Thursday 23 November 2017

Doctor was following guidelines in ectopic pregnancy, Medical Council inquiry told

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Isabel Hayes

A doctor accused of misdiagnosing an ectopic pregnancy and prescribing drugs to terminate it was following guidelines in what could have been an extremely risky situation, a Medical Council inquiry has been told.

The consultant obstetrician and gynaecologist told mother-of-three Laura Esmonde she could “die in her sleep” and “bleed to death” if she took no action in relation to her suspected ectopic pregnancy in January 2013.

The doctor, identified as Dr A, is accused of poor professional performance in his care of Ms Esmonde at South Tipperary General Hospital

The Medical Council inquiry has heard allegations Dr A wrongly diagnosed Ms Esmonde with an ectopic pregnancy on January 8, when in fact it was a normal pregnancy. He prescribed her two courses of methotrexate, a medication used to stop ectopic pregnancies from growing, which she took.

Nearly three weeks later, on January 26, subsequent ultrasound scans revealed the pregnancy was not ectopic, the inquiry heard. However at that stage, it was not viable and she miscarried on February 2.

Dr A is facing a number of allegations including that he misinterpreted ultrasound scans, placed disproportionate reliance on those scans to make a diagnosis of ectopic pregnancy and diagnosed methotrexate without excluding the possibility of an intra-uterine pregnancy.

He did not give evidence at the inquiry, which took place over a number of days in September and November.

In closing submissions on Friday, Neasa Bird BL, representing the case against Dr A, said the inquiry committee could be satisfied “beyond reasonable doubt” that Ms Esmonde's pregnancy was intra-uterine, or in the womb.

She said once the drug methotrexate was taken, “there was no going back”.

“Once it is administered, any possibility of a viable intra-uterine pregnancy has come to an end,” Ms Bird said.

Ms Esmonde “clearly agreed to methotrexate on the basis (of Dr A's assertion) that 100 per cent of her uterus was empty,” Ms Bird said. “That was incorrect and that can not have been absolutely categoric.”

Ms Bird said Dr A gave no consideration to conservative management of the pregnancy, that is, waiting to see if the outcome changed. When asked by Ms Esmonde if she could do this, Dr A told her she might not develop any symptoms of an ectopic pregnancy and could die in her sleep, the inquiry heard.

Simon Mills BL, representing Dr A, said the consultant was following medical guidelines when he prescribed methotrexate to Ms Esmonde.

He noted that a total of four medical observers were unable to identify a pregnancy in Ms Esmonde's uterus in ultrasound scans before the decision was made. Her blood levels of the pregnancy hormone HCG were also low and in the medical “discriminatory zone”, Mr Mills said.

“The guidelines applied, the guidelines were followed,” he said, adding, “What is a doctor supposed to follow if not the guidelines?”

“You have to put yourself in the position of Dr A on the afternoon of January 8. He couldn't know what the scans on January 26 would show...You may conclude Dr A was wrong. That's not what this case is about. It's about whether it was poor professional performance to take the course he did.”

Mr Mills pointed to evidence from Rotunda master, Professor Fergal Malone, and consultant obstetrician Dr Peter Lenehan, who appeared before the inquiry and who were “clear about the risks faced” in the case of a suspected ectopic pregnancy.

“These two Irish experts both say they would have proceeded in the same way, had they found themselves in Dr A's position,” Mr Mills said.

The inquiry committee, chaired by Dr Michael Ryan, will hand down its decision next week.

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