If a woman experiencing abdominal pain had undergone a tubal ligation, would you still order a pregnancy test?
John Tafuri, MD, FAAEM, regional director of emergency medicine at Cleveland (OH) Clinic and chief of staff at Fairview Hospital in Cleveland, is aware of multiple malpractice cases against EPs involving this very scenario. A gynecologist told one patient suffering from abdominal pain, “Well, at least you can’t be pregnant.”
“The patient came to the ER that night with a ruptured ectopic pregnancy,” Tafuri says. “The patient was extremely dissatisfied and angry.”
Tafuri says it is “absolutely essential” that physicians subject every female patient of childbearing age who has not undergone a hysterectomy receive a pregnancy test, even those patients with tubal ligations.
“Three out of 1,000 will get pregnant, and a high percentage of those will be ectopic,” he warns. “I’ve actually seen more ectopic pregnancies in patients with tubal ligations than patients without.”
While urine pregnancy tests are far more accurate than they used to be, such tests still are not as accurate as serum pregnancy tests. False negatives are entirely possible.
“If a woman is drinking a lot of fluid in preparation for an expected ultrasound test, the urine may be diluted and produce a false negative,” Tafuri notes.
In his clinical practice, Tafuri has observed two false-negative urine pregnancy tests in patients who ended up experiencing ectopic pregnancies.
“The best course of action is to obtain a serum test,” he advises.
If an ectopic pregnancy does not appear on an ultrasound, Tafuri says sending the patient home is an acceptable option, so long as there’s close follow-up. In this situation, Tafuri makes a point of contacting the patient’s obstetrician directly to let him or her know why he’s concerned about the patient.
“It’s not a deviation from the standard of care to send a possible ectopic home, per se,” he explains. “But you are certainly at potential risk, in my view.” Ensuring adequate follow-up is a way of minimizing this risk. A negative ultrasound that does not identify an intrauterine pregnancy doesn’t rule out the possibility of an ectopic pregnancy.
“It’s not accurate enough to rely on to send somebody home without any follow-up,” Tafuri warns.
On the plaintiff’s side, finding an expert witness to testify against an EP who did this would not be a problem.
“I’m certain they could find a gynecologist willing to testify that it was a potentially life-threatening situation for a young healthy woman, and it wasn’t worth taking that chance,” Tafuri says.
Trust, but Verify
Jon Mark Hirshon, MD, PhD, MPH, FACEP, professor in the Department of Emergency Medicine and an attending EP at the University of Maryland Medical Center, says the most critical component related to missed ectopic pregnancy is something surprisingly simple: The EP just didn’t consider it in the first place.
“This is not a complicated diagnosis. This is an ‘I didn’t think of it.’ You have to have it in your differential,” he says. Hirshon suggests these risk-reducing practices:
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If ectopic is ruled out, make sure the chart shows why.
A patient may report some abdominal cramping along with diarrhea, with a history of traveling on a cruise ship with many other sick contacts, for instance. In this case, the EP should document that ectopic pregnancy was believed to be very unlikely based on the history and physical.
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If the patient denies being pregnant, don’t disregard the possibility.
Hirshon says to take a “trust, but verify” approach. He’s seen many positive pregnancy tests in the ED for patients who denied they could be pregnant, including girls as young as 12 years of age. One young woman came in reporting abdominal pain, denied being pregnant, and ended up delivering a baby in the ED.
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Make sure the nursing notes were reviewed and reconciled.
If the nursing notes indicate the patient complained of abdominal pain, but the EP’s notes make no mention of it, “then that discrepancy needs to be reconciled,” Hirshon advises. The EP might chart, for instance, “Reviewed nurse’s notes and spoke to patient. Patient denies any abdominal pain or cramping.”
Tafuri encourages EPs to perform and document serial exams for patients suffering from unexplained abdominal pain.
“Things can change over time,” he explains. Reexamining the patient demonstrates the EP’s concern for the patient. This can happen while the diagnostic workup is underway without substantially increasing the patient’s length of stay. “If after a few hours you are still not sure, you can hold the patient even longer. But those are the minority,” Tafuri adds.
Tafuri says this is a good practice for any situation involving a high-risk abdominal patient in whom a definitive diagnosis hasn’t been established.
“None of us are right the first time all the time,” he notes. “Repeat exams over time, and follow-up with the physician, can really save you if you miss something on the initial visit.”
Also helpful to the defense: documentation showing no risk factors for ectopic pregnancy, such as pelvic inflammatory disease, absence of an intrauterine device, and a benign pelvic exam.
“If you’ve done all that and ensured proper follow-up, it’s hard to argue that something else could have been done,” Tafuri says.
Clear communication with your patient also is legally protective. It’s better to say, “We don’t see an ectopic pregnancy right now, but I can’t tell you for sure it is not,” instead of simply, “Everything’s OK, don’t worry.”
If this patient finds out she is ectopic, “[she’ll] recall that the EP said it was a possibility,” Tafuri says. “[The patient is] less likely to follow up with a lawsuit.”
SOURCES
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Jon Mark Hirshon, MD, PhD, MPH, FACEP, Professor, Department of Emergency Medicine, Attending Emergency Physician, University of Maryland Medical Center. Phone: (410) 328-7474. Fax: (410) 974-0819. Email: [email protected].
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John Tafuri, MD, FAAEM, Chairman, Regional Emergency Medicine, Cleveland (OH) Clinic; Chief of Staff, Fairview Hospital, Cleveland. Phone: (216) 476-7312. Email: [email protected].
