Nausea and vomiting are common during early pregnancy, but symptoms that persist consistently after 16 to 20 weeks or are accompanied by abdominal pain should be considered abnormal and evaluated appropriately, states the author of a commentary from the September 2015 edition of the Agency for Healthcare Research and Quality's (AHRQ) online case study review, WebM&M. In the spotlight case, a 34-year-old woman who was 14 weeks pregnant presented to the emergency department (ED) after experiencing five days of nonspecific abdominal pain, nausea, and vomiting. After laboratory results confirmed an elevated white blood cell count and a urinalysis indicated nitrates and leukocyte esterase, she was diagnosed with a urinary tract infection and discharged on antibiotic therapy. She returned the next day with unchanged symptoms. A fetal ultrasound was performed that found normal fetal heart activity, so she was discharged with instructions to continue the antibiotics. After another 24 hours, the patient returned to the ED with worsening symptoms, and an MRI revealed a ruptured appendix with signs of peritonitis. Clinicians performed an emergent laparoscopic appendectomy, and although the patient initially tolerated the procedure well, three hours later she experienced a spontaneous abortion and required multiple transfusions due to severe bleeding. According to the commentary's author, because appendicitis is the most common cause of acute abdomen in pregnancy, and a delay in diagnosis can increase fetal mortality, the patient's pregnancy location and gestational age should have been determined and documented during the initial visit, and a further investigation into the patient's signs and symptoms should have prompted imaging studies of the abdomen and pelvis and consultation with an obstetric specialist. He emphasizes that imaging used to evaluate abdominal pain among pregnant patients should begin with ultrasound or MRI, but when clearly indicated by the clinical situation, imaging involving ionizing radiation should not be delayed or withheld due to concerns of fetal harm. Although radiation can potentially harm a fetus (e.g., miscarriage, fetal anomalies, fetal growth restriction, intellectual disability, and future childhood cancer), he notes that the risk is low, especially at lower radiation doses. To mitigate these risks, he recommends that ED physicians partner with obstetric specialists to develop a diagnostic imaging algorithm for pregnant patients with abdominal pain based on the availability and expertise of the facility's radiologic staff. Other case studies in the September 2015 issue of WebM&M discuss a patient who mistakenly remained on dual anticoagulation therapy for years because his medications were not reconciled and another who was mistakenly sent to an inappropriate inpatient rehabilitation facility.
HRC Recommends: Because both maternal and fetal lives may be at risk, a diagnostic error (e.g., a diagnosis that is missed, wrong, or delayed, as detected by a subsequent definitive test or finding) in pregnant patient is among the most dangerous and most costly of medical errors. To reduce the risk of diagnostic error, some experts recommend that clinicians improve their awareness of cognitive biases through education and teamwork; consideration of base rates (prior probabilities), sensitivity, and specificity of diagnostic tests and maneuvers when diagnosing common clinical conditions, and actively seek information that could refute the current provisional diagnosis. Risk managers should investigate ways to incorporate reporting of diagnostic errors into the organization's event reporting system and promote an environment that supports reporting. Strategies that may be used to help prevent diagnostic errors include use of electronic health records, optimization of test result communication, standardized handoffs, postdischarge follow-up, audits (e.g., retrospective chart reviews), mandatory second opinions on error-prone diagnoses, educational case studies, clinical decision support, electronic access to reference material (e.g., medical reference books, journals), promotion of clinical guidelines and algorithms, diagnostic checklists, feedback to physicians, and reduction of distractions and fatigue.
