Sample Case Descriptions

Issue: Is a single screen sufficient for all patients? How often does barely passing a GDM screen produce complications later in pregnancy typical of GDM? Is HbA1c an appropriate substitute for the traditional two-step GDM screening?

Issues: Does the degree of apparent force and trauma correlate with the likelihood of injuring a pregnancy? Does this question vary from trimester to trimester? What is the appropriate use of a Kleihauer-Betke test in this situation? Conversely, what are inappropriate uses of the K-B test?

Is fetal fibronectin testing valid in the late second trimester? If fFN contradicts the finding of a fern or nitrazine test, what course of action is most appropriate?

Defining Category II vs. III monitor strips. Timing of birth with a Category II strip. How long does the OB wait on a Category III strip to improve?

Issues: Now that proteinuria is no longer a diagnostic criterion for preeclampsia, how do we screen patients in clinic? How often should we screen them – and with just blood pressure measurements?

A woman with four prior healthy uncomplicated full-term pregnancies was in a MVC at 34 weeks’ gestation. Her only complication until now was well-controlled gestational diabetes. On the day of the MVC, her fetal monitoring strip was non reassuring; attempted corrective measure of rehydration, antiemetics and correction of hyperglycemia failed to improve the fetal strip. Preterm Cesarean section was indicated and performed; neonate continued with developmental issues thought due to being born prematurely.

Consultative issues: Causation of the baby’s developmental issues: were they caused by preterm delivery, or some other antepartum or postpartum cause?

A morbidly obese 19-year-old with otherwise normal prenatal course experienced a prolonged deceleration during labor. Progress in labor until now had been slow; a big baby was suspected. The EFM got progressively worse over the next 2.5 hours and no further progress was made. Once urgent Cesarean was declared, the baby was delivered within 17 minutes; he weighed 8 ½ pounds and had a significant caput. Brain injury was noted in the child; birth injury was alleged.

Consultative issues: Causation of the brain injury: intrapartum vs. antepartum or postpartum causes.

Distraught mother alleges malpractice in 16 week PROM and resulting stillbirth. Records analysis demonstrates two prior growth restricted babies, minimal prenatal care, poor weight gain, but a normal ultrasound two weeks prior to PROM. Ultrasound on day of birth showed unusually collapsed fetal skull and large blood clot adjacent to the skull, suggesting traumatic cause.

Consultative issues: Causation of the fetal death was suspected to be very different than what was believed by the conscientious counselor/attorney advocating for his client.

A woman with multiple risk factors (smoking, strenuous work habits) presents with atypical symptoms of rupture of membranes; the leaking fluid is thrice identified by care providers as ‘pus-like liquid’ rather than the typically clear amniotic fluid. Patient has a history of carrying Group B Streptococcus (GBS), UTIs, and recurrent bacterial vaginosis.

Consultative issues: The value of assessment tests of fluids including fetal fibronectin and ferning, vaginal exam and ultrasound in the evaluation of possible preterm rupture of membranes.

A young woman had elevated blood pressure beginning at 20 weeks of pregnancy, responsive to hydralazine. She lacked hyperreflexia, blood lab abnormalities, or proteinuria. Fetal growth was at the lower end of normal growth. The baby died the day after a reassuring ultrasound. At birth, the baby was small, and the placenta was small with several small infarcts.

Consultative issues: Clinically distinguishing gestational hypertension vs. preeclampsia. During discovery, evidence of a thrombophilia (Protein S deficiency) was buried deeply in the chart, representing a more likely cause of placental infarcts than preeclampsia.

A 19-year-old man alleged birth trauma caused his permanent neurologic injury. Indeed, some of his characteristics were consistent with cerebral palsy.

Consultative issues included assessing proper credentialing for delivering babies, minimum requirements of rural hospitals wishing to offer obstetric services, and demonstrating causation of birth injury two decades after a baby is born.

A woman accused her doctor of not warning her that SSRIs can cause birth defects. Consultative issues included: 1) comprehensive review of the medical literature; 2) briefing attorney’s staff on literature findings; 3) then injecting the opinion of the American Congress of Obstetricians and Gynecologists on the subject, and 4) epidemiologic analysis that although some risk was present, it was quantitatively quite small.

A mother is sure stress caused her preterm labor (PTL). Pre pregnancy she had taken Adderall, Cymbalta, Prozac and Xanax for dysthymia, ADHD and GAD. She was given a diagnosis of incompetent cervix, although she had two prior full-term pregnancies.

Consultative issues involved proving proximate cause with “softer” cause-and-effect relationships involving the difficult to measure the entity - ‘stress’.

A 21-year-old mother of four alleged that a poorly repaired cervical laceration contributed to her fifth baby being born at 23 weeks. Competing causative factors included GBS, BV, multiparity, history of progressively faster labors, and various socioeconomic issues. Competing intervening factors were drug use and an active sex life.

Consultative issues involved an epidemiologic/statistical balancing of these factors in causation.

A woman with two prior healthy deliveries now pregnant again had had five prenatal visits without complications, then suffered a significant MVC; she complained of headache, neck pain and lower back pain. Fetal evaluation was normal. Three weeks later, she went through a fairly normal labor; amniotic fluid was lightly stained with meconium. Four minutes before delivery, the fetus dropped her heart rate to the 50s; Apgar scores were 0/1 and cord pH was 6.58 with a pCO2 of 131 suggesting respiratory acidosis. The neonate expired during transport; mother alleged negligent delivery.

Consultative issues involved causation analysis of multiple complex medical issues requiring careful acquisition of all records postmortem. Autopsy had been declined by family. However, various records were produced that various abnormalities were discovered in the baby but not present in initial records reviewed: a very elevated 17-hydroxyprogesterone level suggesting adrenal disease, slightly elevated TSH suggesting thyroid dysfunction, an MRI showing classic signs of hypoxic/ischemic encephalopathy (HIE, which could not have occurred within four minutes), and a remote report sent off from the hospital demonstrating multiple elevated neonatal serum amino acids. Postpartum, the baby’s demise was caused by pulmonary hemorrhage during transport – not an event typically due to respiratory acidosis/birth injury.

A mother is sure that a car accident caused her son’s deformed twisted neck. The accident was rather low impact. Mother’s pregnancy was complicated by placenta previa and preterm labor and the umbilical cord had a tight knot within it at delivery; two urinary drug screens were positive for cannabinoids. Child had a positive finding in his acyl carnitine profile as part of his metabolic profile.

Consultative issue was demonstrating proximate cause in the presence of multiple potential factors, some of which of a challenging nature to present to the finder of fact.