Pregnant Patient Dies From Hemorrhage Following Misread Ultrasound

Case Overview

This case involves a 35-year-old pregnant patient from Colorado who presented to the hospital with severe abdominal pain in her second trimester. An ultrasound was performed on the patient, and the sonographer interpreted fetal demise, even though he was not qualified to interpret ultrasound studies. No other doctor reviewed the ultrasound, and the patient was subsequently discharged. This was contrary to hospital policy, as she had not received a radiologist’s interpretation. As the patient was on her way home, she began to hemorrhage and returned to the ER. It was discovered that ultrasound study had shown the patient was unknowingly hemorrhaging. The patient died within a few hours. A radiology expert was sought to opine on the proper protocol for reading obstetrical ultrasounds.

Questions to the Radiology expert and their responses

How often do you read obstetrical ultrasounds?

I have operational experience with both community and academic hospitals with regards to turnaround times and critical results reporting.

If a patient presents in their second trimester with abdominal pain, who should read their ultrasound and how quickly should it be done?

Who interprets the ultrasound depends on the individual hospital. There are hospitals where obstetricians perform and interpret the 2nd/3rd trimester ultrasound exams, and there are hospitals where radiologists interpret these ultrasound exams. This case sounds like it was the responsibility of the radiology department.

How quickly should those results be relayed back to the ER physician?

How quickly the results should be relayed back to the ER is usually defined by the hospital/radiology department's critical results reporting policy. Critical results policies generally specify communicating results in 30 minutes or less and can depend on how easy or hard it is to get in touch with someone.

About the expert

This highly qualified expert received his bachelor's in Neuroscience from the University of California before completing his MD, PhD in Neuroscience and an internship in Internal Medicine at the same institution. This expert then went on to complete a residency in Radiology at the University of Pennsylvania and a fellowship in Abdominal Imaging at the University of Pennsylvania Hospital. He is board certified in Radiology and he is a member of several distinguished national associations including the Radiological Society of North America, the American College of Radiology and the Association of University Radiologists. He is well published in his field with over 35 peer-reviewed journal articles and he previously worked as an Attending Radiologist at Aria Health and Radiology Associates of the Main Line. Currently, this expert works as an Assistant Professor and as the Abdominal Imaging Fellowship Program Director at a major medical university in Virginia.

E-092292

Specialties:

Radiology