OBG Management

In 2 months, the new coding set will become the only accepted format for diagnostic coding on medical claims. By now, most clinicians and their staffs should have begun the training process, including the examination of current documentation patterns, to ensure that the more specific ­International Classification of Diseases, 10th Revision, ­Clinical Modification (ICD-10-CM) codes can be reported.

In 2014, I informed you about the more general changes that are to come in the format and ideas for preparation.¹ But now it is time to get down to the nitty-gritty (or granu­larity, if you prefer) of this coding format to ensure correct coding every time for your gynecology services. A separate article will appear in the September 2015 issue of OBG Management to describe diagnostic coding for obstetric care.

No wheel reinvention necessary
Many of the guidelines for ICD-9-CM will transfer over to ICD-10-CM, so it will not be necessary to reinvent the wheel—but there are important changes that will affect both your documentation and payers’ requirements for the highest level of specificity. There also will be some instructions in the tabular section of ICD-10-CM that will let you know whether a combination of codes can or cannot be reported together (called “excludes” notes). In the beginning, this process may require additional communication between practice staff and clinicians.

However, if your practice has prepared a teaching document that outlines currently used codes and compares them with ICD-10-CM code choices and provides comments in regard to issues such as code combinations, conversion to the new system should be almost seamless.

Remember, the documentation of the clinician drives the selection of the code. The less information provided, the less specificity—and the result may be increased ­denials due to medical necessity for procedures and treatments.

Most reported codes will begin with “N”
Although the format of the codes will change under ICD-10-CM, diagnostic reporting will remain the same for most of the gynecologic conditions reported, and clinicians should be aware that the codes they will be reporting mainly will come from those that begin with “N.” One advantage: None of these codes require a 7th character or utilize the “x” placeholder code. In fact, the majority of codes from this chapter will have a one-to-one counterpart in the ICD-9-CM codes. A few exceptions are outlined below.

In addition to the core of “N” codes, a handful of codes will come from other chapters to capture reasons for a gynecologic encounter or surgery. For instance, “Z” codes will be reported for encounters for reasons other than illness and include codes for contraceptive and procreative management, general counseling, history of diseases, preventive gynecologic examinations, and screening scenarios, to name just a few. “R” codes will be used most often for general signs and symptoms, such as abdominal pain or nausea and vomiting.

Your documentation will need to change in some important areas
When you see a patient for an injury to the urinary or pelvic organs that is not a complication of a procedure, or for a complication of a genitourinary prosthetic device, implant, or graft, you will need to document whether this is an initial or subsequent encounter or a sequela. This information is added as a 7th alpha character (a = initial, d = subsequent, s = sequela).

ICD-10-CM defines an initial encounter as the time period in which the patient is actively being treated. A subsequent encounter would be reported after the patient’s active treatment, while she is receiving routine care during the healing or recovery phase. For instance, you would report the encounter as subsequent when the patient is seen after her surgery for an injury to the ovary due to an automobile accident, but you would report an initial encounter for all visits through the surgical date of service when a patient presents with symptoms of mesh erosion requiring surgery. Sequela refers to a condition that developed as a result of another condition. For instance, if the patient’s intrauterine device (IUD) becomes embedded in the ostium due to an undetected uterine fibroid, that is a sequela.

The requirement to indicate laterality also will affect documentation, but this concept is limited to a few codes that might be reported by ObGyns. A designation of the right versus left organ will be required for reported cases of primary, secondary, borderline, or benign tumors of the breast, ovary, fallopian tube, broad ligament, and round ligament, as well as cancer in situ of the breast. However, the terms “bilateral” and “unilateral” are applied only to codes that describe hernias, acquired absence of the ovaries, and injuries to the ovaries and fallopian tubes that are not due to a surgical complication.

Unspecified codes still play a role
Unspecified ICD-10-CM codes still come into play when the clinician does not have enough information to assign a more specific code—that is, when, by the end of an encounter, no further information is available to assign a more specific diagnosis. For example, if a patient has signs of a fibroid upon examination, only the unspecified code can be reported until the clinician can discover whether it is intramural, submucosal, or subserosal. However, it would be equally incorrect to assign an unspecified code to an encounter once the nature of the fibroid has been determined.

Take note of these differences in coding
Here is a list of important new gynecologic coding requirements, which are presented in alphabetical order.

Amenorrhea, oligomenorrhea (N91.0–N91.5) and dysmenorrhea (N94.4–N94.5) will require documentation to indicate whether the condition is primary or secondary. Although an unspecified code is available, once treatment is begun the cause should be known and documented.

Artificial insemination problems will have a section:

Breast cancer codes will require documentation of which breast and what part of the breast is affected.

Contraceptive management highlights:

Conversion of a laparoscopic procedure to an open procedure will not have a code.

Cystocele, unspecified, will have code N81.10.

Dysplasia of vagina will be expanded into 3 codes based on mild, moderate, or unspecified: N89.0–N89.3.

Female genitourinary cancer codes:

Genuine stress urinary incontinence will only be referred to as stress incontinence (male or female). The code is now located in the urinary section of Chapter N: N39.3.

Genitourinary complications due to procedures and surgery will be organized in 1 section: N99

• Some conditions have more than 1 code based on cause:
  - N99.2 Stricture of vagina due to surgical complication
  - N89.5 Stricture of vagina not due to surgical complication
  - N99.4 Pelvic adhesions due to surgical complication
  - N73.6 Pelvic adhesions not due to surgical complication
• Other codes will differentiate between intraoperative or postprocedure complications and whether the surgery is on the genitourinary system or a different surgery:
  - N99.61 Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure
  - N99.62 Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating other procedure
  - N99.820 Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure
  - N99.821 Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following other procedure.

Gynecologic examinations will have to include information on whether or not there were genitourinary abnormal findings on the exam. If so, an additional secondary code will be required to identify the abnormality: Z01.411 and finding code. (Without abnormal findings: Z01.419.) For instance, a diagnosis of bacterial vaginosis is made during the examination. The abnormal findings are not those from other areas such as the breast or thyroid.

Hematuria documentation must differentiate between gross: R31.0, benign essential:R31.1, or other forms: R31.2.

High-risk sexual behavior problems must be documented by heterosexual, bisexual, or homosexual behavior: Z72.51–Z72.53.

Hormonal contraceptives, long-term use, will have a specific code: Z79.3.

Hyperplasia without atypia (simple, complex, or benign) will be rolled into a single code: N85.01.

Immunizations, prophylactic, will not have specific codes as to type. An encounter for any type of immunization is Z23.

Pelvic pain will have its own symptom code: R10.2.

Personal history for cancer has been expanded:

• Personal history of cancer in situ:
  - Z86.000 of breast
  - Z86.001 of cervix uteri
  - Z86.008 of other site
• Personal history of benign neoplasm:
  - Z86.012 of other benign neoplasm
  - Z86.03 of uncertain behavior (borderline malignancies).

Procedures not carried out will be expanded in ICD-10 to include 2 new codes:

• Z53.01 Procedure contraindicated due to patient smoking
• Z53.21 Procedure not carried out because patient left before seeing physician.

Procreative management changes:

• Artificial insemination will not have a specific code
• New code for male factor infertility: Z31.81
• New code for Rh incompatibility: Z31.82. This code would be used when the patient presents for prophylactic rho(D) immune globulin in addition to the Z23 code for immunization. This code also would be reported for the patient being tested for isoimmunization with no test result at the time of the visit.

Uterine prolapse without vaginal wall prolapse (618.1) will not have a code replacement.

Vaginal conditions such as vaginal lacerations (old), leukorrhea not specified as infective, and vaginal hematoma will be represented by an “other” code: N89.8.

Vulvar cyst will have its own code: N90.7.

Vulvovaginitis has been expanded into category codes for acute, subacute/chronic conditions of both the vagina and the vulva, which changes the documentation requirements in order to code correctly: N76.0–N76.3.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

In 2 months, the new coding set will become the only accepted format for diagnostic coding on medical claims. By now, most clinicians and their staffs should have begun the training process, including the examination of current documentation patterns, to ensure that the more specific ­International Classification of Diseases, 10th Revision, ­Clinical Modification (ICD-10-CM) codes can be reported.

In 2014, I informed you about the more general changes that are to come in the format and ideas for preparation.¹ But now it is time to get down to the nitty-gritty (or granu­larity, if you prefer) of this coding format to ensure correct coding every time for your gynecology services. A separate article will appear in the September 2015 issue of OBG Management to describe diagnostic coding for obstetric care.

No wheel reinvention necessary
Many of the guidelines for ICD-9-CM will transfer over to ICD-10-CM, so it will not be necessary to reinvent the wheel—but there are important changes that will affect both your documentation and payers’ requirements for the highest level of specificity. There also will be some instructions in the tabular section of ICD-10-CM that will let you know whether a combination of codes can or cannot be reported together (called “excludes” notes). In the beginning, this process may require additional communication between practice staff and clinicians.

However, if your practice has prepared a teaching document that outlines currently used codes and compares them with ICD-10-CM code choices and provides comments in regard to issues such as code combinations, conversion to the new system should be almost seamless.

Remember, the documentation of the clinician drives the selection of the code. The less information provided, the less specificity—and the result may be increased ­denials due to medical necessity for procedures and treatments.

Most reported codes will begin with “N”
Although the format of the codes will change under ICD-10-CM, diagnostic reporting will remain the same for most of the gynecologic conditions reported, and clinicians should be aware that the codes they will be reporting mainly will come from those that begin with “N.” One advantage: None of these codes require a 7th character or utilize the “x” placeholder code. In fact, the majority of codes from this chapter will have a one-to-one counterpart in the ICD-9-CM codes. A few exceptions are outlined below.

In addition to the core of “N” codes, a handful of codes will come from other chapters to capture reasons for a gynecologic encounter or surgery. For instance, “Z” codes will be reported for encounters for reasons other than illness and include codes for contraceptive and procreative management, general counseling, history of diseases, preventive gynecologic examinations, and screening scenarios, to name just a few. “R” codes will be used most often for general signs and symptoms, such as abdominal pain or nausea and vomiting.

Your documentation will need to change in some important areas
When you see a patient for an injury to the urinary or pelvic organs that is not a complication of a procedure, or for a complication of a genitourinary prosthetic device, implant, or graft, you will need to document whether this is an initial or subsequent encounter or a sequela. This information is added as a 7th alpha character (a = initial, d = subsequent, s = sequela).

ICD-10-CM defines an initial encounter as the time period in which the patient is actively being treated. A subsequent encounter would be reported after the patient’s active treatment, while she is receiving routine care during the healing or recovery phase. For instance, you would report the encounter as subsequent when the patient is seen after her surgery for an injury to the ovary due to an automobile accident, but you would report an initial encounter for all visits through the surgical date of service when a patient presents with symptoms of mesh erosion requiring surgery. Sequela refers to a condition that developed as a result of another condition. For instance, if the patient’s intrauterine device (IUD) becomes embedded in the ostium due to an undetected uterine fibroid, that is a sequela.

The requirement to indicate laterality also will affect documentation, but this concept is limited to a few codes that might be reported by ObGyns. A designation of the right versus left organ will be required for reported cases of primary, secondary, borderline, or benign tumors of the breast, ovary, fallopian tube, broad ligament, and round ligament, as well as cancer in situ of the breast. However, the terms “bilateral” and “unilateral” are applied only to codes that describe hernias, acquired absence of the ovaries, and injuries to the ovaries and fallopian tubes that are not due to a surgical complication.

Unspecified codes still play a role
Unspecified ICD-10-CM codes still come into play when the clinician does not have enough information to assign a more specific code—that is, when, by the end of an encounter, no further information is available to assign a more specific diagnosis. For example, if a patient has signs of a fibroid upon examination, only the unspecified code can be reported until the clinician can discover whether it is intramural, submucosal, or subserosal. However, it would be equally incorrect to assign an unspecified code to an encounter once the nature of the fibroid has been determined.

Take note of these differences in coding
Here is a list of important new gynecologic coding requirements, which are presented in alphabetical order.

Amenorrhea, oligomenorrhea (N91.0–N91.5) and dysmenorrhea (N94.4–N94.5) will require documentation to indicate whether the condition is primary or secondary. Although an unspecified code is available, once treatment is begun the cause should be known and documented.

Artificial insemination problems will have a section:

Breast cancer codes will require documentation of which breast and what part of the breast is affected.

Contraceptive management highlights:

Conversion of a laparoscopic procedure to an open procedure will not have a code.

Cystocele, unspecified, will have code N81.10.

Dysplasia of vagina will be expanded into 3 codes based on mild, moderate, or unspecified: N89.0–N89.3.

Female genitourinary cancer codes:

Genuine stress urinary incontinence will only be referred to as stress incontinence (male or female). The code is now located in the urinary section of Chapter N: N39.3.

Genitourinary complications due to procedures and surgery will be organized in 1 section: N99

• Some conditions have more than 1 code based on cause:
  - N99.2 Stricture of vagina due to surgical complication
  - N89.5 Stricture of vagina not due to surgical complication
  - N99.4 Pelvic adhesions due to surgical complication
  - N73.6 Pelvic adhesions not due to surgical complication
• Other codes will differentiate between intraoperative or postprocedure complications and whether the surgery is on the genitourinary system or a different surgery:
  - N99.61 Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure
  - N99.62 Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating other procedure
  - N99.820 Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure
  - N99.821 Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following other procedure.

Gynecologic examinations will have to include information on whether or not there were genitourinary abnormal findings on the exam. If so, an additional secondary code will be required to identify the abnormality: Z01.411 and finding code. (Without abnormal findings: Z01.419.) For instance, a diagnosis of bacterial vaginosis is made during the examination. The abnormal findings are not those from other areas such as the breast or thyroid.

Hematuria documentation must differentiate between gross: R31.0, benign essential:R31.1, or other forms: R31.2.

High-risk sexual behavior problems must be documented by heterosexual, bisexual, or homosexual behavior: Z72.51–Z72.53.

Hormonal contraceptives, long-term use, will have a specific code: Z79.3.

Hyperplasia without atypia (simple, complex, or benign) will be rolled into a single code: N85.01.

Immunizations, prophylactic, will not have specific codes as to type. An encounter for any type of immunization is Z23.

Pelvic pain will have its own symptom code: R10.2.

Personal history for cancer has been expanded:

• Personal history of cancer in situ:
  - Z86.000 of breast
  - Z86.001 of cervix uteri
  - Z86.008 of other site
• Personal history of benign neoplasm:
  - Z86.012 of other benign neoplasm
  - Z86.03 of uncertain behavior (borderline malignancies).

Procedures not carried out will be expanded in ICD-10 to include 2 new codes:

• Z53.01 Procedure contraindicated due to patient smoking
• Z53.21 Procedure not carried out because patient left before seeing physician.

Procreative management changes:

• Artificial insemination will not have a specific code
• New code for male factor infertility: Z31.81
• New code for Rh incompatibility: Z31.82. This code would be used when the patient presents for prophylactic rho(D) immune globulin in addition to the Z23 code for immunization. This code also would be reported for the patient being tested for isoimmunization with no test result at the time of the visit.

Uterine prolapse without vaginal wall prolapse (618.1) will not have a code replacement.

Vaginal conditions such as vaginal lacerations (old), leukorrhea not specified as infective, and vaginal hematoma will be represented by an “other” code: N89.8.

Vulvar cyst will have its own code: N90.7.

Vulvovaginitis has been expanded into category codes for acute, subacute/chronic conditions of both the vagina and the vulva, which changes the documentation requirements in order to code correctly: N76.0–N76.3.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

In 2 months, the new coding set will become the only accepted format for diagnostic coding on medical claims. By now, most clinicians and their staffs should have begun the training process, including the examination of current documentation patterns, to ensure that the more specific ­International Classification of Diseases, 10th Revision, ­Clinical Modification (ICD-10-CM) codes can be reported.

In 2014, I informed you about the more general changes that are to come in the format and ideas for preparation.¹ But now it is time to get down to the nitty-gritty (or granu­larity, if you prefer) of this coding format to ensure correct coding every time for your gynecology services. A separate article will appear in the September 2015 issue of OBG Management to describe diagnostic coding for obstetric care.

No wheel reinvention necessary
Many of the guidelines for ICD-9-CM will transfer over to ICD-10-CM, so it will not be necessary to reinvent the wheel—but there are important changes that will affect both your documentation and payers’ requirements for the highest level of specificity. There also will be some instructions in the tabular section of ICD-10-CM that will let you know whether a combination of codes can or cannot be reported together (called “excludes” notes). In the beginning, this process may require additional communication between practice staff and clinicians.

However, if your practice has prepared a teaching document that outlines currently used codes and compares them with ICD-10-CM code choices and provides comments in regard to issues such as code combinations, conversion to the new system should be almost seamless.

Remember, the documentation of the clinician drives the selection of the code. The less information provided, the less specificity—and the result may be increased ­denials due to medical necessity for procedures and treatments.

Most reported codes will begin with “N”
Although the format of the codes will change under ICD-10-CM, diagnostic reporting will remain the same for most of the gynecologic conditions reported, and clinicians should be aware that the codes they will be reporting mainly will come from those that begin with “N.” One advantage: None of these codes require a 7th character or utilize the “x” placeholder code. In fact, the majority of codes from this chapter will have a one-to-one counterpart in the ICD-9-CM codes. A few exceptions are outlined below.

In addition to the core of “N” codes, a handful of codes will come from other chapters to capture reasons for a gynecologic encounter or surgery. For instance, “Z” codes will be reported for encounters for reasons other than illness and include codes for contraceptive and procreative management, general counseling, history of diseases, preventive gynecologic examinations, and screening scenarios, to name just a few. “R” codes will be used most often for general signs and symptoms, such as abdominal pain or nausea and vomiting.

Your documentation will need to change in some important areas
When you see a patient for an injury to the urinary or pelvic organs that is not a complication of a procedure, or for a complication of a genitourinary prosthetic device, implant, or graft, you will need to document whether this is an initial or subsequent encounter or a sequela. This information is added as a 7th alpha character (a = initial, d = subsequent, s = sequela).

ICD-10-CM defines an initial encounter as the time period in which the patient is actively being treated. A subsequent encounter would be reported after the patient’s active treatment, while she is receiving routine care during the healing or recovery phase. For instance, you would report the encounter as subsequent when the patient is seen after her surgery for an injury to the ovary due to an automobile accident, but you would report an initial encounter for all visits through the surgical date of service when a patient presents with symptoms of mesh erosion requiring surgery. Sequela refers to a condition that developed as a result of another condition. For instance, if the patient’s intrauterine device (IUD) becomes embedded in the ostium due to an undetected uterine fibroid, that is a sequela.

The requirement to indicate laterality also will affect documentation, but this concept is limited to a few codes that might be reported by ObGyns. A designation of the right versus left organ will be required for reported cases of primary, secondary, borderline, or benign tumors of the breast, ovary, fallopian tube, broad ligament, and round ligament, as well as cancer in situ of the breast. However, the terms “bilateral” and “unilateral” are applied only to codes that describe hernias, acquired absence of the ovaries, and injuries to the ovaries and fallopian tubes that are not due to a surgical complication.

Unspecified codes still play a role
Unspecified ICD-10-CM codes still come into play when the clinician does not have enough information to assign a more specific code—that is, when, by the end of an encounter, no further information is available to assign a more specific diagnosis. For example, if a patient has signs of a fibroid upon examination, only the unspecified code can be reported until the clinician can discover whether it is intramural, submucosal, or subserosal. However, it would be equally incorrect to assign an unspecified code to an encounter once the nature of the fibroid has been determined.

Take note of these differences in coding
Here is a list of important new gynecologic coding requirements, which are presented in alphabetical order.

Amenorrhea, oligomenorrhea (N91.0–N91.5) and dysmenorrhea (N94.4–N94.5) will require documentation to indicate whether the condition is primary or secondary. Although an unspecified code is available, once treatment is begun the cause should be known and documented.

Artificial insemination problems will have a section:

Breast cancer codes will require documentation of which breast and what part of the breast is affected.

Contraceptive management highlights:

Conversion of a laparoscopic procedure to an open procedure will not have a code.

Cystocele, unspecified, will have code N81.10.

Dysplasia of vagina will be expanded into 3 codes based on mild, moderate, or unspecified: N89.0–N89.3.

Female genitourinary cancer codes:

Genuine stress urinary incontinence will only be referred to as stress incontinence (male or female). The code is now located in the urinary section of Chapter N: N39.3.

Genitourinary complications due to procedures and surgery will be organized in 1 section: N99

• Some conditions have more than 1 code based on cause:
  - N99.2 Stricture of vagina due to surgical complication
  - N89.5 Stricture of vagina not due to surgical complication
  - N99.4 Pelvic adhesions due to surgical complication
  - N73.6 Pelvic adhesions not due to surgical complication
• Other codes will differentiate between intraoperative or postprocedure complications and whether the surgery is on the genitourinary system or a different surgery:
  - N99.61 Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure
  - N99.62 Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating other procedure
  - N99.820 Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure
  - N99.821 Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following other procedure.

Gynecologic examinations will have to include information on whether or not there were genitourinary abnormal findings on the exam. If so, an additional secondary code will be required to identify the abnormality: Z01.411 and finding code. (Without abnormal findings: Z01.419.) For instance, a diagnosis of bacterial vaginosis is made during the examination. The abnormal findings are not those from other areas such as the breast or thyroid.

Hematuria documentation must differentiate between gross: R31.0, benign essential:R31.1, or other forms: R31.2.

High-risk sexual behavior problems must be documented by heterosexual, bisexual, or homosexual behavior: Z72.51–Z72.53.

Hormonal contraceptives, long-term use, will have a specific code: Z79.3.

Hyperplasia without atypia (simple, complex, or benign) will be rolled into a single code: N85.01.

Immunizations, prophylactic, will not have specific codes as to type. An encounter for any type of immunization is Z23.

Pelvic pain will have its own symptom code: R10.2.

Personal history for cancer has been expanded:

• Personal history of cancer in situ:
  - Z86.000 of breast
  - Z86.001 of cervix uteri
  - Z86.008 of other site
• Personal history of benign neoplasm:
  - Z86.012 of other benign neoplasm
  - Z86.03 of uncertain behavior (borderline malignancies).

Procedures not carried out will be expanded in ICD-10 to include 2 new codes:

• Z53.01 Procedure contraindicated due to patient smoking
• Z53.21 Procedure not carried out because patient left before seeing physician.

Procreative management changes:

• Artificial insemination will not have a specific code
• New code for male factor infertility: Z31.81
• New code for Rh incompatibility: Z31.82. This code would be used when the patient presents for prophylactic rho(D) immune globulin in addition to the Z23 code for immunization. This code also would be reported for the patient being tested for isoimmunization with no test result at the time of the visit.

Uterine prolapse without vaginal wall prolapse (618.1) will not have a code replacement.

Vaginal conditions such as vaginal lacerations (old), leukorrhea not specified as infective, and vaginal hematoma will be represented by an “other” code: N89.8.

Vulvar cyst will have its own code: N90.7.

Vulvovaginitis has been expanded into category codes for acute, subacute/chronic conditions of both the vagina and the vulva, which changes the documentation requirements in order to code correctly: N76.0–N76.3.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Was the ObGyn’s dexterity compromised?
A woman underwent a hysterectomy. During surgery, the patient’s bladder was injured; the ObGyn called in a urologist to make the repair. 

Patient’s claim The ObGyn failed to inform the patient about the possible complications from hysterectomy. The patient also claimed fraudulent concealment because the ObGyn had suffered a serious injury 3 years earlier that affected his dexterity. At the time of surgery, the ObGyn had a pending lawsuit against the owner of the premises where he fell in which he claimed that he was unable to continue his surgical practice because of the injury. The ObGyn never informed the patient of the extent of his injury or any associated risks related to his injury.

Defendants’ defense The patient was fully informed that bladder injury is a known risk of the procedure. The ObGyn maintained that his injury only affected his ability to stand for many hours while operating. The hospital settled during trial.

Verdict A $12,000 Louisiana settlement was reached with the hospital. Summary judgment was granted to the ObGyn on the informed consent claim. A $30,000 verdict was returned on the fraud count.

Placental abruption: Was child dead?
At 32 weeks’ gestation, a woman was found to have placental abruption. At the hospital, her ObGyn could not find a fetal heartbeat or detectable fetal movement on ultrasonography. A radiologist performed another ultrasound 30 minutes later and detected a fetal heart rate of 47 bpm. An emergency cesarean delivery was performed. Soon after birth, the child had seizures and was found to have hypoxic ischemic encephalopathy and diffuse brain injury. The child is profoundly disabled. 

Parents’ claim The ObGyn was negligent for failing to detect the fetal heart rate and in failing to respond properly to placental abruption. Cesarean delivery should have been performed immediately after placental abruption was identified.

Defendant’s defense The case was settled at trial.

Verdict A $13 million Illinois settlement was reached, including $5 million in cash and $8 million placed in trust for the child.

Large fetus, shoulder dystocia: Erb’s palsy
Labor was induced at 39 weeks’ gestation because the fetus was anticipated to be large. During vaginal delivery, shoulder dystocia was encountered. At birth, the baby weighed 9 lb 2 oz. She sustained a brachial plexus injury to the posterior shoulder with permanent nerve root damage and Erb’s palsy. The child continues to have limited use of her left arm and hand even after 3 corrective operations.  

Parents’ claim While performing maneuvers to relieve shoulder dystocia, the ObGyn exerted excessive traction on the baby’s head, causing a C-5 nerve root injury and complete avulsion at C-8. A cesarean delivery should have been performed.

Physician’s defense There was no negligence. The nerve injury was caused by the natural forces of labor and the mother’s pushing while the posterior shoulder was wedged behind the mother’s sa-
cral promontory.

Verdict A $1 million Illinois verdict was returned.  

Woman dies from toxemia
A 22-year-old woman was seen by her ObGyn 4 days after vaginal delivery. Early the next day, the patient had a seizure at home and was transported by ambulance to the hospital. She could not be resuscitated and died. At autopsy, the cause of death was determined to be toxemia from pregnancy. 

Estate’s claim The ObGyn failed to properly diagnose and treat the patient’s hypertension.

Defendant’s defense The case was settled during trial.

Verdict A $775,000 New York settlement was reached.

Blood transfusion delayed for hours: $14.75M net award
After emergency cesarean delivery, the baby was extremely anemic. The physicians determined that a fetal-maternal hemorrhage had started days before, causing the fetus to lose most of her blood.

An hour after birth, the attending neonatologist ordered blood from the hospital’s blood bank and arranged for emergency transport to a neonatal intensive care unit (NICU). Blood transfusion did not occur prior to transport. The child has severe cerebral palsy (CP) and cannot walk or talk at age 8 years.

Parents’ claim The neonatologist ordered cross-matched blood, which, because it is tested for compatibility, takes longer to supply. Universal donor blood could have been delivered in 20 minutes or less because it is readily available. The ambulance from the receiving hospital took an hour to drive 9 miles between the facilities, a trip that should have taken 12 minutes. The ambulance staff did not call ahead to the medical center to have blood ready for the baby. It took 4.5 hours before the newborn received a blood transfusion, a delay that caused severe injury to the child.

Defendants’ defense The matter went to trial against the neonatologist and his employer after the other defendants settled. 

Verdict Before trial, an ObGyn and the hospital settled for a combined $750,000, and the county agreed to a $12 million settlement. During trial, a $2 million Illinois settlement was reached.

Pregnant woman has a massive stroke: $10.9M
Pregnant with her third child and at 26 weeks’ gestation, a 35-year-old woman had a massive intracerebral hemorrhage at home.

The day before, she had contacted her ObGyn’s office to report severe headache and abdominal pain. The call was taken by an associate of her ObGyn, who told her there was no need to go to the hospital and suggested that she had a gastrointestinal virus.

The stroke caused severe cognitive impairment, loss of memory, partial vision loss, dysphasia, and partial paralysis on her right side. At trial, she was still undergoing therapy to regain mobility, speech, and memory. She uses a wheelchair. 

Patient’s claim The covering ObGyn was negligent for not sending the patient to the hospital when she reported severe headache.

Defendants’ defense The ObGyn and medical practice denied negligence, contending that the patient’s pregnancy was normal and that there was no indication that she was at risk for a stroke.

Verdict A $10,928,188 Ohio verdict was returned.

Was the fetus properly monitored?
One month before her due date, a woman was found to have premature rupture of membranes. She had gestational diabetes controlled by diet. She was admitted for induction of labor.

For more than 12 hours, external fetal monitor heart-rate tracings were reassuring. Then tracings began to show variable decelerations. For a period of 90 minutes, it was impossible to evaluate the fetal heart rate because the monitor was not working. An internal monitor was not placed. Just prior to birth, the tracings showed a 15-minute period of fetal tachycardia with the heart rate at 180 bpm. The physician’s notes indicated that the baby’s head had crowned for a prolonged period of time.

The baby was floppy at birth with Apgar scores of 2, 4, and 6 at 1, 5, and 10 minutes, respectively. The child was resuscitated and transferred to the NICU. She was found to have perinatal asphyxia, severe metabolic acidosis, multiorgan injury, hypoxic ischemic encephalopathy, and seizures. She stayed in the NICU for 1 month. At age 9 years, she has developmental delays and memory problems, but no motor injuries. 

Parents’ claim During the 90 minutes in which the fetal heart-rate monitor was not working properly, the fetus was in distress. An emergency cesarean delivery should have been performed when variable decelerations were seen on tracings.

Physician’s defense The lack of motor injury indicates that the injury was not related to birth.

Verdict A $2 million Michigan settlement was reached.

Rectal tear after vacuum extraction
Vacuum extraction was used to deliver a 47-year-old woman’s child. Later, the mother developed a rectovaginal fistula that became inflamed and involved vaginal passage of stool. The patient required 2 operations and still has residual complications.

Patient’s claim The ObGyn should have found and repaired the rectal tear at delivery. Vacuum extraction was used after only 2 pushes. The mother did not consent to the use of the vacuum extractor.

Physician’s defense The ObGyn admitted that he did not specifically remember this delivery. He claimed that there was informed consent and that the rectal injury was small and easy to overlook.

Verdict A $1.02 million New York verdict was returned.

 

Preeclamptic mother dies after giving birth
A 24-year-old woman developed preeclampsia when under prenatal care at a hospital clinic. At 36 weeks’ gestation, she presented to the clinic with a headache, “seeing spots,” and feeling ill; her blood pressure (BP) was 169/89 mm Hg. She was admitted for induction of labor and treated for preeclampsia with magnesium sulfate. A healthy baby was born 2 days later. The mother continued to have high BP and was prescribed nifedipine.

Her BP was 148/88 mm Hg at discharge. No antihypertensive medications were prescribed. She was given standard postpartum instructions and told to schedule a follow-up appointment in 6 to 8 weeks.

Five days after discharge, she experienced shortness of breath and swelling in her extremities, but did not seek medical attention until the next day, when breathing became labored. When emergency medical services arrived, she was in cardiac arrest. Prolonged resuscitation was required with intubation and artificial respiration. A computed tomo­g-raphy (CT) scan revealed cerebral edema from prolonged hypoxia. She was transferred to another hospital where a neurologist determined that she had suffered a profound anoxic brain injury. She died 3 days later.

Estate’s claim The hospital staff was negligent for failing to inform the patient of the signs and symptoms of continuing preeclampsia and for not prescribing antihypertensive medication at discharge. Her follow-up appointment should have been scheduled for 1 week.

Defendant’s defense The patient was given oral instructions regarding postpartum preeclampsia. The case was settled during trial.

Verdict A $50,000 North Carolina settlement was reached.

 

Was delivery properly managed?
When a 16-year-old woman was found to have preeclampsia, she was admitted and labor was induced using oxytocin. An external fetal heart-rate monitor was placed.

Three hours later, her ObGyn took over her care from the attending physician. He saw the patient once in the evening, then left to deliver a baby at another hospital. He maintained telephone contact with labor and delivery nurses, who told him that the mother’s labor was progressing as planned. Early the next morning, the nurse called the ObGyn to report that the mother was fully dilated and ready to deliver. The ObGyn was at the patient’s bedside within 30 minutes. After the mother pushed once, the ObGyn determined that a cesarean delivery was necessary.

After birth, the child suffered seizures in the NICU and was transferred to another facility. With CP and microcephaly, he cannot speak, is incontinent, has motor difficulties, and will require 24-hour care for life. 

Parent’s claim Labor was not properly monitored. Oxytocin doses were too large and continued for too long.

Defendants’ defense The mother’s treatment was appropriate and timely. There was no negligence.

Verdict A confidential Kansas settlement was reached with another defendant during the trial. A defense verdict was returned for the ObGyn.

Evidence of CMV on ultrasonography
During her pregnancy in 2012, a woman contracted congenital cytomegalovirus (CMV), although she did not have any symptoms. The child has CP, a hearing deficiency, and other complications caused by the virus.

Parents’ claim The ObGyn failed to identify CMV, despite ultrasound evidence that the virus was affecting the fetus. Studies available at the time of the pregnancy show considerable success in treating the condition in utero with hyperimmune globulin antiviral agents.

Defendant’s defense The case was settled during trial.

Verdict A confidential Idaho settlement was reached.  

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements, & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Was the ObGyn’s dexterity compromised?
A woman underwent a hysterectomy. During surgery, the patient’s bladder was injured; the ObGyn called in a urologist to make the repair. 

Patient’s claim The ObGyn failed to inform the patient about the possible complications from hysterectomy. The patient also claimed fraudulent concealment because the ObGyn had suffered a serious injury 3 years earlier that affected his dexterity. At the time of surgery, the ObGyn had a pending lawsuit against the owner of the premises where he fell in which he claimed that he was unable to continue his surgical practice because of the injury. The ObGyn never informed the patient of the extent of his injury or any associated risks related to his injury.

Defendants’ defense The patient was fully informed that bladder injury is a known risk of the procedure. The ObGyn maintained that his injury only affected his ability to stand for many hours while operating. The hospital settled during trial.

Verdict A $12,000 Louisiana settlement was reached with the hospital. Summary judgment was granted to the ObGyn on the informed consent claim. A $30,000 verdict was returned on the fraud count.

Placental abruption: Was child dead?
At 32 weeks’ gestation, a woman was found to have placental abruption. At the hospital, her ObGyn could not find a fetal heartbeat or detectable fetal movement on ultrasonography. A radiologist performed another ultrasound 30 minutes later and detected a fetal heart rate of 47 bpm. An emergency cesarean delivery was performed. Soon after birth, the child had seizures and was found to have hypoxic ischemic encephalopathy and diffuse brain injury. The child is profoundly disabled. 

Parents’ claim The ObGyn was negligent for failing to detect the fetal heart rate and in failing to respond properly to placental abruption. Cesarean delivery should have been performed immediately after placental abruption was identified.

Defendant’s defense The case was settled at trial.

Verdict A $13 million Illinois settlement was reached, including $5 million in cash and $8 million placed in trust for the child.

Large fetus, shoulder dystocia: Erb’s palsy
Labor was induced at 39 weeks’ gestation because the fetus was anticipated to be large. During vaginal delivery, shoulder dystocia was encountered. At birth, the baby weighed 9 lb 2 oz. She sustained a brachial plexus injury to the posterior shoulder with permanent nerve root damage and Erb’s palsy. The child continues to have limited use of her left arm and hand even after 3 corrective operations.  

Parents’ claim While performing maneuvers to relieve shoulder dystocia, the ObGyn exerted excessive traction on the baby’s head, causing a C-5 nerve root injury and complete avulsion at C-8. A cesarean delivery should have been performed.

Physician’s defense There was no negligence. The nerve injury was caused by the natural forces of labor and the mother’s pushing while the posterior shoulder was wedged behind the mother’s sa-
cral promontory.

Verdict A $1 million Illinois verdict was returned.  

Woman dies from toxemia
A 22-year-old woman was seen by her ObGyn 4 days after vaginal delivery. Early the next day, the patient had a seizure at home and was transported by ambulance to the hospital. She could not be resuscitated and died. At autopsy, the cause of death was determined to be toxemia from pregnancy. 

Estate’s claim The ObGyn failed to properly diagnose and treat the patient’s hypertension.

Defendant’s defense The case was settled during trial.

Verdict A $775,000 New York settlement was reached.

Blood transfusion delayed for hours: $14.75M net award
After emergency cesarean delivery, the baby was extremely anemic. The physicians determined that a fetal-maternal hemorrhage had started days before, causing the fetus to lose most of her blood.

An hour after birth, the attending neonatologist ordered blood from the hospital’s blood bank and arranged for emergency transport to a neonatal intensive care unit (NICU). Blood transfusion did not occur prior to transport. The child has severe cerebral palsy (CP) and cannot walk or talk at age 8 years.

Parents’ claim The neonatologist ordered cross-matched blood, which, because it is tested for compatibility, takes longer to supply. Universal donor blood could have been delivered in 20 minutes or less because it is readily available. The ambulance from the receiving hospital took an hour to drive 9 miles between the facilities, a trip that should have taken 12 minutes. The ambulance staff did not call ahead to the medical center to have blood ready for the baby. It took 4.5 hours before the newborn received a blood transfusion, a delay that caused severe injury to the child.

Defendants’ defense The matter went to trial against the neonatologist and his employer after the other defendants settled. 

Verdict Before trial, an ObGyn and the hospital settled for a combined $750,000, and the county agreed to a $12 million settlement. During trial, a $2 million Illinois settlement was reached.

Pregnant woman has a massive stroke: $10.9M
Pregnant with her third child and at 26 weeks’ gestation, a 35-year-old woman had a massive intracerebral hemorrhage at home.

The day before, she had contacted her ObGyn’s office to report severe headache and abdominal pain. The call was taken by an associate of her ObGyn, who told her there was no need to go to the hospital and suggested that she had a gastrointestinal virus.

The stroke caused severe cognitive impairment, loss of memory, partial vision loss, dysphasia, and partial paralysis on her right side. At trial, she was still undergoing therapy to regain mobility, speech, and memory. She uses a wheelchair. 

Patient’s claim The covering ObGyn was negligent for not sending the patient to the hospital when she reported severe headache.

Defendants’ defense The ObGyn and medical practice denied negligence, contending that the patient’s pregnancy was normal and that there was no indication that she was at risk for a stroke.

Verdict A $10,928,188 Ohio verdict was returned.

Was the fetus properly monitored?
One month before her due date, a woman was found to have premature rupture of membranes. She had gestational diabetes controlled by diet. She was admitted for induction of labor.

For more than 12 hours, external fetal monitor heart-rate tracings were reassuring. Then tracings began to show variable decelerations. For a period of 90 minutes, it was impossible to evaluate the fetal heart rate because the monitor was not working. An internal monitor was not placed. Just prior to birth, the tracings showed a 15-minute period of fetal tachycardia with the heart rate at 180 bpm. The physician’s notes indicated that the baby’s head had crowned for a prolonged period of time.

The baby was floppy at birth with Apgar scores of 2, 4, and 6 at 1, 5, and 10 minutes, respectively. The child was resuscitated and transferred to the NICU. She was found to have perinatal asphyxia, severe metabolic acidosis, multiorgan injury, hypoxic ischemic encephalopathy, and seizures. She stayed in the NICU for 1 month. At age 9 years, she has developmental delays and memory problems, but no motor injuries. 

Parents’ claim During the 90 minutes in which the fetal heart-rate monitor was not working properly, the fetus was in distress. An emergency cesarean delivery should have been performed when variable decelerations were seen on tracings.

Physician’s defense The lack of motor injury indicates that the injury was not related to birth.

Verdict A $2 million Michigan settlement was reached.

Rectal tear after vacuum extraction
Vacuum extraction was used to deliver a 47-year-old woman’s child. Later, the mother developed a rectovaginal fistula that became inflamed and involved vaginal passage of stool. The patient required 2 operations and still has residual complications.

Patient’s claim The ObGyn should have found and repaired the rectal tear at delivery. Vacuum extraction was used after only 2 pushes. The mother did not consent to the use of the vacuum extractor.

Physician’s defense The ObGyn admitted that he did not specifically remember this delivery. He claimed that there was informed consent and that the rectal injury was small and easy to overlook.

Verdict A $1.02 million New York verdict was returned.

 

Preeclamptic mother dies after giving birth
A 24-year-old woman developed preeclampsia when under prenatal care at a hospital clinic. At 36 weeks’ gestation, she presented to the clinic with a headache, “seeing spots,” and feeling ill; her blood pressure (BP) was 169/89 mm Hg. She was admitted for induction of labor and treated for preeclampsia with magnesium sulfate. A healthy baby was born 2 days later. The mother continued to have high BP and was prescribed nifedipine.

Her BP was 148/88 mm Hg at discharge. No antihypertensive medications were prescribed. She was given standard postpartum instructions and told to schedule a follow-up appointment in 6 to 8 weeks.

Five days after discharge, she experienced shortness of breath and swelling in her extremities, but did not seek medical attention until the next day, when breathing became labored. When emergency medical services arrived, she was in cardiac arrest. Prolonged resuscitation was required with intubation and artificial respiration. A computed tomo­g-raphy (CT) scan revealed cerebral edema from prolonged hypoxia. She was transferred to another hospital where a neurologist determined that she had suffered a profound anoxic brain injury. She died 3 days later.

Estate’s claim The hospital staff was negligent for failing to inform the patient of the signs and symptoms of continuing preeclampsia and for not prescribing antihypertensive medication at discharge. Her follow-up appointment should have been scheduled for 1 week.

Defendant’s defense The patient was given oral instructions regarding postpartum preeclampsia. The case was settled during trial.

Verdict A $50,000 North Carolina settlement was reached.

 

Was delivery properly managed?
When a 16-year-old woman was found to have preeclampsia, she was admitted and labor was induced using oxytocin. An external fetal heart-rate monitor was placed.

Three hours later, her ObGyn took over her care from the attending physician. He saw the patient once in the evening, then left to deliver a baby at another hospital. He maintained telephone contact with labor and delivery nurses, who told him that the mother’s labor was progressing as planned. Early the next morning, the nurse called the ObGyn to report that the mother was fully dilated and ready to deliver. The ObGyn was at the patient’s bedside within 30 minutes. After the mother pushed once, the ObGyn determined that a cesarean delivery was necessary.

After birth, the child suffered seizures in the NICU and was transferred to another facility. With CP and microcephaly, he cannot speak, is incontinent, has motor difficulties, and will require 24-hour care for life. 

Parent’s claim Labor was not properly monitored. Oxytocin doses were too large and continued for too long.

Defendants’ defense The mother’s treatment was appropriate and timely. There was no negligence.

Verdict A confidential Kansas settlement was reached with another defendant during the trial. A defense verdict was returned for the ObGyn.

Evidence of CMV on ultrasonography
During her pregnancy in 2012, a woman contracted congenital cytomegalovirus (CMV), although she did not have any symptoms. The child has CP, a hearing deficiency, and other complications caused by the virus.

Parents’ claim The ObGyn failed to identify CMV, despite ultrasound evidence that the virus was affecting the fetus. Studies available at the time of the pregnancy show considerable success in treating the condition in utero with hyperimmune globulin antiviral agents.

Defendant’s defense The case was settled during trial.

Verdict A confidential Idaho settlement was reached.  

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements, & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Was the ObGyn’s dexterity compromised?
A woman underwent a hysterectomy. During surgery, the patient’s bladder was injured; the ObGyn called in a urologist to make the repair. 

Patient’s claim The ObGyn failed to inform the patient about the possible complications from hysterectomy. The patient also claimed fraudulent concealment because the ObGyn had suffered a serious injury 3 years earlier that affected his dexterity. At the time of surgery, the ObGyn had a pending lawsuit against the owner of the premises where he fell in which he claimed that he was unable to continue his surgical practice because of the injury. The ObGyn never informed the patient of the extent of his injury or any associated risks related to his injury.

Defendants’ defense The patient was fully informed that bladder injury is a known risk of the procedure. The ObGyn maintained that his injury only affected his ability to stand for many hours while operating. The hospital settled during trial.

Verdict A $12,000 Louisiana settlement was reached with the hospital. Summary judgment was granted to the ObGyn on the informed consent claim. A $30,000 verdict was returned on the fraud count.

Placental abruption: Was child dead?
At 32 weeks’ gestation, a woman was found to have placental abruption. At the hospital, her ObGyn could not find a fetal heartbeat or detectable fetal movement on ultrasonography. A radiologist performed another ultrasound 30 minutes later and detected a fetal heart rate of 47 bpm. An emergency cesarean delivery was performed. Soon after birth, the child had seizures and was found to have hypoxic ischemic encephalopathy and diffuse brain injury. The child is profoundly disabled. 

Parents’ claim The ObGyn was negligent for failing to detect the fetal heart rate and in failing to respond properly to placental abruption. Cesarean delivery should have been performed immediately after placental abruption was identified.

Defendant’s defense The case was settled at trial.

Verdict A $13 million Illinois settlement was reached, including $5 million in cash and $8 million placed in trust for the child.

Large fetus, shoulder dystocia: Erb’s palsy
Labor was induced at 39 weeks’ gestation because the fetus was anticipated to be large. During vaginal delivery, shoulder dystocia was encountered. At birth, the baby weighed 9 lb 2 oz. She sustained a brachial plexus injury to the posterior shoulder with permanent nerve root damage and Erb’s palsy. The child continues to have limited use of her left arm and hand even after 3 corrective operations.  

Parents’ claim While performing maneuvers to relieve shoulder dystocia, the ObGyn exerted excessive traction on the baby’s head, causing a C-5 nerve root injury and complete avulsion at C-8. A cesarean delivery should have been performed.

Physician’s defense There was no negligence. The nerve injury was caused by the natural forces of labor and the mother’s pushing while the posterior shoulder was wedged behind the mother’s sa-
cral promontory.

Verdict A $1 million Illinois verdict was returned.  

Woman dies from toxemia
A 22-year-old woman was seen by her ObGyn 4 days after vaginal delivery. Early the next day, the patient had a seizure at home and was transported by ambulance to the hospital. She could not be resuscitated and died. At autopsy, the cause of death was determined to be toxemia from pregnancy. 

Estate’s claim The ObGyn failed to properly diagnose and treat the patient’s hypertension.

Defendant’s defense The case was settled during trial.

Verdict A $775,000 New York settlement was reached.

Blood transfusion delayed for hours: $14.75M net award
After emergency cesarean delivery, the baby was extremely anemic. The physicians determined that a fetal-maternal hemorrhage had started days before, causing the fetus to lose most of her blood.

An hour after birth, the attending neonatologist ordered blood from the hospital’s blood bank and arranged for emergency transport to a neonatal intensive care unit (NICU). Blood transfusion did not occur prior to transport. The child has severe cerebral palsy (CP) and cannot walk or talk at age 8 years.

Parents’ claim The neonatologist ordered cross-matched blood, which, because it is tested for compatibility, takes longer to supply. Universal donor blood could have been delivered in 20 minutes or less because it is readily available. The ambulance from the receiving hospital took an hour to drive 9 miles between the facilities, a trip that should have taken 12 minutes. The ambulance staff did not call ahead to the medical center to have blood ready for the baby. It took 4.5 hours before the newborn received a blood transfusion, a delay that caused severe injury to the child.

Defendants’ defense The matter went to trial against the neonatologist and his employer after the other defendants settled. 

Verdict Before trial, an ObGyn and the hospital settled for a combined $750,000, and the county agreed to a $12 million settlement. During trial, a $2 million Illinois settlement was reached.

Pregnant woman has a massive stroke: $10.9M
Pregnant with her third child and at 26 weeks’ gestation, a 35-year-old woman had a massive intracerebral hemorrhage at home.

The day before, she had contacted her ObGyn’s office to report severe headache and abdominal pain. The call was taken by an associate of her ObGyn, who told her there was no need to go to the hospital and suggested that she had a gastrointestinal virus.

The stroke caused severe cognitive impairment, loss of memory, partial vision loss, dysphasia, and partial paralysis on her right side. At trial, she was still undergoing therapy to regain mobility, speech, and memory. She uses a wheelchair. 

Patient’s claim The covering ObGyn was negligent for not sending the patient to the hospital when she reported severe headache.

Defendants’ defense The ObGyn and medical practice denied negligence, contending that the patient’s pregnancy was normal and that there was no indication that she was at risk for a stroke.

Verdict A $10,928,188 Ohio verdict was returned.

Was the fetus properly monitored?
One month before her due date, a woman was found to have premature rupture of membranes. She had gestational diabetes controlled by diet. She was admitted for induction of labor.

For more than 12 hours, external fetal monitor heart-rate tracings were reassuring. Then tracings began to show variable decelerations. For a period of 90 minutes, it was impossible to evaluate the fetal heart rate because the monitor was not working. An internal monitor was not placed. Just prior to birth, the tracings showed a 15-minute period of fetal tachycardia with the heart rate at 180 bpm. The physician’s notes indicated that the baby’s head had crowned for a prolonged period of time.

The baby was floppy at birth with Apgar scores of 2, 4, and 6 at 1, 5, and 10 minutes, respectively. The child was resuscitated and transferred to the NICU. She was found to have perinatal asphyxia, severe metabolic acidosis, multiorgan injury, hypoxic ischemic encephalopathy, and seizures. She stayed in the NICU for 1 month. At age 9 years, she has developmental delays and memory problems, but no motor injuries. 

Parents’ claim During the 90 minutes in which the fetal heart-rate monitor was not working properly, the fetus was in distress. An emergency cesarean delivery should have been performed when variable decelerations were seen on tracings.

Physician’s defense The lack of motor injury indicates that the injury was not related to birth.

Verdict A $2 million Michigan settlement was reached.

Rectal tear after vacuum extraction
Vacuum extraction was used to deliver a 47-year-old woman’s child. Later, the mother developed a rectovaginal fistula that became inflamed and involved vaginal passage of stool. The patient required 2 operations and still has residual complications.

Patient’s claim The ObGyn should have found and repaired the rectal tear at delivery. Vacuum extraction was used after only 2 pushes. The mother did not consent to the use of the vacuum extractor.

Physician’s defense The ObGyn admitted that he did not specifically remember this delivery. He claimed that there was informed consent and that the rectal injury was small and easy to overlook.

Verdict A $1.02 million New York verdict was returned.

 

Preeclamptic mother dies after giving birth
A 24-year-old woman developed preeclampsia when under prenatal care at a hospital clinic. At 36 weeks’ gestation, she presented to the clinic with a headache, “seeing spots,” and feeling ill; her blood pressure (BP) was 169/89 mm Hg. She was admitted for induction of labor and treated for preeclampsia with magnesium sulfate. A healthy baby was born 2 days later. The mother continued to have high BP and was prescribed nifedipine.

Her BP was 148/88 mm Hg at discharge. No antihypertensive medications were prescribed. She was given standard postpartum instructions and told to schedule a follow-up appointment in 6 to 8 weeks.

Five days after discharge, she experienced shortness of breath and swelling in her extremities, but did not seek medical attention until the next day, when breathing became labored. When emergency medical services arrived, she was in cardiac arrest. Prolonged resuscitation was required with intubation and artificial respiration. A computed tomo­g-raphy (CT) scan revealed cerebral edema from prolonged hypoxia. She was transferred to another hospital where a neurologist determined that she had suffered a profound anoxic brain injury. She died 3 days later.

Estate’s claim The hospital staff was negligent for failing to inform the patient of the signs and symptoms of continuing preeclampsia and for not prescribing antihypertensive medication at discharge. Her follow-up appointment should have been scheduled for 1 week.

Defendant’s defense The patient was given oral instructions regarding postpartum preeclampsia. The case was settled during trial.

Verdict A $50,000 North Carolina settlement was reached.

 

Was delivery properly managed?
When a 16-year-old woman was found to have preeclampsia, she was admitted and labor was induced using oxytocin. An external fetal heart-rate monitor was placed.

Three hours later, her ObGyn took over her care from the attending physician. He saw the patient once in the evening, then left to deliver a baby at another hospital. He maintained telephone contact with labor and delivery nurses, who told him that the mother’s labor was progressing as planned. Early the next morning, the nurse called the ObGyn to report that the mother was fully dilated and ready to deliver. The ObGyn was at the patient’s bedside within 30 minutes. After the mother pushed once, the ObGyn determined that a cesarean delivery was necessary.

After birth, the child suffered seizures in the NICU and was transferred to another facility. With CP and microcephaly, he cannot speak, is incontinent, has motor difficulties, and will require 24-hour care for life. 

Parent’s claim Labor was not properly monitored. Oxytocin doses were too large and continued for too long.

Defendants’ defense The mother’s treatment was appropriate and timely. There was no negligence.

Verdict A confidential Kansas settlement was reached with another defendant during the trial. A defense verdict was returned for the ObGyn.

Evidence of CMV on ultrasonography
During her pregnancy in 2012, a woman contracted congenital cytomegalovirus (CMV), although she did not have any symptoms. The child has CP, a hearing deficiency, and other complications caused by the virus.

Parents’ claim The ObGyn failed to identify CMV, despite ultrasound evidence that the virus was affecting the fetus. Studies available at the time of the pregnancy show considerable success in treating the condition in utero with hyperimmune globulin antiviral agents.

Defendant’s defense The case was settled during trial.

Verdict A confidential Idaho settlement was reached.  

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements, & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients¹:

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.¹

The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.¹ Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims¹:  

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”¹ See “Tips for reducing malpractice claims in obstetrics” below.

“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.¹

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients¹:

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.¹

The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.¹ Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims¹:  

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”¹ See “Tips for reducing malpractice claims in obstetrics” below.

“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.¹

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

An analysis of 882 obstetric claims closed between 2007 and 2014 highlighted 3 common allegationsby patients¹:

Together, these 3 allegations accounted for 59% of claims. Other allegations included diagnosis-related claims, delay in delivery, improper performance of operative delivery, retained foreign bodies, and improper choice of delivery method.¹

The Obstetrics Closed Claims Study findings were released earlier this spring by the Napa, California−based Doctors Company, the nation’s largest physician-owned medical malpractice insurer.¹ Susan Mann, MD,a spokesperson for the company, provided expert commentary on the study at the 2015 Annual Clinical Meeting of the American College of Obstetricians and Gynecologists in San Francisco (see “Frequent sources of malpractice claims” below).

Top 7 factors contributing to patient injury
The Doctors Company identified specific factors that contributed to patient injury in the closed claims¹:  

“Studying obstetrical medical malpractice claims sheds light on the wide array of problems that may arise during pregnancy and in labor and delivery,” the study authors conclude. “Many of these cases reflect unusual maternal or neonatal conditions that can be diagnosed only with vigilance. Examples include protein deficiencies, clotting abnormalities, placental abruptions, infections, and genetic abnormalities. More common conditions should be identified with close attention to vital signs, laboratory studies, changes to maternal and neonatal conditions, and patient complaints.”¹ See “Tips for reducing malpractice claims in obstetrics” below.

“Obstetric departments must plan for clinical emergencies by developing and maintaining physician and staff competencies through mock drills and simulations that reduce the likelihood of injuries to mothers and their infants,” the study authors conclude.¹

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

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Duchenne muscular dystrophy (DMD), an X-linked condition, is the most common muscular dystrophy in children and affects families of all ethnicities. Incidence is about 1 in 3,500 boys. Approximately two-thirds of clinically diagnosed cases of DMD are attributable to a carrier mother, who is likely unaware that she is a carrier. In addition to providing information about reproductive risks, carrier screening can identify women who are, themselves, at risk of health effects caused by defects in the DMD gene.

This supplement examines the latest crucial advances in DMD carrier screening.

Click here to download the PDF.

To view an exclusive video on the pivotal findings discussed in this supplement, click here.

Duchenne muscular dystrophy (DMD), an X-linked condition, is the most common muscular dystrophy in children and affects families of all ethnicities. Incidence is about 1 in 3,500 boys. Approximately two-thirds of clinically diagnosed cases of DMD are attributable to a carrier mother, who is likely unaware that she is a carrier. In addition to providing information about reproductive risks, carrier screening can identify women who are, themselves, at risk of health effects caused by defects in the DMD gene.

This supplement examines the latest crucial advances in DMD carrier screening.

Click here to download the PDF.

To view an exclusive video on the pivotal findings discussed in this supplement, click here.