My Most Memorable CLNC^® Case: Ectopic Pregnancy Legal Nurse Consultant Job

My most memorable case involves a failure to timely diagnose and treat ectopic pregnancy. I obtained this legal nurse consultant job through an attorney I met at a legal conference. The CLNC services I provided included summarizing the medical records, identifying deviations from the standard of care and identifying expert witnesses.

LT was a pregnant female admitted to the emergency department (ED) complaining of abdominal pain and vaginal discharge. Although her quantitative HCG showed her to be pregnant, the pelvic sonogram showed no intrauterine pregnancy. Her urinalysis showed a moderate amount of bacteria. She was diagnosed with a urinary tract infection and discharged home. She returned to the ED two days later complaining of abdominal pain, rating it 8/10. She still had a positive urine pregnancy test and a positive quantitative serum pregnancy test. She was seen by an obstetrician. The pelvic sonogram was repeated and again showed no intrauterine pregnancy. LT was admitted to the hospital and was treated conservatively. Her pain lessened. The doctor stated in a progress note that he would consider a diagnostic laparoscopy if her pain returned and he would follow up with her in two days. She was discharged home after a three-day stay in the hospital.

The day after discharge, LT returned to the ED complaining of vaginal bleeding. A repeat pelvic sonogram showed no intrauterine pregnancy. After an extensive discussion with the obstetrician, LT elected to proceed with surgery. The procedure was listed as a laparoscopy, a right salpingostomy and removal of ectopic pregnancy. Important findings were an unruptured right ectopic pregnancy and the left ovary was adhered to the cul-de-sac. Products of conception were removed. The pathology report identified a blood clot but no products of conception (chorionic villi or synchtiotrophoblastic elements).

Ten days later LT returned to the ED complaining of diffuse abdominal pain. Her quantitative HCG was greater. She still had a positive urine pregnancy. After a pelvic and transvaginal sonogram, she was taken to the operating room for an exploratory laparotomy and right salpingectomy by a different obstetrician. The right fallopian tube was removed. The left fallopian tube was freed up and noted to have no fimbrae at the end of the tube. The pathology report identified a right fallopian tube, an ectopic pregnancy and products of conception. Following surgery she was admitted to the hospital for pain control for two more days.

LT is now considered infertile because her only remaining fallopian tube was scarred and without fimbrae. My research showed the fimbrae, that were noted to be missing during LT’s surgery, pick up the oocyte to transport it for fertilization. If the ectopic pregnancy had been removed properly in the first surgery, the right fallopian tube could have been preserved for future conception. The first obstetrician failed to diagnose an ectopic pregnancy in a timely manner and failed to remove the ectopic pregnancy in the first surgery.

To develop this legal nurse consultant job I used the details of the medical record to piece together the facts of the case. I also tied in the relevant lab results, sonogram results, operative report and pathology report. This was my first case and it motivated me to seriously build my legal nurse consulting business. That’s why it will always be memorable.

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Marcia L. Bell, RN, BSN, CAPA, CLNC owns Bell Legal Nurse Consulting in Maryland. Marcia works as a consulting expert on medical malpractice, personal injury and criminal cases. She also works as a testifying expert in PACU cases. Marcia is clinically active part time at Mercy Medical Center, a magnet hospital in downtown Baltimore.

P.S. Comment to congratulate Marcia and to share your most memorable CLNC case.

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