tubal rupture.
The CMPA conducted a review of all medico-legal cases involving a diagnosis of ectopic pregnancy that occurred between 2003 and 2007, which represents a total of 23 open and closed cases. In the 17 closed cases, a delay in the diagnosis of ectopic pregnancy was the leading reason for the medico-legal problems encountered. In four of these closed cases, a diagnosis of spontaneous abortion was initially made. Although tubal rupture was confirmed in 10 of the ectopic pregnancies, there were no maternal deaths in this case series.
In the closed cases in which experts were critical of the physician's care, they were of the opinion that the following factors contributed to the diagnostic delay:
Delay in attending the patient
Failure to perform a pelvic examination
Failure to perform appropriate diagnostic investigations in women of reproductive age who presented with abdominal pain and vaginal bleeding
Inadequate systems for the follow up of diagnostic investigations and/or patients
Inadequate documentation was also problematic; in particular, related to the physician's clinical impressions at the time of assessment, telephone discussions with consultants and instructions given to patients.
The following two case studies illustrate some of the factors that may contribute to a diagnostic delay.
Failure to perform appropriate diagnostic investigations
An obese woman, known to be approximately seven weeks pregnant, presented to a walk-in clinic with a four-day history of light vaginal bleeding and increasing lower abdominal pain. The patient reported passing grayish-white tissue per vagina at the outset of these symptoms and provided a history of two miscarriages.
On examination, the patient's vital signs were normal and she was in no acute distress. The family physician noted suprapubic tenderness but no rebound tenderness. A pelvic examination was not performed. The family physician diagnosed a threatened abortion as he considered ectopic pregnancy to be unlikely. He discussed the possible diagnoses with the patient, advised her to rest and directed her to go to the emergency department (ED) if the abdominal pain or vaginal bleeding increased.
Two days later, the patient attended the ED complaining of severe abdominal pain. Another physician diagnosed a ruptured ectopic pregnancy for which the patient underwent an uneventful surgery. The patient initiated a regulatory authority (College) complaint alleging the family physician failed to properly assess, diagnose and treat the ectopic pregnancy.
The College suggested serial ß-hCG blood levels and urgent ultrasound imaging would have been indicated in this case. Additionally, the College expressed concerns about the family physician's failure to perform a pelvic examination to evaluate lower abdominal pain and vaginal bleeding in a patient of seven weeks' gestation. However, the College also believed it would have been unlikely for a physician to differentiate between threatened abortion and ectopic pregnancy by clinical examination alone.
Failure to arrange timely follow up of test results
A 25-year-old woman underwent a left salpingostomy for ectopic pregnancy. On discharge, the obstetrician ordered weekly serum ß-hCG levels. The first two serum ß-hCG levels, drawn one week apart, were elevated and rising. However, both the obstetrician and his secretary were on vacation and no arrangements had been made with another physician to monitor the patient's serial ß-hCG results during the absence.
Approximately three weeks after the salpingostomy, the patient developed sudden
severe abdominal pain and was diagnosed with persistent ectopic pregnancy. She underwent a left salpingectomy.When the obstetrician returned from vacation, he noted the elevated ß-hCG levels and contacted the patient, who advised him of her recent surgery. Following this event, the obstetrician established a new system to follow up serial ß-hCG results. The patient complained to the College alleging she required a salpingectomy due to the obstetrician's failure to follow up her serial ß-hCG results, thereby decreasing her chance of future pregnancy.
The College was of the opinion that this situation was preventable and, regardless of the circumstances, the physician should have had an office procedure in place to follow up test results. However, since the College was satisfied with the physician's modified office procedures to follow up ß-hCG results in a timely manner, the College took no further action.
Risk management considerations
Based on the College decisions in the cases presented and the opinions of experts in the other cases, the following risk management considerations are suggested:
Have you considered the diagnosis of ectopic pregnancy when a woman of reproductive age presents with abdominal pain and vaginal bleeding?
Are you familiar with the current clinical practice guidelines for the investigation and management of suspected ectopic pregnancy?
Have you performed the appropriate physical examination and arranged for any appropriate diagnostic investigations?
Is there a system in place to facilitate timely follow up of investigations and/or patients?
Does the documentation reflect your clinical impressions at the time of assessment, discussions with consultants, and patient instructions?