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Medico Legal Aspects In Pregnancy And Labor

Medico legal Aspects in pregnancy and labor

Obstetrics is a dynamic field where we deal with two lives. We all strive to reduce obstetric complications; however, it is not uncommon to land in these complications during our day to day practice. With doctors being pulled into court for medical negligence, it is prudent to know the medico legal aspects of our branch, so that we can give proper care to our patients without landing into litigations.

MEDICOLEGAL ASPECTS DURING PREGNANCY

First trimester Loss – Medico Legal Aspects.

• Failure to diagnose correctly may occur in this situation. A presumed completed abortion may be an ectopic pregnancy with passage of clot, where the clot was thought to be issue. Missing an ectopic pregnancy can be a life- threatening situation. Be careful. If uncertainty exists regarding whether the passed tissue is tissue or clot, have a pathologist to evaluate it prior to sending the patient out.
• If a suction D and C is performed, then a known complication in a small percentage of cases is Asherman syndrome or intrauterine synechiae. This situation may cause amenorrhea infertility or miscarriage in these patients in the future. Be gentle with the sharp curettage after the suction, and if there is difficulty , ultrasound guidance may be helpful. Do not forgot that bleeding may be occurring due to DIC, ehich will not respond to a D and C but needs the missing factors replaced.
• Perforation of the uterus may occur if a suction D and C is performed. Pregnant uteri are softer that the non- pregnant state, and it is easier to perforate. Uterine perforation may occlude itself naturally because the uterus is muscle that can undergo contraction and place its own pressure on the site until the bleeding stops. However, uncontrolled internal bleeding from a uterine perforation may require additional surgery, either a laparoscopy or laparotomy to control the bleeding. Occasionally, a hysterectomy may be the last resort to control the bleeding, which would eliminate the patient’s ability to conceive in the future. Unrecognized uterine perforations may lead to significant internal bleeding that could be a life threat. Observe patient closely after a D and C and listen when patient complains of unusual symptoms ( E.g. Shoulder pain, unexpectedly significant abdominal pain).
• Misdiagnoses of an early intrauterine pregnancy for an ectopic pregnancy and administering methotrexate inappropriately may occur if the physician is not familiar with the laboratory and ultrasound departments’ discriminatory zone. Thinking about the patient’s history and physical examination, differential diagnoses, the accuracy of the gestational age, the HCG level ( and pattern of HCG levels if checked every 2 days), and the ultrasonographic finding are very important to make an appropriate diagnosis. This is an area of rapidly growing malpractice in obstetrics and gynecology.

• Misdiagnosis of an ectopic pregnancy as an incomplete or inevitable abortion can be a problem. In these cases, it is important to follow up on the pathology findings from the suction D and C specimen. If one is uncertain ask pathologist to evaluate the specimen while one is still in the operating room and proceed to laparoscopy if no chronic villi are found in the suction D and C specimen.

Complete and incomplete Abortions – Medico legal Aspects

• Ectopic pregnancy

• Endometrial shedding, which clinically simulates miscarriage, may occur with an actopic pregnancy. This misdiagnosis is the greatest potential pitfall.
• An empty uterus on ultrasound may represent an ectopic pregnancy.

• Retained products

• Sonography for the diagnosis of retained products can yield false- positive rates, with one report of an overall false- positive rate of 34 percent.
• Retained products may be more commonly found when an evacuation is performed after 15 weeks gestation.

Threatened Abortion – Medico legal Aspects

• Failure to diagnose pregnancy : every woman of reproductive age with lower abdominal pain and/ or vaginal bleeding should have a pregnancy test.
• Failure to diagnose an ectopic pregnancy: an ectopic pregnancy must be excluded in every pregnant woman with abdominal pain / vaginal bleeding. With early diagnoses, ectopic pregnancy in a patient who is stable can be treated non surgically.
• Failure to provide important follow up care : in patients who are being monitored with serial hCG titers and sonograms, documenting a contact person with telephonic number and address is prudent in the event that the patient is lost to follow up.
• Failure to document discussion and patient understanding of warning symptoms and complications that require immediate medical attention.
• Failure to prevent isoimmunization : unsensitized Rh- negative women should receive the appropriate doise of RhoGAM.
• Failure to assess the true intensity of hemorrhage: external bleeding may not accurately reflect total blood loss. Blood can be concealed in the vagina or uterus, or a hemoperitoneum may exist.

Missed abortion – Medico legal Aspect

• The primary medico legal pitfall in the diagnosis and management of missed abortion is the failure to recognize an ectopic pregnancy. Usually, findings on the sonogram confirm that the pregnancy is intrauterine. However, in rare instances, a pseudo sac consisting of retained blood clot exists and can be confused with mixed abortion. In cases in which sonogram does not clearly show a well developed sac, ectopic precautions should be continued until evacuated products of conception are document by pathologic examination. In the case of pregnancy resulting from artificial reproductive technology, a coexisting ectopic pregnancy should always be a consideration.
• A second medico-legal pitfall is diagnosis of an early normal pregnancy as a missed abortion. This eventually can be prevented by use if serial ultrasonographic studies.

Abortions complications

Post abortion complications develop as a result of three major mechanisms as follows :
(1) incomplete evacuation of the uterus and uterine atony, which leads to hemorrhagic complication,

(2)infection

(3) Instrumental injury

Complication of spontaneous and therapeutic abortion include

1. Complication anesthesia,
2. Post abortion triad
3. Hematometra
4. Retained product of conception
5. Uterine perforation
6. Bowel and bladder injury
7. Failed abortion
8. Septic abortion
9. Cervical shock.

Medico legal aspects

Do not underestimate the amount and rate of bleeding. In the supine position, more than 500cc of blood may collect in the vagina without severe external bleeding. Always perform a pelvic examination on the post abortion patient who is bleeding.

• Aggressively treat vaginal bleeding even if it seems minimal. Stabilize the patient with two large –bore IV’s and with oxygen. Closely monitor vital signs.
• The chance of missed ectopic pregnancy always exists. Do not presume intrauterine pregnancy in a patient who has just had an abortion; she may have had a missed ectopic pregnancy.
• Do not delay administrations of antibiotics of a patient has signs of severe post abortion infection. Administer broad- spectrum antibiotics before completing diagnostic workup.