Case 30 A hoped-for pregnancy

Celia was a 38-year-old woman who had had tubal surgery at the age of 33 after some years of subfertility. Unfortunately, despite the surgery she failed to conceive for many years. She was therefore delighted when she consulted Dr Anton with two sequential positive pregnancy tests and her LMP 6 weeks earlier.

What would you do now?

Dr Anton congratulated Celia, sent a urine sample for a hospital pregnancy test, referred Celia to the midwife and arranged to see her again in four weeks.

Three days later Dr Anton’s colleague Dr Boulton received and reviewed the results of the pregnancy test (Dr Anton was on holiday). The hospital test was negative (‘< 25 IU HCG/L’). Dr Boulton recorded that the urine sample had probably not been the first of the day. The following day Celia rang another GP at the surgery Dr Clarke and advised that she had had a little lower abdominal cramp but no vaginal bleeding. Dr Clarke advised her of the result of the test but suggested a repeat early morning urine sample to test and to see the midwife as planned but to report any further pain.

What would be your differential diagnosis and what would you do?

One week later Celia was admitted as an emergency via A&E in a collapsed state with an ectopic pregnancy. After an emergency laparotomy, salpingectomy and a transfusion of 6 units of blood Celia was discharged three weeks later.

Celia made a complaint to the practice that she had been told in the hospital that she should have been referred urgently for an ultrasound scan when she was pregnant because she was at such high risk of ectopic pregnancy. Dr Anton explained that there was nothing in the correspondence from the fertility clinic that had advised this course of action. Later Celia brought an action against Dr Anton and her colleagues for failure to refer her urgently for an ultrasound once it was realized she was pregnant.

Do you think her claim will succeed?

Expert comment

Claims against general practitioners for alleged failures to diagnose or suspect ectopic pregnancies remain common. This is unsurprising since approximately 1 in 100 pregnancies are ectopic (1% risk).

A review article in The Lancet in 1998 gave risk factors for ectopic pregnancy (Pisarska et al., 1998). The odds ratio (essentially equivalent to a likelihood ratio) was 21 with a past history of tubal surgery. This corresponds to an absolute risk of ectopic pregnancy of about 17.5% (21/120). NICE (2004) gave guidance on fertility assessment and treatment quotes research evidence for an ectopic rate of 23% per pregnancy in patients who underwent surgery for distal tubal occlusions and 8% who underwent surgery for proximal tubal occlusion. The odds ratio associated with past pelvic inflammatory disease is about 4.

This very high risk of ectopic pregnancy after tubal surgery does not appear to be widely publicized and there is no general guidance that advises urgent referral for an ultrasound to confirm that the pregnancy is intra uterine. Yet the very high risk of ectopic pregnancy in this situation would seem to indicate that urgent referral for an ultrasound when the woman is found to be pregnant is absolutely necessary.

There is no guidance that indicates that referral for ultrasound is uniform practice and many general practitioners may be unaware of the very high risk of ectopic pregnancy in cases such as Celia. At first impression, this would appear to offer Dr Anton a Bolam defence. Many competent general practitioners would be unaware of quite how high the risk of ectopic pregnancy is after tubal surgery. However, given the clear published figures, a failure to refer appears unlikely to stand up to the logical scrutiny of the Court. Thus Dr Anton’s treatment of Celia is likely to fail on the Bolitho test.

The specialist fertility clinic was also arguably at fault for failing to warn the general practitioners or Celia that an urgent ultrasound would be required if she became pregnant.

Dr Boulton appeared to be unaware that modern monoclonal antibody based urine tests (ELISA tests) brought in the late 1980s were far more sensitive and will detect βhCG at levels as low as 25 mIU/ml. This means pregnancy can be detected by two weeks after ovulation or four weeks after the last period (virtually by the time the next period would be due if the woman was not pregnant). It has not been necessary to have a concentrated early morning urine sample for many years. It is important that general practitioners keep up to date with the performance characteristics of tests they regularly use.

A urinary pregnancy test that reverts from being positive to being negative at six weeks is highly suggestive of a failed pregnancy. This could be due to an intra-uterine blighted ovum or it could be due to the implanted ovum failing because it is in an ectopic site. The negative pregnancy test was another indication that an urgent ultrasound was required to see if Celia had an intra-uterine pregnancy, or an ectopic one.

The last problem was that Dr Clarke appears not to have acted when notified about the presence of lower abdominal pain. Tay et al. (2000) put it succinctly:

Any sexually active woman presenting with abdominal pain and vaginal bleeding after a period of amenorrhea has an ectopic pregnancy until proved otherwise. Women who present in a collapsed state usually have had prodromal symptoms that have been overlooked. Tubal rupture is rarely sudden since it is due to invasion of the trophoblast. Therefore if there is any suspicion hospital referral for investigation is mandatory.

Once Celia had significant lower abdominal pain plus a positive pregnancy test (particularly as it had turned from positive to negative) it was essential that she was referred urgently into hospital.

It is often the case, as in this example, that the harm occurs because of a concatenation of errors by different individuals. Experts are often asked to advise on ‘apportionment’ in such cases – how much should each defendant (or, more usually, their MDO) pay.

If all three general practitioners are found to be in breach of duty (which would be likely in this case) their degree of liability (the fraction of the whole damages that their MDO has to pay) will be determined by relative degree of the Claimant’s loss consequent upon each breach of duty. ‘But for’ each act Celia’s loss (the collapse and need for urgent surgery) would have been avoided. If the case came to Court (which would be unlikely – see the legal comment) the damages would be split equally between the three general practitioners. It is the consequences of the individual breaches of duty that determines the apportionment of damages, rather than whether each action was a slip or a more serious error.

Legal comment

As mentioned above, it will prove difficult to defend Dr Anton’s standard of care. Even if he can be defended in terms of the Bolam test, he will probably fail on the logical analysis demanded by the Bolitho test. The other defendant’s would be equally liable.

But the value of the case will not be high. A gynaecological expert will conclude that Celia would have had to undergo the salpingectomy (or would have lost the use of the affected fallopian tube) in any event. She may have been saved the laparotomy; that is to say, the surgery perhaps could have been performed laparoscopically or medically. With earlier intervention, the surgery would have been earlier and she would have been saved several days pain. She would also probably have been discharged earlier. The damages will be limited to a few thousand pounds.

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