Takeaway: A patient’s presentation may align imperfectly with clinical indications for a concerning diagnosis like preeclampsia. Nevertheless, the progression, or even persistence, of certain symptoms deserves prompt investigation, accompanied by patient education and documentation.
The Case: The patient, with a family history of hypertension and stroke, was followed prenatally. At 35 weeks, the patient called complaining of swelling in her hands and feet. She was seen in the office the next day. Her blood pressure was 120/78, and urine dipstick revealed 1+ proteinuria, which is the presence of excessive protein in the urine and a potential indicator of preeclampsia. The obstetrician documented no complaints of headache; however, the patient said she reported having a headache. The obstetrician documented a discussion with the patient on the signs of preeclampsia but did not specifically list them. No written instructions on the signs of preeclampsia were provided to the patient. The patient reported that the obstetrician told her not to worry and that her symptoms were normal in pregnancy.
The patient returned in two days for her scheduled appointment. She had gained two pounds, and her blood pressure was 129/85, which was her highest blood pressure to date. The obstetrician documented no complaints of headache; however, the patient said she reported a headache that was worse than before. There was trace protein in her urine. The obstetrician’s documentation again indicated a verbal review of signs of preeclampsia with the patient, but no written instructions. Three days later, the patient had a headache and malaise all day. Later in the day, the headache suddenly became worse. The patient became incoherent and vomited, then 911 was called, and the patient was taken to the hospital.
The patient’s blood pressure was 174/112. A head CT showed a left basal ganglia hemorrhage. She underwent an emergent cesarean section. She has persistent right hemiplegia, a paralysis that affects the right side of the body, walks with a quad cane, and uses an ankle-foot orthotic.
Analysis: Although this patient did not meet the American College of Obstetricians and Gynecologists’ criteria for preeclampsia, the trend of increasing edema and rising blood pressure with proteinuria was not noted or acted upon. More frequent monitoring could have been ordered. Experts noted concern about the lack of detailed instructions to the patient regarding preeclampsia warning signs, as well as the relative absence of documentation of patient instructions.
This case example comes from a recent study analyzing The Doctors Company’s medical professional liability closed claims related to maternal morbidity and mortality. The study used an evidence-based taxonomy and included 385 closed claims from the loss years 2010 through 2023.1
Consistent with this case, patient assessment featured prominently among the studied medical malpractice claims in which clinical judgment was a contributing factor.
Tips for Malpractice Risk Reduction: Address Symptom Progression, Educate Patients, and Document
In the case example, delayed diagnosis and treatment of preeclampsia led to a hemorrhagic stroke. This patient’s family history, especially, merited an elevated awareness of the potential for preeclampsia. That said, even for patients without these particular risk factors, effective patient assessment includes patient education. Many women may not recognize the signs of preeclampsia or may feel uncomfortable sharing their concerns with their practitioner for fear of being perceived as overreacting. Patient education promotes timely disclosure of symptoms and thus promotes timely diagnosis.
Likewise, documentation is part of communication with a patient’s medical team. Insufficient or lack of documentation of clinical findings was a notable contributing factor among the studied claims.
Practitioners who dedicate attention to patient assessment, patient education, and documentation will witness downstream improvements in their patients’ safety and a diminishment of their own liability risks.
This discussion of practice risks related to maternal morbidity and mortality is based on “Maternal Morbidity and Mortality in Medical Malpractice Claims: Learning From the Past, Planning for a Safer Future,” published by The Doctors Company.