Medicolega - Cases

Medicolegal Cases In Mtp:

In other consultations about illness, patient readily accepts advice offered by the doctor. In contrast, in most consultations about MTP, patients own opinion matters a lot. There is no illness here and hence providing proper information about the methods and the risk of abortion becomes very important. Unfortunately especially in our country, this aspect is given least importance and hence is a problematic situation; patient's unhappiness is aggravated. Medicolegal cases in MTP arise I various ways. It could be:

• Due to omission to follow technical procedures of the law.
• It could be because of complications during the procedure.
• They could be due to certain unavoidable circumstances like atonic hemorrhage
• They could be because of peculiarity of the patients condition itself.
• They could be sequelae of MTP procedure either short term or long term.

MTP law is quiet precise. However, in our situation many times laws are not followed in the spirit or the letter.

MTP by a nonrecognized person: in one of the cases, a doctor was held responsible because he allowed his nonrecognised assistant to carry out the MTP, which ended with complications.

MTP in nonrecognised centers: MTP law lays down precise requirement and procedures for recognition of place for MTP. In recent survey carried out by an NGO (Cehat), it was found that only 22% of eligible centers are registered under MTP Act. There are many reasons including 'red tapism'. But that hardly protects one in the court of law.

Consents and Opinions: Law also requires certain forms of consents and opinions to be filled in before an MTP, though it is rarely followed to the letter of the law, when a mishap occurs. Lawyers tend to dig out all details to show that the doctor was negligent. Hence, it is always better to atleast make notes in proper format on the case paper regarding these matters. A proper consent is extremely important for MTP. Consent in case of MTP is many times controversial. One thing is certain that an adult woman can give consent for her own MTP, and her spouse's consent is not required. However, it is wise to get either husband or any other adult person's signature as a witness to the woman's consent.

In case of an unmarried girl her boyfriend has no legal status and his consent is not valid in the yes of the law. A doctor got into trouble where a minor girl claimed herself to be a major and signed the consent. As in the eyes of law it is the doctor's responsibility to ensure the age of the patient and to take her guardian's consent if she is minor.

Medical Problems arising due to complications because of the procedure: there is a case of sudden death due to anaphylaxis to local anesthesia. There even though it may have been unavoidable, but he questions remain whether testing was done for the local anesthesia and whether proper treatment of anaphylaxis was tried or not, becomes proper medicolegal issue. Sometimes a gynecologist takes all the due care but if the case records are incomplete, he or she is likely to be implicated. In another case death was caused even before starting the procedure during induction of Pentothal anesthesia, but the doctor was implicated because no preoperative investigations were done and patient turned out to be a diabetic.

These are the situations where guidelines should be laid down, which are the minimum investigations needed before a simple procedure like MTP. Then comes the problem of complications. In a famous case from the south, bleeding occurred due to perforation of the previous lower segment cesarean section scar. The patient went to the court implying negligence. The defence pleaded that it was a cervical pregnancy, perforation was unavoidable and hence there was no negligence. Reading of this case truly makes an interesting lesson as to how lawyers can take part all actions on part of the doctors absolutely thread bare. In this case the prosecution lawyer brought out several problems, example:

• Patient did not want MTP;
• USG was not done before MTP;
• Proper procedures not followed, for example forms etc;
• Laminaria tents should not have been used;
• Cervical pregnancy should have been proved by histology of removed uterus;
• Anesthetists notes mentioned persistent pulmonary hypertension;
• Noted records did not ay which type of cervical pregnancy it was.

So this was how all the minute details were discussed. Fortunately solid defence by the defendant saved the day.

There have been other problems like perforation and perforation with injuries to intestines and bladder. Perforations may not be called as negligence, but failure to diagnose a perforation even when indicating sign are present, is held to be negligent. In recently reported case, VP Patel v. Dr. Ajmera , patient had perforation during MTP. It was not diagnosed early and the patient developed fecal fistula and the doctor was held negligent by the Gujarat state Forum and the compensation of Rs.2 lakhs was awarded. Sometimes situations are peculiar. In one case, before National Consumer Forum. Compensation upto Rs.50 lakhs was asked. Here patient was having pregnancy with large fibroid. The pregnancy was sought to be terminated but apparently continued. Patient delivered normally a healthy child, but still the patient has gone to the court claiming mental agony and possible harm to the baby. This case is yet to be decided. In these cases of failure of MTP, it is say for the lawyers to conclude negligence. Fortunately in a recent case where an ectopic pregnancy was missed when D and E was carried out, the gynecologist was held not guilty of negligence by the Tamil Nadu State forum. Hence the gynecologist must emphasize the fact that here is always a small failure rate in all these procedures, which may not be necessarily mean negligence. This is true of other complications also. In such cases advice for proper follow-up if documented can go a long way absolving the doctor.

Then comes the last category of immediate or long-term sequelae. Proper documentation and meticulous explanation help alleviate the medicolegal problems especially if mention of complications have been made in the consent forms. In a recent case of short-term sequelae, peculiar circumstances where MTP was carried out can be pointed out. The Patient was alright for 2 weeks, and then suddenly expired while walking on the road. Because of the sudden death postmortem was carried out in which few infected products of conception were reported in the uterus. Since no other cause of death could be given, the police made out a case of criminal negligence against the doctor. This case is also yet to be decided.

In conclusion one can see, a simple procedure like MTP has a lot of legal implications, most of which can be avoided with proper pre-operative information and care.