Splenic artery aneurysm

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CASE: Failure to search for source of postpartum hemorrhage

FACTS: Plaintiff’s decedent, a 31-year-old first-time mother, was admitted to Defendant Hospital for induction of labor at 38 weeks, 2 days. She labored from the day she was admitted through the next day and night. Shortly before 1:18 AM on her third day at the hospital, mom experienced a sudden onset of severe lower right quadrant and epigastric pain and her baby’s heart rate dropped precipitously to the 50s-80s. The Defendant Obstetrician decided to perform an emergent C-Section due to the non-reassuring fetal heart tracing.

The C-Section began as expected. However, when the OB team cut into the peritoneum, they encountered a “gush of bright red blood”. There should not be blood in the peritoneum, and the fact that blood came gushing out of the peritoneum. At the time, the OB team estimated the gush of blood to be approximately 100 milliliters. The team proceeded to perform a hysterotomy in order to deliver the baby. Once the baby (a 3930-gram boy) was delivered, Defendant Obstetrician turned her attention to Mom.

The OB team cleared the uterus of clots and began repairing the uterine incision. They observed a single area of oozing blood along the uterine incision and cauterized it. They then documented in the chart that bleeding from the incision had stopped.

Throughout this time, however, the OB team observed that there continued to be bright red blood collecting in Plaintiff’s pelvis. They swept the abdomen with lap pads to sop up the blood. After this sweep, they observed the return of blood and clot on the left side, but only scant return of blood on the right. Again, there was concern about where this blood was coming from. The OB team inspected the pelvis, looking for gynecologic sources of the bleeding and found none.

Having failed to identify any other pelvic source for the bleeding, the OB team made an assumption that Mom was experiencing uterine atony (a condition where the many small blood vessels inside the uterus fail to contract, causing ongoing bleeding inside the uterus). This assumption was not supported by their own observations. Nowhere in their documentation did Defendant OB team report seeing significant bleeding inside the uterus before it was closed and the OB team observed that there was minimal bleeding from the vagina during this process. Accordingly, Plaintiff’s uterus could not have been the source of significant hemorrhage.

The OB team estimated the unexplained blood loss at 2500 ml based on the amount of blood in the suction canister and the weight of the lap sponges. They obtained intraoperative labs, which revealed a significant drop in hemoglobin levels. On admission Plaintiff’s hemoglobin had been 13.0. At 3:29 AM an arterial blood sample was collected and resulted on a point of care device, which gave a reading of 9.8. However, a venous blood sample collected at 3:15 AM and sent to the hospital lab, resulted in a hemoglobin of 4.8—a result so critically low that the lab tech called the result into the OR and, in accordance with hospital protocol, told the nurse who answered the phone to repeat back the result. After receiving the critically low hemoglobin result, Defendant Obstetrician ordered transfusion of blood, but did not call for a surgical consult to consult about whether the bleeding might be coming from outside the pelvis. At this point, Plaintiff’s vital signs remained stable, blood had stopped running down the left paracolic gutter, and the uterus became moderately firm. The OB team closed without definitively identifying a source of the bleeding.

Plaintiff was then transported to the PACU where she required respiratory support and additional blood transfusions. Plaintiff arrived in the PACU at approximately 4:40 AM. Shortly after arrival, a respiratory therapist observed no obvious spontaneous efforts to breathe, and observed that Plaintiff’s abdomen was “very distended." He reported his findings to the anesthesiologist who immediately instructed the team to intubate.

At 5:03 AM a code blue was called and Defendant Obstetrician ordered activation of a massive transfusion protocol. CPR was initiated. Blood was collected and lab results were notable for another critically low hemoglobin of 5.9 at 5:36 AM. An ultrasound of Plaintiff’s abdomen determined that there was a large amount of free fluid in the abdomen. At approximately at 5:45 AM, 42 minutes after the code was called, Defendant Obstetrician called for a surgeon to come emergently to the PACU. A general surgeon arrived and took the Plaintiff to the OR.  He performed an exploratory laparotomy and found copious amount of blood in the lesser sac. Hissuspicion at this point in time was a ruptured mesenteric aneurysm. At that point CPR had been underway for 90 minutes without the return of spontaneous circulation. The decision was made to declare Plaintiff dead at 6:30 AM.

DEFENSE: Defendants’ experts focused heavily on the fact splenic artery aneurysm ruptures are rare and the standard of care did not require Defendant Obstetrician to recognize and diagnose the SAA – though Plaintiff’s theory of liability never claimed otherwise. As for specifics, the defense claimed that 1) the gush of blood on entry into the peritoneum was caused by damaged vessels, and 2) the bleeding observed after delivery was caused by uterine atony. Essentially, the defense claimed that the bleeding observed during surgery and the rupture of the splenic artery aneurysm were two separate and unrelated processes. Further, the defense suggested that Mom would not have survived even if Defendant Obstetrician had called for a timely surgical consult.

INJURIES: Mom died as a result of the defendants’ negligence. Her newborn son survived. She was a loving step-mother to her husband’s two daughters, and her son will grow up without her. In preparation for mediation, witnesses expected to testify on the issue of loss of enjoyment of life submitted statements to Plaintiff’s counsel. The common theme was that Mom was witty, kind, and compassionate. She was devoted to her stepdaughters and her husband and was looking forward to having a child of her own.

SPECIAL DAMAGES: Lost wages and earning capacity: $1,302,400 - $1,387,170; funeral expenses: $13,200.

SETTLEMENT: The parties agreed to settle at mediation for a confidential amount.

PLAINTIFF’S COUNSEL: Randolph J. Reis, Kimberly Kirkland, and Kara Skogsholm (Reis & Kirkland, PLLC)

CASE/COUNTY: Anonymous v. Anonymous