Preeclampsia litigation

To identify the cases described in this section of the chapter, a search was done in Lexis-Nexis using the words pre-eclampsia, eclampsia, and pregnancy-induced hypertension for the period 1 January 1998 through 31 December 2003. The search identified 61 cases involving pre-eclampsia related to litigation. An overview of the maternal and perinatal outcomes for these 61 cases is listed in Table 34.5.

These cases support the observations of the Harvard Study (Brennan et al., 1996) that law suits are often related to the severity of the injury and the age of the patient. For example, this group of patients were all young, in the reproductive age group, and had either a severe injury such as permanent brain damage or had died. As noted

Table 34.5. Maternal and perinatal outcome for 61 litigation cases reported in Lexis-Nexis for the years 1998-2003. [Perinatal outcome includes two sets of twins]

Maternal outcome (N=

- 61)

Death

15

(25%)

Brain damage

5

(8%)

Blind

1

(2%)

Normal

40

(65%)

Perinatal outcome (N=

-63)

Brain damage

23

(37%)

Fetal death

19

(30%)

Neonatal death

2

(3%)

Leg amputation

1

(2%)

Unknown

3

(5%)

Normal

15

(23%)

in the Harvard study, the least reliable indicator of whether a law suit was brought was the quality of care. Whether quality of care was an issue in reported cases is less clear because there was not always sufficient information to draw an accurate conclusion.

The causes of maternal or perinatal death or disability are illustrated in Tables 34.6 and 34.7. As noted in Table 34.6, the leading cause of maternal death or permanent brain injury was intracerebral hemorrhage due, in most cases, to uncontrolled hypertension. However, what is less well known is how many of these pre-eclamptic patients who presented to a physician's office or hospital with the complaint of a severe headache in association with hypertension had already had a pre-existing intracerebral bleed. Not infrequently, the sole manifestation of a prior bleed is a slow maternal heart rate and a widened pulse pressure due, in part, to an increase in intracranial pressure. Under these circumstances, the cerebral vascular response is designed to limit and prevent further bleeding by localized cerebral artery spasm and thrombosis. When medical therapy with agents such as magnesium sulfate or hydralazine is administered, the physiologic impact of these agents is frequently directed at relieving central

Table 34.6. Identifiable causes of maternal death or permanent neurologic disability in 21 cases of pre-eclampsia reported in Lexis-Nexis for the years 1998-2003. [The remaining 40 women had apparently normal outcomes. BP, Blood pressure]

Intracerebral hemorrhage

9 (46%)

Postpartum hemorrhage

5 (24%)

Hepatic rupture

2 (10%)

Peripartum cardiomyopathy

1 (4%)

Pulmonary edema

1 (4%)

Amniotic fluid embolus

1 (4%)

Blind-uncontrolled BP

1 (4%)

Unknown

1 (4%)

or peripheral vasospasm. As such, the administration of these agents has the potential to negatively affect these protective mechanisms, and, to potentiate a pre-existing bleed.

The Bustamonte matter (Bustamonte v. Granada Hills Community Hospital, 2001) is an example of a patient who presented to the hospital with hypertension and widened pulse pressures of 201/ 92mmHg and 191/100 mmHg. Around the time of delivery, the decedent's blood pressure was 224/ 106 mmHg and she complained of a severe headache. Whether the decedent had a slow heart rate during her time prior to the manifestation of her intracerebral bleed is unknown because that information was not included in the synopsis. But, the key to the Bustamonte matter is to recognize this physiologic pattern and to obtain immediate consultation with a specialist in maternal—fetal medicine, neurology, or internal medicine.

Table 34.7 illustrates the causes of fetal death or brain damage. Of note, placental abruption was responsible for the death or permanent brain damage of 10 (16%) fetuses. These findings support, in part, the relationship between maternal hypertensive disease and placental abruption. As previously demonstrated by Abdella et al. (1984), the incidence of placental abruption is directly related to the level of the maternal blood pressure.

Table 34.7. Identifiable causes of fetal or neonatal death or permanent brain damage in cases of pre-eclampsia reported in Lexis-Nexis for the years 1998-2003. [SRS, sudden, rapid, and sustained deceleration; SIDS, Sudden Infant Death Syndrome]

Abruption 9

SRS deceleration 2

Maternal death 4

Maternal seizures 1

Unknown 2

Preadmission 4

Hon pattern of asphyxia 1

Maternal arrest 1

SRS deceleration 3

Maternal seizures 1

Vacuum related 1

Intracerebral hemorrhage 3

Abruption 1

Pneumonia 1

SIDS 1

This means that the higher the maternal BP the greater the risk of an abruption. While this relationship appears to exist, the harder question is to identify among those patients with an elevated blood pressure which person, if any, will have an abruption and when that patient will actually separate her placenta.

Nevertheless, the patient with a significant blood pressure elevation will require antihyperten-sive drug(s) to lower her blood pressure. The lowering of the maternal blood pressure should, theoretically, reduce the risk of placental abruption. In addition, in a patient with the diagnosis of pre-eclampsia and signs or symptoms of placental abruption, consideration should be given to delivery, as soon as it is technically feasible, rather than waiting for fetal signs of an abruption.

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