Death and Lost Fertility
The following is a hypothetical situation designed to demonstrate a common form of medical error. It is not a real case, and no physician has reviewed it or offered an opinion about it.
Two ER visits, 31 hours apart
A woman of 26 came to an emergency department on a Friday at 11:40 at night. She had 2 days of pain low on the left side of her abdomen and some light spotting. She told the triage nurse her last period had been lighter than usual. A urine sample showed a small number of white blood cells and some blood. She was told she had a urinary tract infection, given antibiotics and medication for pain, and discharged at 2:15 in the morning. Her pulse was 96 at discharge, up from 88 on arrival. No pregnancy test appears anywhere in the chart. She came back by ambulance 31 hours later, pale and sweating, with a pulse of 128 (tachycardia) and a blood pressure of 78/44. In surgery that morning the surgeon found 1.8 liters of blood in her abdomen and a torn fallopian tube. She received 4 units of blood, and the tube was removed.
The short answer
An ectopic pregnancy is a pregnancy that implants outside the womb, almost always in a fallopian tube. The tube cannot hold a growing pregnancy. When it tears, the patient bleeds into her own abdomen.
The failure that repeats in these cases is not a subtle one. It is a pregnancy test that nobody ordered. Everything downstream, the ultrasound, the hormone levels, the surgeon, depends on that one test, and in these charts it is often simply absent.
There are two legal questions. Did the care fall below what a careful doctor, nurse, or hospital would have done? And would finding the pregnancy at that first visit have changed the outcome?
The rest of this page explains how to tell what happened in your own case. Our guide to severe abdominal pain emergencies covers the other conditions that go wrong this way.
Contact Us for a Free, Confidential Consultation
Article written by Gregory Unatin, Esq. Greg is a managing partner in the law firm of Lupetin & Unatin, a medical malpractice law firm located in Pittsburgh and serving Western Pennsylvania.
Our practice is limited to high-value catastrophic cases because that is where we can do the most for our clients and for patient safety.
What an ectopic pregnancy actually is
After an egg is fertilized it normally travels down the fallopian tube and implants in the womb. Sometimes it stops along the way and implants in the tube itself. That is an ectopic pregnancy.
The womb is built to stretch. The tube is not. It is a narrow tube of muscle a few millimeters wide, wrapped in blood vessels. A pregnancy growing inside it burrows into the wall and thins it out from the inside.
Eventually the tube tears. What follows is bleeding, into the abdomen rather than out of the body. The torn tissue is fed by vessels that do not reliably clot themselves off, so the bleeding can keep going.
One honest point, because it matters to these cases. Not every ectopic pregnancy ruptures. Some stop growing and resolve on their own, and some are treated with medicine instead of surgery. That is exactly why finding it early matters. What cannot be watched and waited out is a tube that has already torn.
Why a ruptured ectopic pregnancy gets missed
The miss almost always happens at the first step, and the first step is a pregnancy test.
Sometimes the patient does not know she is pregnant. Early pregnancy can be quiet. Spotting gets read as a light period, which is what makes the menstrual history in the chart so important later.
Sometimes she says she cannot be pregnant, and she believes it. She is on birth control. She had her tubes tied. She has an intrauterine device. She does not think the timing works. Every one of those makes pregnancy less likely. Not one of them makes it impossible.
Then the symptoms point somewhere else. Pain low in the abdomen with some spotting looks like a urinary infection, an ovarian cyst, appendicitis, or a stomach virus. A urine sample from a woman who is bleeding internally can show blood and a few white cells. That reads as a urinary infection to any health care provider who is not questioning a different condition.
The last reason is the most dangerous. Bleeding inside the abdomen shows nothing on the outside. There is no bruise and no visible blood. A young, healthy patient can lose a significant amount and still have a blood pressure that looks acceptable. Often the pulse drifts up first, and often nothing else changes at all.
That mistake is understandable. Urinary infections and ovarian cysts are common, and ectopic pregnancy is not. The overlap in symptoms is real. And a patient telling a doctor she is not pregnant is information, not nothing.
What is harder to defend is a chart with no test in it. A pregnancy test takes minutes and costs almost nothing.
The test that should have been done
The pregnancy test. A urine test is fast and is usually enough. A blood test that measures the pregnancy hormone is more sensitive. A urine test can read negative very early in a pregnancy, or when the urine is dilute. So a negative urine test in a patient whose story fits is not the end of the question. While a qualitative urine test is the standard rapid screening tool, an indeterminate or negative urine test in a patient with severe pelvic symptoms, risk factors, or hemodynamic instability warrants a blood test called a quantitative serum -hCG test
The ultrasound. Once the pregnancy test is positive, an ultrasound looks for the pregnancy inside the womb. The kind of ultraound that sees this best is done with a probe placed internally rather than only on the abdomen. Here is the part families are rarely told. An ultrasound that does not find a pregnancy in the womb does not rule out an ectopic pregnancy. It raises the concern. The ectopic pregnancy itself is not always visible. What the scan can also show is free fluid in the abdomen, which in this setting means blood.
The hormone levels. A quantitative level is a number rather than a yes or a no. It is sometimes repeated over days to see whether it rises the way a normal pregnancy does. One number by itself cannot make this diagnosis or exclude it. There is no level low enough to rule out an ectopic pregnancy.
What happens when the tests do not settle it. This situation has a name in obstetrics, a pregnancy of unknown location, and it comes with a plan. Repeat levels at a set interval. A specific person responsible for the result. Written instructions about what to come back for. What is not a plan is a follow up appointment for a patient whose pulse is climbing. A patient with a positive pregnancy test combined with free pelvic fluid, adnexal mass, and a rising tachycardia mandates urgent gynecological consultation and immediate surgical evaluation.
The clock
Before the tube tears, the timeline is usually days to weeks. That is the window where this is a manageable problem.
After it tears, the timeline changes completely. How fast depends on which vessels are torn, and it varies from patient to patient. Blood collects in the abdomen. The heart speeds up to compensate, and it can compensate for a surprisingly long time before blood pressure falls. Once blood pressure starts to fall, the patient is already far along.
Nobody can put a reliable number of hours on it. What is not in dispute is the direction. Diagnosis before rupture is a different medical problem than diagnosis after it.
The treatment reflects that. Found early, an ectopic pregnancy can sometimes be treated with medicine that stops it from growing, and the tube is left in place. Found after rupture, the treatment is surgery to stop the bleeding, usually with blood transfusion, and the torn tube often cannot be saved.
In this case, a pregnancy test on the first visit would have changed the plan. Diagnosing the condition prior to rupture provides the opportunity for medical treatment or fertility-sparing surgical options that avoid emergency hemorrhagic shock and unscheduled tube removal.
Who is at highest risk
- Any patient who could be pregnant and who comes in with abdominal pain. This is the one that matters most, because it is the one that should trigger the test.
- A prior ectopic pregnancy, which raises the risk of another.
- Prior surgery on the tubes, including having them tied.
- An intrauterine device in place, which prevents most pregnancies but changes where a pregnancy is likely to be if one happens.
- A prior pelvic infection, which can scar the tubes.
- Fertility treatment.
What to look for in the records
These are things you can check, or ask a lawyer to check.
- Whether a pregnancy test was ordered at all, and if so, the result and the time it was run.
- The triage note, and whether the date of the last period appears anywhere in it.
- The physician note, and whether pregnancy is mentioned as a possibility and then ruled out or not.
- Whether a pelvic examination was performed, and what it recorded.
- The urinalysis result, and whether the blood in the urine was ever explained.
- The ultrasound report, whether the study was done internally, and whether free fluid is described.
- Hormone levels with their times, and whether a repeat was arranged and by whom.
- The complete vital sign record, read as a trend rather than one number at a time.
- The medication record, and whether repeat doses of pain medicine were given before discharge.
- The discharge instructions, and whether they told her what to come back for.
- The transfusion records show how much blood was given and when.
The central question: should a pregnancy test have been done?
Most patients who come to an emergency department with abdominal pain are not pregnant. Most pregnancies are not ectopic. The symptoms here overlap almost completely with several conditions that are far more common and mostly harmless. A defense expert will say the presentation was nonspecific, the patient herself said pregnancy was not possible, and hindsight makes an ordinary visit look negligent. Sometimes that is right.
The two central questions remain. Did the care fall below what a careful doctor, nurse, or hospital would have done in the same situation? And would finding the pregnancy at the first visit have changed the outcome?
The argument here is not that this diagnosis is easy. It is narrower. It is that this patient was of childbearing age, had pain low in her abdomen, and reported an unusual period with spotting. The chart holds no record that anyone checked. The medical evidence must then show that checking would have led to treatment before the tube tore.
How people die from this, and what happens to those who survive
Most ectopic pregnancies that are found before the tube tears are treated without a catastrophe.
When it goes the other way, it usually goes one of two ways. The more common is bleeding faster than anyone can replace, called hemorrhagic shock. Blood collects in the abdomen, pressure falls, organs stop getting oxygen, and at some point, the process cannot be reversed even in an operating room. The other is death in the days after surgery, in a patient whose organs had already been injured by the time the bleeding was stopped. Death from this condition is uncommon once a patient is in a hospital. It remains one of the leading causes of death in early pregnancy.
Among those who survive, the injuries that permanently change a life are these, the most common first.
- Loss of the fallopian tube. This is the reliable catastrophic injury in these cases, because a tube that has torn often cannot be repaired. Many women go on to conceive with one tube. Others do not, and the risk of a future ectopic pregnancy is higher after the first one.
- A hysterectomy, meaning removal of the womb. This is uncommon in these cases, and it happens when the bleeding cannot be controlled any other way.
For a woman who wanted children, the fertility injury is the one that lasts. It is also the one most often undervalued.
How we prove a case like this
A handful of records decide this condition.
Whether a pregnancy test was ordered, and what it showed, is usually the first thing we look for and often the whole case. The triage documentation of menstrual history is what establishes that the information was available to the people treating her. The ultrasound and hormone results, with their timestamps, show what was known and when. The transfusion records measure the blood loss in units, which is how the delay gets converted into harm. The operative report describes the state of the tube, which tells us whether it could have been saved earlier.
These cases usually need emergency medicine, obstetrics and gynecology, and radiology.
Pennsylvania also requires a licensed professional to certify that the care fell below the accepted standard before a case can move forward. Our guide to severe abdominal pain emergencies walks through the full investigation process.
Frequently Asked Questions
No, and this is the most common thing families are told. What a patient believes about her own pregnancy status is information, and it is not a test result. Patients are wrong about this often, sometimes because the timing surprised them and sometimes because they were using birth control. That is exactly why the test exists and why it is standard for abdominal pain in a patient who could be pregnant. A doctor is allowed to consider what she said. Relying on it instead of testing is a different thing.
Having the tubes tied prevents the great majority of pregnancies, but not all of them. When a pregnancy does happen afterward, the odds that it sits in the tube rather than the womb are higher, not lower. The same is true for a pregnancy that happens with an intrauterine device in place. A history that makes pregnancy unlikely can make an ectopic pregnancy more likely if one occurs.
No. The records that matter here include laboratory logs, triage notes, ultrasound images, and transfusion records, which are among the harder ones to obtain. We request the complete record ourselves.
No. An initial conversation is free, and so is our review of the case. We work on a contingency basis, which means a fee only if we recover money for you.
In Pennsylvania, a medical malpractice lawsuit must be filed in a proper court within two years of the date of death or in the absence of death, the date when the patient knew or should have known they suffered an injury which may have been related to health care. The practical point is that these cases turn on a laboratory record that either exists or does not. Memories fade too. Waiting costs you something even when no deadline is close.
What to do now
Gather what you have: discharge paperwork from every visit, any operative report, and the hospital name and dates. Then write down what she told them, while it is fresh. What she said about her last period. Whether anyone asked her about pregnancy. What she was told her diagnosis was, and what she was told to do if the pain got worse. Families are often the only source for what was said out loud and never written down. Then call us.