Physician Assistant Allegedly Fails to Diagnose Pre-Eclampsia

This case takes place in Michigan involves a pregnant patient in her early thirties. The patient, who was previously using Yasmin for contraceptive, received prenatal care at a community hospital with no reported complications. The patient presented to the hospital complaining of spotting and was discharged with no restrictions. On two weeks later, the patient presented to the defending hospital complaining of a two week history of lower leg extremity swelling. She was seen by a perinatology physician assistant who ordered ultrasound to rule out a DVT. A urinalysis was also performed but no urine culture. The urinalysis revealed proteinuria 2+. The patient’s blood pressure was 155/92, pulse 73, respiratory rate of 20, and she was apyrexial. She was diagnosed with bilateral leg edema and was given instructions to elevate her leg as much as possible. She was discharged with instructions to go see her doctor in 3-7 days. Within the next three days, an ambulance was called to the patient’s home as she was found unconscious on the floor with swelling on her face and legs. The patient had been vomiting periodically throughout that day. She was displaying seizure-like activity. Magnesium sulfate was administered by EMS for suspected eclampsia. The patient went to a local hospital and admitted to the maternity ward. Three days later the fetus died. The patient endured two days of attempting to deliver the deceased fetus naturally before having to undergo a dilation and evacuation procedure.

Question(s) For Expert Witness

1. Based on the circumstances from the summary, would it be appropriate for the patient to be seen by a physician assistant rather than an MD?

2. What investigations should have been performed when the patient presented herself to the ER?

3. Based on the clinical findings should the patient have been diagnosed with pre-eclampsia when she was seen by the PA?

Expert Witness Response E-007048

I work very closely with PA's in my practice and have great confidence in their abilities. The relationship between PA and physician is a close one built on trust and understanding. Depending upon how that specific practice operates, it's hard to say if the patient "should" have been seen by a physician. I'd need to review the chart to see what the presenting chief complaint was, initial vitals and triage ESSI. Regardless of who evaluated the patient, the concern, in my mind, is that the patient's condition was inappropriately "framed,” meaning the providers likely saw a young female with leg swelling and negative Doppler and concluded that there was no DVT and was safe for discharge, failing to recognize the other presenting signs and symptoms, specifically hypertension in a pregnant female, proteinural and leg swelling which can indicate preeclampsia. More information is needed about this case to comment further. Specifically, the patient's gestational history, medical history, review of systems and the provider's medical decision making. In addition, I would like to know the specific institution's policies on where OB patients are triaged to. Some hospitals send any pregnant patient past a certain date directly to L&D. Should this patient have been triaged elsewhere? Independent of where the patient was seen, once the clinical suspicion for preeclampsia was raised, I would like to know if OB/GYN was consulted either in person or on the phone and if the patient was counseled on this specific concern and its potential severity.