9 Case 1: Black cat in the dark


s E, a 25-year-old clinical psychologist, became pregnant unexpectedly after her means of contraception failed. She sought a medical termination at a private clinic promptly at six weeks gestation. While at the clinic, Ms E was


M


reported as showing that she was experiencing some abdominal pain and spotting; an ultrasound was performed. Dr X examined the scan; although she found it difficult to read, she was satisfied that it was normal. After being appropriately consented for the procedure, Ms E was given medication to induce the termination over a course of two days. She was also given antibiotics and an appointment was made two weeks later. Ms E never made it to the repeat appointment, as she was admitted to the local emergency department unit suffering from back and abdominal pain, and pain at the tip of her right shoulder.


A scan revealed an ectopic pregnancy in her left fallopian tube and she was taken into theatre. The condition of the tube was such that the only option was salpingectomy. This had catastrophic consequences for Ms E, as the right tube had been damaged due to a ruptured appendix during her childhood. Ms E, now unable to conceive naturally, issued a claim against the clinic, alleging that there were signs that the pregnancy was not developing in utero. A review of the


LEARNING POINTS


■ According to the RCOG, one in 90 pregnancies is an ectopic pregnancy. ■ Ectopic pregnancy is likened to trying to spot a black cat in the dark: an ectopic pregnancy that has not ruptured can have silent or no symptoms; if it has ruptured it may produce shoulder tip pain, abdominal pain and shock.


■ Where a patient is known to be in the early stages of pregnancy, or is of child-bearing age, and describes abdominal or pelvic pain, ectopic pregnancy must be considered high on the list of possible diagnoses.


Case 2: Mother knows best


they had supported her through three miscarriages and an ectopic pregnancy. Mrs M had given up on having her own children and had adopted a child. She presented at the surgery after a period of amenorrhea and was delighted, if somewhat apprehensive, to be diagnosed as being pregnant in her early 30s. Dr P, the GP partner who saw her, was aware of her


M LEARNING POINTS


■ Patients should make informed decisions about whether to be screened or otherwise. Some patients may decide against having diagnostic testing or screening. This discussion and the reasons given should be documented.


■ Screening identifies some women where the risk of congenital disease is sufficiently high to justify invasive tests that can carry a risk of miscarriage.


■ Blood tests are screening tools; they provide an indication of the risk of an abnormality whereas an amniocentesis is a diagnostic tool and will be able to tell the parents whether or not they have, eg, a Down’s syndrome child.


■ All women should be offered screening for Down’s as part of a national screening programme. It should be stressed


that it does not give a definite diagnosis. According to NICE: − The “combined test” (nuchal translucency, beta hCG


and PAPP-A) should be offered to women between 11 weeks 0 days and 13 weeks 6 days.


− For women who book later, the most clinically and cost-effective serum screening test (triple or quadruple test) should be offered between 15 weeks 0 days and 20 weeks 0 days.


− When it is not possible to measure nuchal translucency (because of fetal position or maternal raised BMI), women should be offered serum screening (triple or quadruple test) between 15 weeks 0 days and 20 weeks 0 days.4


DISCLAIMER: THESE SCENARIOS ARE BASED ON MPS CASES AND FACTS HAVE BEEN ALTERED TO PRESERVE CONFIDENTIALITY


rs M had been with her GP surgery for many years and


apprehension and felt that the most important thing to Mrs M was to have her own child. Given her previous history and the slight but real risk of losing a pregnancy following an amniocentesis, he decided against counselling her on the national guidelines regarding screening for Down’s syndrome. She had a torrid obstetric history despite only being in her early 30s and, given her age, he felt the chances of her having a baby with Down’s was low or unlikely, and that she would


be unlikely to take the chance of losing the pregnancy if an amniocentesis was suggested. A few months later, Mrs


M gave birth to a baby with Down’s syndrome. She made a claim against the hospital alleging negligent actions and poor genetic counselling. It was held that Dr P had failed in his duty of care to Mrs M by failing to initiate the screening of Mrs M. Mrs M was awarded a substantial sum by the NHSLA to pay for the increased costs of bringing


up a child with a disability.


USEFUL LINKS ■ DH, UK National Screening Programme, Fetal Anomaly Screening Programme (2010)


■ NICE, Antenatal care (2008 ■ Contains extensive web links and advice


■ RCOG, RCM, Multiple Pregnancy (2011)


■ RCOG, Non-invasive Prenatal Diagnosis Using Cell-free DNA in Maternal Blood (SAC Opinion Paper 15, 2009)


earlier ultrasound photos that Dr X was given clearly showed the absence of an intrauterine pregnancy that was not investigated. The clinic admitted breach of duty, which took into account Ms E’s reduced fertility, and the claim was settled for a moderate sum.


USEFUL LINKS ■ RCOG, The Management of Tubal Pregnancy (reviewed 2010)


■ RCOG, Early Pregnancy Loss, Management (Green Top 25, 2006)


ARTICLE


UNITED KINGDOM CASEBOOK | VOLUME 20 | ISSUE 1 | JANUARY 2012 www.mps.org.uk


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