Medical-legal considerations on a recent case of ‘abruptio placentae with fetal death’ .
I have recently examined a case of birth at the 39th week of pregnancy complicated by diabetes and hypertension, with detachment of the placenta from the uterine wall and death of the fetus. Due to severe abdominal pain, the patient went to the hospital at 8.30 am, and was immediately subjected to monitoring of the fetal heart beat and uterine contractions.
Once interrupted this examination after two hours, the painful symptomatology intensified, but despite her calls for help she was no longer controlled. At 13.30, i.e. 5 hours after entering the hospital, she had profuse sweating, anguish, hypotension, vaginal blood loss, sense of failure, state of imminent shock, and finally she was visited. They told her that the fetal heartbeat was no longer perceptible, ‘the uterus was full of blood’ and it was necessary to proceed urgently to the cesarean section. At surgery, the fetus was dead and the placenta was completely detached from the uterine wall. The following day, as a consequence of the profuse bleeding, she needed a blood transfusion, but no further complications occurred, and she was discharged on the sixth day.
Diabetes and hypertension are well-known risk factors for placental detachment: careful monitoring of pregnancy and childbirth is necessary in patients suffering from these pathologic conditions. All this was known to the doctors: the pregnancy had in fact been classified as ‘medium risk’ and the woman was on antihypertensive and insulin therapy. Continuous cardiotocographic monitoring is required in these patients, i.e. the fetal heartbeat and uterine contractions must be monitored for the duration of labor, up to delivery. Close control is useful because the untimely detachment of the placenta does not take place instantaneously, but requires a certain amount of time, even hours to complete, generally following uterine contractions, which constitute its preeminent triggering cause.
In the presence of too intense and frequent contractions, it is necessary to intervene by administering drugs capable of relaxing the uterine muscle.
In the case in question, the fetus was certainly alive at 10.40 am, but after this hour the monitoring had been suspended despite the intense painful symptoms. Furthermore, the cardiotocographic traces performed between 9 and 10.40 were abnormal mainly due to the excessive frequency of uterine contractions. In fact, there are sections with more than 5 contractions in 10 minutes.
The most relevant element for a correct evaluation of contraction is its intensity: as midwives know well, its precise detection is obtained only through direct palpation of the wall of the uterus. Severe cases of placental detachment ending in fetal death are marked by a tetanic uterine contraction, called ‘hard-wooden consistency’. But the simple maneuver of palpation was never carried out between 10.40 and 13.30, despite the intense painful symptoms, the miserable state of the patient and even her invocations for help. Certainly continuous cardiotocographic monitoring, with the progress of detachment and the consequent fetal hypoxia, would have expressed its characteristic signs: the decelerations of the fetal heart rate, at first ‘variable’, then ‘late’, would have allowed doctors to remedy it in time to avoid irreparable damage.
How a complete 3-hour ‘document vacuum’ could have happened in a perfectly equipped department, in a case properly framed ‘at medium risk’ by doctors, remains difficult to understand.
Who was in charge of checking the patient? Who was in charge of alerting doctors?
These are just some of the questions that await an answer, and which will be clarified through the ongoing justice process.
