Miscarriage following laparoscopy

A patient saw her GP requesting referral to a gynaecologist following recurrent lower abdominal pain and sub-fertility. The GP's referral letter mentioned a history of recurrent intermittent lower abdominal pain for more than 12 months, with irregular periods.

The patient saw the gynaecologist, who was an MDU member. He noted 'LMP just finished' and an irregular menstrual cycle of 45-50 days. Examination was unremarkable and the uterus found to be normal in size. Laparoscopy and a dye test were arranged, partly to assess whether the pain could be due to adhesions around the left fallopian tube and partly to assess tubal patency.
 
The member noted that the patient had not been using any contraception for the last two years.

A month after seeing the gynaecologist, the patient was admitted for laparoscopy under general anaesthesia. The first day of the patient's last period was not recorded in the admission record, although it was recorded that the patient considered she was not pregnant.

The laparoscopy showed that the uterus was enlarged to the size equivalent to a six week pregnancy. No cause of pain was identified and there was no spill of dye via the fallopian tubes. The member considered the likeliest diagnosis was tubal occlusion together with adenomyosis.

Some time later the patient attended hospital complaining of a three day history of lower abdominal pain, described as sharp and dull. A six week history of 'staining and bleeding, passing clots, increasingly severe over past 2-3 days' was recorded. A pregnancy test proved positive and an ultrasound scan showed an empty uterus with some retained tissue. Incomplete miscarriage was diagnosed. The patient underwent evacuation of retained products of conception (ERPC).
 
The gynaecologist member later received notification of a claim. The patient alleged that the member negligently failed to establish whether or not she was pregnant before proceeding with the laparoscopy. The patient alleged that the laparoscopy caused her to suffer a miscarriage and that she now suffered psychological problems.

The MDU's response

The MDU instructed an obstetrician/gynaecologist to give expert opinion on the case. The expert advised that, although it was reasonable for the member to have advised the patient to undergo laparoscopy, failure to establish whether the claimant was pregnant was unfortunate. He advised that a potentially fertile woman having unprotected intercourse and undergoing surgery must be asked: 'When was the first day of your last period?'.

The expert explained that while it was not routine practice to perform a pregnancy test prior to laparoscopy without an indication of pregnancy, in this case there was a clear indication.
 
When it came to the causative link between laparoscopy and the subsequent miscarriage, the MDU's expert advised that had there really been a significant amount of pain and heavy bleeding following the laparoscopy, then the miscarriage would have occurred within a matter of days, not several weeks later.

The outcome

Given the expert's view that a pregnancy test should have been carried out, the member agreed to the claim being settled. The key issue in determining the value of the claim was whether or not the patient was likely to have had a miscarriage as a result of laparoscopy, and whether she suffered psychological problems as a consequence.

Learning points

  • In these circumstances asking a patient whether she thinks she is pregnant is not enough. The question should be asked: 'When was the first day of your last period?'
  • Following this case, the member drafted a protocol stating that the possibility of pregnancy must be excluded in all potentially fertile women before laparoscopy. A urinary pregnancy test is now performed pre-operatively on all woman from 'menarch to menopause' regardless of LMP or use of contraception.

This page was correct at publication on 16/12/2010. 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.