Legal Review & Commentary
Severe preeclampsia causes massive stroke
$900K awarded for alleged negligent monitoring
By Leslie E. Mathews, Esq., MHA
Buchanan Ingersoll & Rooney
Tampa, FL
Lynn Rosenblatt, CRRN, CCM, LHRM
Healthsouth Sea Pines Rehabilitation Hospital
Melbourne, FL
News: A patient with a history of pregnancy-induced preeclampsia was admitted to the hospital for the delivery of her fourth child. After delivering her child via caesarean section, her physician ordered close monitoring of bleeding, blood pressure, and heart rate. Despite a falling heart rate, rising pulse, and lack of urine output, all classic signs of blood loss shock, a physician was not contacted for several hours. When the patient was found to be unresponsive, she was moved to the intensive care unit. The patient suffered massive blood loss, which caused oxygen deprivation to the brain and a massive stroke. The patient sued the hospital and physicians for negligence. During a bench trial, the court entered a judgment against the hospital for $900,000.
Background: In February 2005, a patient was admitted to the hospital for the delivery of her fourth child. The patient had a history of pregnancy-induced high blood pressure, or severe preeclampsia. The patient gave birth to a baby boy in the evening and later was transferred to another room for recovery. The patient was attached to a machine to closely monitor her blood pressure and heart rate.
The patient's nurse was assigned only one patient for the night. She was instructed to check the patient's incision site and uterus for bleeding initially every half-hour and then every hour. The patient's partner reported that over the next several hours, the patient's heart rate and blood pressure were erratic, her urine output declined, and her physical condition declined. When he noticed that the patient was sweating and having hot flashes, he called the nurse several times and received no response. An hour and half later, he again called the nurse when he noticed the patient's heart rate was increasing and her blood pressure was dropping.
At 2:26 a.m., another nurse responded to a significant difference in the patient's systolic and diastolic arterial blood pressures. This nurse instructed the patient's nurse to administer intravenous fluid. Shortly thereafter, the patient's blood pressure descended precipitously. At this time, the patient was clammy, unresponsive, and sweating profusely. At 2:48 a.m., the nurses began summoning the patient's physician. After at least two calls were made, the physician responded by phone at 3:08 a.m. At 3:10 a.m., the house resident arrived in the patient's room. She was emergently transferred to the surgical intensive care unit (ICU).
Upon evaluation in the ICU, it was determined that the patient had lost about half of her blood volume, which caused oxygen deprivation to the brain and a massive stroke. The patient underwent additional surgery as well as transfusions. As a result of the stroke, the patient suffered severe and painful physical and cognitive impairments.
The patient filed a suit against the hospital in response to the nurse's negligence and filed a suit against the physicians for medical negligence. The patient's expert OB-GYN testified that falling blood pressure, rising pulse rate, and lack of urine output are "classic signs of blood loss shock" that can be a result of excessive bleeding. The expert also testified that excessive bleeding was a well-known risk to patients with preeclampsia. The doctor stated that he believed the patient suffered from hemolyses low platelets (HELLP) syndrome, a severe form of preeclampsia.
During a bench trial, the court entered a judgment against the hospital for $900,000. The hospital appealed the decision. It stated that the OB-GYN was barred from testifying as an expert witness with respect to the standard of care for a nurse's postpartum monitoring of high risk patients with preeclampsia. The appellate court disagreed with the hospital and upheld the district courts award of $900,000 to the patient.
What this means for you: There is no question that the nurse assigned to monitor an immediate postoperative C-section patient with a known history of preeclampsia failed in providing an acceptable standard of care. She failed to monitor a high risk patient after specifically being ordered to do so, and she did not appropriately respond to the obvious evidence that the patient was in fact experiencing large volume blood loss. It appears that the assumption was that the patient was hypertensive as a result of preeclampsia and after the delivery by C-section her blood pressure would stabilize without issue. However, there were other risk factors that the nurse should have considered, as preeclampsia was not this patient's only issue as a post surgical patient having undergone a C-section delivery of a fourth infant.
After delivery, some women experience postpartum hemorrhage from the uterus, or significant bleeding after childbirth. Postpartum hemorrhage can be caused by several factors, such as placental problems or uterine atony. Uterine atony is when the uterus does not contract after the placenta is delivered. In a fourth pregnancy following a C-section, atony is certainly a possibility that a responsible OB nurse should have considered.
Additionally some women develop problems with the placenta during pregnancy that may cause unexpectedly heavy bleeding during a C-section. For example, the placenta sometimes grows into and attaches itself more strongly to the wall of the uterus than is normal during the pregnancy. This can prevent easy separation of the placenta after the baby is delivered and cause it to bleed.
In rare cases, frgagments of the placenta can be left behind and also can be a major source of bleeding. Placental problems are more common in women who have had at least one previous C-section or have had placental problems in the past. We know this patient had a history of preeclampsia which involves irregularities of the placenta, and this was her fourth pregnancy.
The expert witness stated that he believed the patient suffered from HELLP syndrome. HELLP stands for Hemolysis (breakdown of red blood cells), Elevated Liver enzymes (liver function) and Low Platelets counts (platelets help the blood clot). It is thought that preeclampsia occurs when the placenta abnormally invades the uterus by growing into the spiral arteries of the uterus incorrectly. The body regards the placenta as a tumor and is resistant to high blood pressure, which can result in poor pregnancy outcome. Some clinicians expect preeclampsia to be "cured" with the delivery of the child. But recent studies show that in some women, preeclampsia may develop in the postpartum or worsen following a pregnancy.
In this case, the nurse was ordered to check the patient's incision site and uterus for bleeding initially every half-hour and then every hour. Such visual inspection together with monitor readings are standard postsurgical recovery room processes and are basic to the nurse's role in that setting. If the nurse was checking the patient every 30 minutes for evidence of bleeding, she should have become concerned over the erratic blood pressure readings, fluctuating pulse rate, and diminished urinary output, as these are in fact classic indicators of rapid and/or prolonged blood loss.
Later that evening, the patient was noted by her partner who was at her bedside to be diaphoretic, which is the medical term for perspiring profusely. This is also indicative of blood loss. While he had summoned the nurse to check the patient, his perception was that the nurse was indifferent to the situation as she failed to respond to his repeated calls. One might surmise that such poor response and failure to react to what obviously was a life-threatening situation indicates a dereliction of duty and serious evidence of malpractice.
Eventually another nurse correctly identified the patient's failing condition as hypovolumnia from low blood volume. She ordered the first nurse to increase the circulating blood volume by administering a bolus of fluid to raise the patient's diastolic pressure, as it was evident that the patient was in shock. Additionally, the second nurse notified the attending physician. It is unclear what exactly transpired from the time of the first call to the physician to the second nearly 30 minutes later when the patient had become unresponsive. What is clear is the fact that she had been profusely bleeding for some time and the assigned nurse had failed in her duty to properly monitor the patient. It is also clear that this patient demonstrated a near textbook picture of drastic blood loss, but it went unrecognized by a nurse who was assigned to monitor just that possibility.
Cases such as this one require root case analysis, which is a mandate from The Joint Commission when investigating sentinel events that result in significant patient harm and/or adverse outcomes. The question that arises is what was the nurse actually doing that night when this was her only assigned patient and where she had been given specific orders to check the patient at 30 minute intervals? Did she even check for bleeding?
One would also wonder why the nurses did not immediately notify the resident staff of a life-threatening emergency when they could not reach the attending physician immediately. The entire episode lacks the credibility of a knowledgeable and caring staff that is well-trained in how to conduct emerency responses. As a result, the patient suffered a stroke. Had the bleeding been identified earlier, routine measures could have been taken to prevent and/or reduce the possibility of stroke and/or death. There was every indication that it could have been prevented, and unfortunately the delay was irreparable.
The hospital's argument on appeal was that the OB-GYN was barred from testifying as an expert witness with respect to the standard of care for a nurse's postpartum monitoring of high risk patients with preeclampsia. That appeal was denied. While professional expert witnesses frequently are called within their own professions, a physician certainly can testify to the expectations that the medical staff rely on in terms of trained and knowledgeable nursing support. In this case the hospital clearly was liable for the negligence of its staff.
REFERENCE
United States Court of Appeals, Fourth Circuit. No. 10-1183.
A patient with a history of pregnancy-induced preeclampsia was admitted to the hospital for the delivery of her fourth child. After delivering her child via caesarean section, her physician ordered close monitoring of bleeding, blood pressure, and heart rate. Despite a falling heart rate, rising pulse, and lack of urine output, all classic signs of blood loss shock, a physician was not contacted for several hours.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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