A FITNESS TO practice inquiry today heard allegations that a doctor at a Tipperary hospital misdiagnosed a woman as having an ectopic pregnancy when in fact her pregnancy was a healthy one.
The Medical Council today heard testimony from 37-year-old Tipperary native Laura Esmonde concerning her experience after she developed a blood clot in her leg in January 2013.
Esmonde, a mother-of-three, had previously suffered a pulmonary embolism, a blood clot on her lung, following the birth of her second child in 1999.
She presented at South Tipperary General Hospital (STGG) on 6 January 2013 after waking up in the night in severe pain with a swollen left leg.
At the hospital she was diagnosed with a deep vein thrombosis (DVT) and placed on blood thinners. In the course of her attendance she was asked as to whether or not she might be pregnant. She said it was a possibility although it was the first time she had considered it. A subsequent pregnancy test revealed that she was indeed pregnant.
Complaint
The complaint made by Esmonde to the Medical Council concerns a consultant gynaecologist, anonymised as Dr A, who treated her at STGG on and around 7 and 8 January 2013.
Dr A is accused of poor professional performance regarding the following:
An ectopic pregnancy is a complication which sees an embryo attaching outside the uterus, while Methotrexate is a drug commonly used to treat cancer which stymies the growth of cells.
A key element of the hearing concerns whether or not Dr A described to Esmonde her pregnancy as an ectopic one on 8 January 2013, or as a pregnancy of unknown location.
Testimony
This afternoon Esmonde spent several hours giving often harrowing testimony concerning her treatment at STGH and CUH in January 2013.
As emotions ran high, Esmonde twice took short breaks in an effort to compose herself.
She told prosecuting barrister Neasa Bird that she underwent four scans between 6 and 8 January 2013 by different practitioners, before being told by Dr A on 8 January that her pregnancy was ectopic as her uterus appeared to be empty.
At the time, while suffering from severe pain due to the clot in her leg, Esmonde was not displaying any of the physical symptoms of an ectopic pregnancy, such as abdominal pain.
According to Esmonde, Dr A suggested that the best course of action was a course of Methotrexate in order to bring the pregnancy to a conclusion. He suggested that to let the pregnancy end naturally could have life-threatening consequences.
Esmonde agreed and a dosage of Methotrexate was administered to her that evening. She was then allowed to return home, only to be readmitted on 17 January after certain blood hormone levels which would be expected to fall following the administration of the drug did not do so.
On this occasion she was administered a second dose of Methotrexate.
On 25 January 2013, Esmonde was transferred to Cork University Hospital for further treatment of the blood clot in her leg.
There she underwent a trans-vaginal scan which indicated that her pregnancy was in fact an intrauterine one, but which was most likely unviable after the administration of Methotrexate.
At CUH it was decided to wait another week to see what might happen.
On 29 January, Dr A wrote by letter to a consultant obstetrician in CUH telling and referred to a diagnosis of ‘pregnancy of unknown location’, something Esmonde vehemently denied he had actually done.
Esmonde was discharged from CUH on 31 January. On 2 February she began to experience bleeding at home in Tipperary. She subsequently miscarried at CUH.
However, as Bird was at pains to emphasise, the Fitness to Practice committee “is not being asked to determine whether or not if Esmonde had not been prescribed Methotrexate her pregnancy would have turned out to be viable”.
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“I was shocked but I was happy,” Esmonde told Bird of discovering at STGH that she was pregnant.
“I was so excited that when a sonographer scanned my leg for an ultrasound I asked her to scan my abdomen so that I could see the baby. She did so but said that she couldn’t see anything,” she said.
Then a consultant radiologist scanned her abdomen and said: “I’m sorry, but I think this is an ectopic pregnancy.”
Esmonde said that while she only had a layman’s knowledge of the nature of ectopic pregnancies, she nevertheless was familiar with the concept.
She said that after a subsequent further scan on 7 January she was again informed she had an ectopic pregnancy and was given an information leaflet regarding the condition.
On 8 January she underwent yet another scan, this time conducted by Dr A.
“The pregnancy was very important to me, I was looking at the screen for hope, something to hold onto. Thus far no-one had said anything to me to give me hope,” she said.
When he finished he turned to me and said ‘you have an ectopic pregnancy’. He said it could be in a number of places. ‘Your uterus is empty’ he said.
He outlined my options and recommended Methotrexate as the only real option. He said I could have a second opinion but to bear in mind ‘I’m not the only one telling you you have an ectopic pregnancy’.
I was tear-stained, and he was very nice and sympathetic. I had trust in him. I said I was happy to go with this medical management of the problem.
When Esmonde re-attended STGH on 18 January she says she was told: “Oh Laura, the Methotrexate doesn’t seem to have worked, but we did warn you that in 10% or 15% of cases it won’t work.”
I agreed to have a second dose of the drug that evening. I had been told that occasionally a second dose is necessary if the first doesn’t work.
On 25 January, Esmonde’s sister asked Dr A what he would do if blood hormone levels didn’t drop and the pregnancy didn’t come to an end. “I will prescribe another dose of Methotrexate,” was his reply according to Esmonde.
Cork University Hospital
After transferring to CUH on 26 January, Esmonde said she underwent another scan and was told by the obstetrician there that her cervix was closed indicating there were no signs of miscarriage.
“They asked me what I’d been diagnosed with. I told them an ectopic pregnancy and that I thought they already knew that. They told me they were having trouble getting my records from STGH,” she said.
During the scan the doctor told me: ‘If I didn’t know better I would have thought you have a pregnancy that something has interfered with very early on’.
I went back to my ward then, I was so very upset. I had difficulty with everything I had been told. It was very distressing.
On 29 January, the obstetrician at CUH told Esmonde that they would wait for a week before their next move.
“I was thinking, ‘Does that mean my baby is ok, that the pregnancy is ok?’ But then I thought about the two doses of Methotrexate, and I thought about dealing with a baby with a lot of problems, from medicine that’s designed to attack growing cells.
“I had to leave the room I was so upset. I wandered the wards, and I could barely walk. I tried to ring my sister to tell her what I was going through, but thankfully I could get through to her.
“I was so, so angry. I was thinking: ‘I don’t care if someone hurts me, but if he’s hurt my baby I just wanted to kill him.
Visit
Before Esmonde returned home, she was visited at CUH by Dr A. She said:
He said ‘I’m not visiting as a doctor, but as a friend. It turns out you had an intrauterine pregnancy, but not an ectopic one’.
“I said I wanted to know the truth. He said it could be a number of possibilities, and he outlined several obscure conditions. To be honest I think he was just trying to blind me with science.
“He did say ‘maybe it’s because you’re so tall’. I think he said that out of nervousness, but it wasn’t appreciated,” she said.
Following her miscarriage, Esmonde complained officially to STGH in March 2013. She subsequently requested all her medical records from the hospital under Freedom of Information.
She says that in doing so she discovered that a report of a scan she underwent on 8 January 2013 was actually created on 24 March 2014.
She also saw the letter from Dr A to CUH on 29 January 2013 in which he described her diagnosis as one of pregnancy of unknown location. Esmonde subsequently had that record updated to say she had been diagnosed with an ectopic pregnancy. “It was important to do that,” she said. “Because what was written there wasn’t true.”
Cross examination
Defending barrister Simon Mills had earlier said he would be working off four points:
Mills further said he wanted to delve into whether or not Esmonde had behaved in an intimidatory manner towards another doctor at STGH having discovered her phone number inadvertently via one of her Freedom of Information requests.
He said he had to explore the possibility as it might point to Esmonde’s credibility.
Mills’ subsequent cross-examination of Esmonde was confrontational, with Esmonde disputing many of the claims he put to her.
Chief among those are the wording used by Dr A to describe her pregnancy on 8 January 2013. Mills claimed that Dr A described her condition as “a pregnancy of unknown location, most likely to be ectopic”.
“That is not true,” Esmonde replied. “I was told I had an ectopic pregnancy of unknown location.”
“I understood that to mean a pregnancy not where it should be, not in the uterus.”
“Can we agree he used the phrase ‘unknown location’?” asked Mills.
“No, I disagree completely,” Esmonde replied. “He spoke only of an ectopic pregnancy.”
The hearing continues.
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