Failure to diagnose pre-eclampsia

Ms B was 28 weeks pregnant with her first child. She became acutely unwell and requested a visit from her GP. Dr M attended the patient, who gave a short history of nausea and headache. She also complained of swollen ankles and puffiness of her fingers and face. Dr M did not have access to the patient’s GP records at the time and did not subsequently make a note of the consultation. However, Ms B showed him her antenatal record card, which documented a weight gain of 25kg. Dr M took Ms B’s blood pressure but performed no other examination. Dr M prescribed Gaviscon and a diuretic and advised Ms B to rest.

A few hours later Ms B developed epigastric pain and loss of vision, followed 20 minutes later by a grand mal seizure. An ambulance was called. During the transfer Ms B suffered two further grand mal seizures, which were treated with IV diazepam. On arrival at hospital the eclampsia protocol was initiated and Ms B underwent an emergency caesarean section. The baby was resuscitated and transferred to SCBU, where she was subsequently noted to have spastic quadriplegic cerebral palsy with dystonia.

Ms B subsequently brought a claim against Dr M for failing to diagnose pre-eclampsia. 

Expert opinion

According to our GP expert, a history of nausea, headache and oedema, coupled with the likelihood she had a mildly elevated blood pressure, should have suggested the possibility of pre-eclampsia, and urinalysis to exclude proteinuria was mandatory. In failing to perform this test, or alternatively to arrange it by referral to hospital, Dr M breached his duty of care to Ms B. The obstetric expert advised that prodromal symptoms such as headache and nausea are more prominent in ante-partum eclampsia than signs, and blood pressure is often not M dramatically increased, hence it is possible that the patient would not have had significant hypertension and/or proteinuria when seen by Dr M. However, the absence of any clinical record of the home visit made it difficult to rebut the claimant’s allegation that she should have been admitted to hospital.

Had Ms B been admitted to hospital at the time and proteinuria detected, it is likely she would have been observed, and antihypertensive treatment would probably have been initiated if the diastolic blood pressure exceeded 110mm/Hg. By the time she complained of epigastric pain, the window of opportunity to alter the outcome would have been missed. 

Expert opinion from a paediatric neurologist concluded that the marked neurological injury sustained by the baby most likely resulted from an acute severe hypoxic ischaemic insult to the thalamus at or around the time of the seizures and a more chronic hypoxic ischaemic insult prior to delivery, rather than as a consequence of premature delivery at 29 weeks gestation. It is likely on the balance of probabilities that had the baby been delivered prior to the onset of maternal seizures she would have sustained mild neurological injury, at most.

Given the absence of GP records for the crucial consultation, it was difficult to rebut the allegations. The claim was therefore settled for a moderate sum.

Learning points

• It is difficult to defend a case without adequate records and it is important that doctors document home visit consultations in the patient’s notes at the earliest opportunity. This is essential for good communication with others caring for the patient, and can prove invaluable should a complaint or claim arise.
• A failure to carry out or record simple bedside tests (e.g. urine dipstix) and temperature can also make a case difficult to defend, especially where they can help to make a serious diagnosis.
• Prodromal symptoms may be more prominent than signs in the immediate pre-eclamptic state. BP readings in particular may not be dramatically raised.
• Delivery before the onset of eclampsia can have a marked effect on outcome and substantially reduce the risk of cerebral injury.