The patient, aged 40, was 16 weeks into her fifth pregnancy when she sought a termination at a private clinic. The gynaecologist, an MDU member, discussed the potential risks of carrying out a termination, including hysterectomy and possible transfer to an NHS hospital should anything untoward occur during surgery. The conversation was recorded in the patient's notes and she signed a consent form that warned of haemorrhage, cervical damage and uterine perforation as serious or frequently occurring risks.
The procedure was carried out a week later. The gynaecologist dilated the patient's cervix and evacuated the pregnancy using open forceps, then emptied the uterine cavity using suction curettage. The whole procedure was carried out under ultrasound guidance. The patient's uterus was soft and she lost approximately 400mls of blood during surgery. Blood loss was controlled with oxytocin.
The gynaecologist asked for the patient to be observed every 15 minutes due to her high parity. Her blood pressure and pulse remained stable and vaginal bleeding was minimal.
However, two hours after surgery, the patient started to pass blood clots. The surgeon re-examined her and found her uterus had contracted and she was not in significant pain. The blood clots soon became heavy again, and uterine massage and continuous oxytocin were used to help her uterus contract. The patient began to complain of pain and the gynaecologist arranged transfer to the nearby NHS hospital.
Laparotomy revealed a large broad ligament haematoma and a perforation above the cervix. Unfortunately, the patient required an abdominal hysterectomy to stem the blood loss.
Some two years later, the gynaecologist received a letter of claim from the patient's solicitor alleging that the termination had been performed negligently, causing a uterine perforation and resulting in hysterectomy. He contacted the MDU for assistance.
The MDU obtained expert advice from a consultant gynaecologist who observed that perforation of the uterus is a recognised complication of termination of pregnancy and may happen even in the hands of an experienced surgeon. The expert advised that the procedure had been carried out in a standard manner, with all necessary precautions to reduce the risks.
The use of ultrasound in a second trimester termination, although not mandatory, can be very helpful, and may reduce the risk of perforation and help ensure that the termination is complete. In this case, the expert added, there was a degree of placenta accreta, which may cause bleeding into the uterine cavity but can also produce bleeding externally from the uterus, depending on the depth of invasion. Possibly, in this patient's case, this may have been into the broad ligament, producing the haematoma. It might be that the damage to the uterine wall and the resultant haematoma were inevitable because of the pathological implantation of the placenta.
In view of the supportive expert advice, the MDU wrote to the claimant's solicitor denying liability. Nothing further happened and some time later the claim was discontinued.
- The consent form contained sufficient information to show that the patient had been properly counselled and warned of the recognised complications of termination. If the discussions had not been noted in the records, the patient's allegation that she had not been properly warned of the risk of infertility may have been more difficult to rebut.
- The practice of using ultrasound was not specifically recorded in the records. However, it was the gynaecologist's invariable practice to use ultrasound in late terminations, which provided supporting evidence of his cautious approach.
This page was correct at publication on 06/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.