Failure to Diagnose Endometritis Resulting in Abdominal Hysterectomy

The Williams Case

Case Summary

This case is about multiple physicians who failed to properly provide care and treatment to a woman who showed clear signs of a severe infection following a C-section. The Defendant physicians failed to timely diagnose this woman’s condition, and therefore, failed to provide the aggressive treatment necessary to prevent permanent damage.

As a result of the negligent treatment, the patient required a total abdominal hysterectomy with a bilateral salpingectomy and was forced to endure a long, painful, and complicated road to recovery. What is more, this woman lost the ability to have children at the young age of 23 years old.

The Medicine

Endometritis is a condition that causes inflammation to the lining of the uterus. Endometritis is more common following a C-section than vaginal birth, and its diagnosis is imperative. If diagnosed quickly, endometritis can be effectively treated; however, if undiagnosed and untreated, endometritis can develop into sepsis (blood poisoning). This is precisely why fever and abdominal pain following a delivery, especially after a C-section, should be treated as endometritis.

Treatment for suspected endometritis should include intravenous therapy that is continued until the patient is afebrile (not feverish) for at least 24-48 hours, symptoms have completely resolved, and the patient’s white blood cells, WBC, decrease or normalize. A high WBC usually means a patient has an active infection or inflammation in the body. While a patient’s WBC may be elevated during and immediately after labor due to inflammation, it will typically decrease to normal levels rapidly following labor.

Cellulitis is a bacterial skin infection that can cause redness or swelling in the infected area. Bilateral cellulitis is an extremely rare and unlikely diagnosis, as there is very little chance of a patient developing an infection at the same time in the same location bilaterally. Additionally, a severely elevated WBC associated with tachycardia indicates far more life-threatening, systemic concerns than cellulitis. Antibiotics used to specifically treat cellulitis do not provide adequate broad coverage for many of the bacteria that cause endometritis or other serious infections.

Case Details

On June 3, 2019, Ms. Williams was 23-years old and pregnant with her first child when she presented to the Defendant Hospital for induction at 39 weeks. She was seen prenatally by Dr. Hobart. Ms. Williams’ prenatal course was unremarkable. Due to a concern for arrest of dilation and cephalopelvic disproportion, CPD, the decision was made to proceed with a C-section on June 4, 2019.

Less than 24-hours after birth, on June 6, 2019, Ms. Williams’ hemoglobin dropped to 5.5 (normal range is between 12 and 16) and a CT scan revealed a large right rectus abdominis muscle hematoma extending into the peritoneal cavity. She also had a recorded temperature of 38.3°C (100.94°F).

Dr. Hobart sought an infectious disease consultation. The infectious disease specialist ordered Vancomycin and Unasyn to cover for potential skin or soft tissue infection and post-partum endometritis. On June 7, 2019, the infectious disease specialist was consulted again and noted that Ms. Williams was afebrile overnight, and the source of her fever may have been inflammation. Therefore, Vancomycin was stopped, and Ms. Williams was left just on Unasyn.

On June 7, 2019, after less than 24 hours of IV antibiotic therapy, Dr. Hobart discharged Ms. Williams home on a 10-day course of Augmentin (oral antibiotic). On the day she was discharged, Ms. Williams had a WBC of 29.6, a considerable increase from her WBC upon admission, which was 13.6 (normal range is between 4.8 and 10.8). Dr. Hobart sent Ms. Williams home without giving IV antibiotics and/or even considering endometritis or sepsis.

In the late evening of June 9, 2019, Ms. Williams returned to the Defendant Hospital Emergency Department with complaints of drainage from her C-section incision, a slight opening at the incision site, and swelling in both of her legs.

Ms. Williams was seen by Dr. Gordon at 12:47 a.m. on June 10, 2019. At this time, Ms. Williams had a WBC of 29.7 – slightly increased from when she was discharged from the Defendant Hospital a few days earlier – she had a band count of 5% (normal being a band count of less than 5%), and an elevated heart rate strongly suggesting the presence of a serious infection. Dr. Gordon diagnosed Ms. Williams with seroma, bilateral cellulitis, and post-partum bleeding. Despite the signs and symptoms that Ms. Williams was exhibiting, endometritis was not even considered or explored by Dr. Gordon.

Dr. Gordon also failed to request an OB/GYN consultation while Ms. Williams was in the emergency department despite Ms. Williams’ obstetrician, Dr. Hobart, being on call at that time. Instead, Dr. Gordon negligently changed Ms. Williams’ antibiotic to Keflex, narrowing her antibiotic coverage, to treat the presumed bilateral cellulitis of the thighs.

Ms. Williams was then sent home at 2:32 a.m. with a diagnosis of cellulitis and abscess of her thighs, hematoma, hemorrhoids, post-partum bleeding, and seroma complicating a procedure. No IV antibiotics were administered during this visit to the Defendant Hospital, the abdominal wall hematoma was not drained, no urine analysis was ordered, and there was no investigation into the possibility of endometritis.

On June 11, 2019, Ms. Williams was again seen by Dr. Hobart with continued bleeding from her incision site. During that visit, Ms. Williams had dark blood that was expressible from the right side of her incision. Dr. Hobart probed the incision but could not push a Q-tip deeper than 0.5 cm. Dr. Hobart drained about 5 mL of dark blood from the incision and placed a pressure dressing. Dr. Hobart did not document anywhere in the record Ms. Williams’ history of a continued elevated WBC and did not complete any blood work while she was in his office. Dr. Hobart also failed to send a culture from the material drained from the abdominal wound and no further work-up for endometritis was undertaken. Rather, Dr. Hobart continued Ms. Williams on Keflex without further intervention and noted for Ms. Williams to follow-up in 1 week.

In the early morning of June 12, 2019, Ms. Williams again presented to the Defendant Hospital Emergency Department with complaints of pain in the lower abdomen, weakness and feeling feverish.

Upon presentation, Ms. Williams had a temperature of 39.4°C (102.92°F), an elevated pulse of 125 bpm, a WBC of 38.1, and a hemoglobin of 7.4. Ms. Williams was immediately started on IV antibiotics. A CT scan of Ms. Williams’ abdomen and pelvis was obtained, which showed an increase in the size of the abdominal wall hematoma with air present, strongly suggesting infection. A fluid density within the endometrial cavity was also noted. Ms. Williams was transferred to another hospital for further treatment and surgical exploration of the hematoma.

At the next hospital, Ms. Williams was finally treated for sepsis, endometritis, and an infected rectus sheath hematoma. Given Ms. Williams’ worsening clinical picture and the concern for an acute abdomen and possible necrotizing soft tissue infection, on June 14, 2019, Ms. Williams underwent a total abdominal hysterectomy and bilateral salpingectomy. Pathologic review revealed acute endometritis, necrosis of the myometrium, and acute salpingitis. Ms. Williams had recurrent fevers and was prescribed a broad spectrum of antibiotics until she was safe to be discharged on June 26, 2019.

As a result of the Defendants’ negligence and failure to provide the proper treatment for Ms. Williams’ condition, she lost the ability to have children at age 23.

We took the deposition of Dr. Hobart, who testified that he chose not to administer IV antibiotics despite Ms. Williams’ elevated WBC before discharging her because “she had been afebrile for greater than 24 hours and clinically she was well and no longer required hospitalization.”  However, Ms. Williams’ lack of a fever was not enough to consider her appropriate for discharge.

Prior to discharge, Ms. Williams was administered acetaminophen and oxycodone, which is a combination of a pain reliever and an antipyretic (fever reducer). Antipyretics can suppress an individual’s temperature, even when an infection is present. Ms. Williams’ lack of fever was a result of medication masking her condition since the medications she was administered included antipyretics. Ms. Williams’ WBC, which was extremely high, was a much more important consideration than her temperature because it is an objective finding that cannot be masked by medication. Therefore, it was negligent for Dr. Hobart to rely on Ms. Williams not having a fever when the lack of fever was caused by medications temporarily reducing the same.

Further, as is the case with many medical malpractice Defendants, Dr. Hobart attempted to shift blame to his patient, Ms. Williams, by claiming that it was her decision to be discharged. However, Dr. Hobart was the doctor and Ms. Williams was the patient. Dr. Hobart made the decisions regarding Ms. Williams’ treatment, and she should not have been given the option of discharge due to her condition, i.e., no patient elects to stay in the hospital when the doctor tells them it’s okay to go home. Further, Dr. Hobart even testified that he believed Ms. Williams was appropriate for discharge despite her significantly elevated WBC and tachycardia.

We also took the deposition of Dr. Gordon, who attempted to defend his diagnosis of bilateral cellulitis by claiming that Ms. Williams’ WBC remained elevated from her time of discharge from the Defendant Hospital on June 7, 2019 to the time she was seen on June 10, 2019 because “she had new infection in both thighs.”  Essentially, Dr. Gordon claimed that whatever infection was causing her WBC to be elevated on June 7, 2019 was healing, but at the same time, a new, coincidental, infection (bilateral cellulitis) was causing her WBC to increase back to the level it was before. Dr. Gordon further claimed that a WBC of 29.7 would be typical of cellulitis.

The critical flaw in Dr. Gordon’s defense is that bilateral cellulitis is an incredibly unlikely diagnosis at best, as it rarely, if ever, occurs. Even if bilateral cellulitis does exist as a clinical entity, a WBC of 29.7 should have suggested the presence of a deep infection possibly requiring drainage, intravenous antibiotics, surgical evaluation, and hospitalization. WBC elevations associated with tachycardia to the degree Ms. Williams was experiencing signifies far more potentially life-threatening, systemic issues than the rarely encountered bilateral cellulitis, and should have been treated as such. By changing Ms. Williams’ antibiotic to Keflex, Dr. Gordon negligently narrowed her antibiotic coverage, which would not have been adequate coverage for many of the bacteria causing endometritis, or for some bacteria that causes infection of the post-operative abdominal wall hematoma.

Result

An agreement was reached to settle the case for a substantial amount.