Family Medicine Expert Witness Discusses Pregnant Patient’s Work-Up

This case involves a pregnant female who presented to labor and delivery to be evaluated by her primary care/perinatology physician for abdominal pain. She previously had issues becoming pregnant, but was able to conceive after using Bravelle. At the time of the event, she was in her 33rd week of pregnancy. Initial work-up included an abdominal sonogram, which showed cholelithiasis, the likely etiology of the abdominal pain. However, the official report conflicted with the initial finding. It read out that there were no gallstones, normal gallbladder wall thickness, and no sonographic Murphy’s sign, with 1 to 3 mm echogenicities in the gallbladder wall, likely due to small polyps. The patient was told she should undergo an elective laparoscopic cholecystectomy following her delivery. Despite the abdominal pain in the presence of fertility, the physician elected not to perform antenatal testing. Consequently, the pregnancy resulted in a stillbirth one day later.

Question(s) For Expert Witness

1. What are the appropriate steps in managing a pregnant woman with abdominal pain?

Expert Witness Response

Occasional abdominal discomfort is a common pregnancy complaint, but it can also be a sign of a serious problem. Severe or persistent abdominal pain during pregnancy is never normal. The point when one experiences abdominal pain or cramping along with spotting, bleeding, fever, chills, vaginal discharge, or faintness is when the doctor must be visited. Symptoms such as discomfort while urinating, nausea, and vomiting, or the pain not subsiding after several minutes of rest, also require a doctor's exam. Severe cases of abdominal pain can be due to ectopic pregnancy, miscarriage, preterm labor, placental abruption, and preeclampsia. Immediate antenatal testing such as transvaginal sonography, biophysical profile, and nonstress test should be carried out. Additional laboratory and imaging studies may also be needed to check fetal viability. Given the patient's symptoms, it is in line with the standard of care to pursue fetal testing such as a biophysical profile and nonstress test. Moreover, the etiology of the patient’s abdominal pain was not likely due to polyps, as they tend to be an incidental finding on sonogram and are often asymptomatic. A more comprehensive workup should have been performed.