A pregnant woman with fever, diarrhea, and vomiting; dies from a uterine infection

A family physician is being sued for negligence in this tragic case. A 39-year old female who was 36 weeks pregnant presented with fever, diarrhea, and vomiting. She was treated conservatively of the flu, given anti-nausea medications and sent home. Not feeling better that night, she went to the hospital for further evaluation. Her fever persisted at 103 degrees despite Tylenol. A few hours later, the mother went into cardiac arrest and died. Apparently, a tocolytic was given, which combined with a previously undiagnosed uterine infection, lead to her death.

I do not have all the facts of the case, but here are some points. There is a question of whether antibiotics were given early enough. In the setting of persistent fever of 103 degrees, empiric antibiotics may have been helpful – I would be curious to see what the white blood cell count was. If there was any sign of abdominal pain (unclear from the story – but there were GI symptoms present), a clinical suspicion of PID or endometritis should have been on the radar screen and considered.

A tocolytic is a medication used to prevent contractions. Typically, a beta-agonist is used – such as terbutaline. Cardiac side effects are an uncommon side effect, from UptoDate:

Myocardial ischemia is a rare complication of beta-adrenergic receptor use. More commonly, chest discomfort (10 versus 1 percent with placebo), shortness of breath (15 versus 1 percent with placebo), palpitations (18 versus 4 percent with placebo), tremor (39 versus 4 percent with placebo) and anxiety result from use of these drugs. Pulmonary edema is an uncommon maternal complication, occurring in 0.3 percent of patients. Pulmonary edema likely occurs as a result of several additive factors including fluid overload, decreased diastolic filling time duration with increased heart rate, and the increased plasma volume of pregnancy.

It was likely that the mother was already septic from the infection, and the addition of the tocolytic medication led to a dangerous drop in blood pressure, which may have caused the cardiac arrest.

Update:

An OB/GYN responds -

PID is extremely unlikely at 36 weeks. It becomes unlikely after 12 weeks as the fetus and gestational sac fill the endometrial cavity and hence it is difficult for an ascending infection to reach the tubes. Likewise endometritis is unlikely prior to delivery but is common after delivery, particularly a c-section.

Far more likely is chorioamnionitis, an infection of the membranes, amniotic fluid and possibly the baby.

Several potential errors in the case include giving the patient a tocolytic at 36 weeks. Not commonly done. I rarely give them after 34 weeks, but my hospital has a NICU. Her presenting symptoms should have been worked up thoroughly on as chorio can present like the flu.

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