OB/GYN Claims Study: High Risk Diabetic Patient

Preexisting diabetes affects 1% of all pregnancies, and this condition must be closely monitored throughout the duration of the pregnancy to avoid endangering the life and health of both the expectant mother and her future child. Poor glycemic control in early pregnancy may be associated with adverse maternal outcomes including preeclampsia (high blood pressure causing organ damage), preterm delivery, cesarean delivery, and maternal mortality; as well as adverse fetal outcomes, such as congenital malformations, perinatal mortality, and macrosomia (infant much larger than average weight), which affects 45% of infants.

The case below involves a high-risk pregnant patient with multiple medical conditions. During her pregnancy, co-management of the patient was not performed in a coordinated effort, resulting in an adverse outcome. We will discuss the details of this case, as well as the importance of defining the roles and responsibilities of each discipline involved to effectively manage the patient’s care.

The Case

This case involves a 37-year-old patient with three previous pregnancies and a 20-year history of diabetes managed with an insulin pump. Her first visit to the obstetrician was at six weeks gestation. The patient’s initial hemoglobin A1C was 8.0, and she was instructed to follow up with her endocrinologist and return to the office in two weeks.

She returned as instructed for a prenatal visit and was seen by the physician’s partner. At that time, genetic testing was offered and refused by the patient. The patient also recently had a visit with the endocrinologist. Her hemoglobin A1C was 7.4, and no changes were made to the plan of care. At some point, the obstetrician ordered a perinatology consult, but no specific referral was documented in the patient’s medical record.

At 16 weeks gestation, the patient was seen for another routine prenatal visit. The patient’s hemoglobin A1C at that visit was 6.7. Documentation of the visit only included a notation on the flow sheet and lab results. The office policy was to document prenatal visits only on the American College of Obstetrics and Gynecology (ACOG) flowsheet, not to create a progress note. The next week, the patient had her initial visit with the perinatologist. An ultrasound was performed and the results were normal. No other consult report or recommendations for management of her care was sent to the treating obstetrician.

Six weeks later, the patient was seen in follow-up by the perinatologist. An ultrasound was ordered and the results were essentially normal, except that the fetus had an irregular heartbeat. The patient was referred to a pediatric cardiologist and began treatment with Digoxin.

Over the next several months, the patient’s care was managed by all three specialists. She had multiple prenatal visits, with little or no documentation found in the medical record. The perinatologist ordered bi-weekly ultrasounds, yet no progress notes or care plans were sent to the obstetrician. The endocrinologist increased the insulin dose based on the hemoglobin A1C results, yet, again, no documentation was in the prenatal records.

At 33 weeks gestation, the patient started experiencing various complications. She went into preterm labor and was evaluated at the hospital, given IV fluids, and discharged.

At 35 weeks, the patient reported brown urine. A progress note was not created. However, on the bottom of the ACOG flowsheet, it was written “discussed with perinatology, patient with brown-colored urine, normal pre-eclamptic labs, and weekly fetal nonstress tests (NST), no other testing needed.” The NST was read by the obstetrician as reactive.

At 37 weeks, nothing was documented other than the cervix was 3 cm and 75% effaced. The NST was read as reactive. Three days later the patient went into labor. Upon arrival at the hospital, she was dilated 5 cm and 100% effaced. No fetal life was detected and an ultrasound confirmed fetal demise. She delivered a 9 lb. 4 oz. male stillborn.

At the postpartum visit, the physician documented that he discussed the cause and risk factors for stillbirth including diabetes, fetal arrhythmia, medications, and the fact that many stillbirths have no clear etiology.

What Went Wrong?

This case was settled before trial as we were unable to find a supportive standard of care expert. The physician’s lack of documentation for this high-risk patient was concerning. The reviewers approved of the physician’s consultations with perinatology and cardiology but were critical on his failure to obtain consult notes and a plan of care. During the depositions, the perinatologists said they were not acting as consultants and their only role in the care and treatment of the patient was to perform ultrasounds.

The reviewers explained that, ideally, this patient’s hemoglobin A1C should have been less than 6 during the pregnancy. The endocrinologist did not document the plan of care or discussion with the patient about her treatment goals. The obstetrician also failed to follow-up with the endocrinologist and failed to document any discussion with the patient regarding her goals for diabetes control during pregnancy.

Finally, the reviewers opined that the final NST at 37 weeks was not normal.  They said the patient needed a biophysical profile and the obstetrician should have strongly considered delivery of the infant. The patient was diabetic and had been referred to multiple specialists; however, the documentation and follow-up from the specialists were non-existent. This patient had several noted complications during the pregnancy, any one of which could have caused the fetal demise, yet the lack of communication regarding treatment and discussions of these risks with the patient was nonexistent and made the case indefensible.

Prior to filing suit, the patient had another baby.  This pregnancy was fully managed by a perinatologist. 

Risk Management Takeaways

• All care provided to the patient should be documented in the medical record. This includes progress and telephone notes, lab and diagnostic study results, as well as consultations with specialists. The ACOG prenatal flowsheet can be used to document visits but should be supplemented with a progress note for care that is outside of routine.
• When multiple specialists are involved in a patient’s care, it’s important to define the roles and responsibilities of each. Communication is key, and written documentation should be shared with all providers involved in the patient’s care.
• High-risk patients should be identified and closely managed. All referrals to specialists should be tracked and followed through from the time the appointment is scheduled until the consultation report returns. The recommendations from the consulting specialist should be incorporated into the patient’s treatment plan and communicated to the patient.