A GP is sued over contraceptive care.
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Smart Practice
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35-YEAR-old mother of two children sought contraceptive advice from her GP. She had been unable to tolerate the combined oral contraceptive pill( COCP) in the past and now sought alternatives to this.
After some discussion it was agreed the woman would trial a low dose, progesterone only, oral contraceptive( mini pill) to assess her tolerance to progesterone with the view of transferring her onto a depot injection for long-acting reversible contraception( LARC). Nine weeks later the patient reported PV bleeding on this mini pill, that her partner had left her and that she wished to proceed to the LARC. A pregnancy test taken at that time was negative.
After discussing the risks and potential side effects, the GP prescribed depot medroxyprogesterone and advised the patient to return for the first injection after she had her next period.
The patient returned seven weeks later stating she had just finished her period and had not been sexually active recently. The GP injected the depot medroxyprogesterone and advise the patient to return in three months for the next injection. She did not record the date of the patient’ s last period nor did she repeat the pregnancy test.
When the patient returned for the second injection, she said she had no vaginal bleeding but some nausea and that she was reconciled with her partner.
When seen three months later for her next injection, the patient complained of heavy breasts with clear nipple discharge and abdominal distention. A pregnancy test was positive and an ultrasound revealed she was 26 / 27 weeks gestation. She went on to have a normal pregnancy and delivered a healthy child.
Duty of care The mother started a legal claim, alleging the GP was negligent in not recommending back-up contraception when the LARC was administered after the seventh day of her menstrual period.
Expert opinions A number of different experts provided the following opinions:
• The patient was pregnant at the time of the
Imperfect timing
EXPERT OPINION
A GP is sued over contraceptive care.
DR CRAIG LILIENTHAL
QUESTIONS FOR OUR EXPERT
Dr Terri Foran is a GP and expert in women’ s health in Sydney, NSW. 1. Should a pregnancy test always be performed before any LARC is initiated? The answer here is yes, but the limitations of pregnancy testing must also be understood. A negative pregnancy test is unreliable if intercourse has occurred in the two or three weeks before. There should be a very low threshold for performing a pregnancy test in any woman of reproductive age— and repeating it three weeks later if there is any doubt as to dates or history.
2. How do we interpret the last expert’ s comment above about peer opinion versus the manufacturer’ s recommendations? The expert is simply reflecting the more nuanced approach taken in clinical practice. Ideally contraception is initiated in the first five days of the cycle since this largely rules out pregnancy and also provides immediate contraceptive cover. However‘ quick-starting’ is now widely accepted for most contraceptives( though not IUDs) and allows starting at any time of the cycle. Women beginning a new method of contraception after day five must use a back-up method for seven days. But the most critical requirement with‘ quick-start’ is that all women have a repeat pregnancy test 3-4 weeks after their last unprotected intercourse.
3. Which opinion is a court of law likely to prefer and find more reliable? Courts are conservative and usually prefer that manufacturer’ s recommendations be followed to the letter. The advantage of this approach is that it is hard to challenge. The disadvantage is that recommendations may be out-of-date with regard to current evidence and practice. Had the clinician recorded the date of the last period, checked the pregnancy test was negative and advised additional precautions for seven days, things may have gone differently. A pregnancy test four weeks after the first injection should have picked up the early pregnancy and allowed for an uncomplicated termination if desired. Lastly, the nausea reported by the patient on return for her second injection is uncommon in women using this method. Contraceptive failure should definitely have been considered.
first injection and a pregnancy test at the time would have been positive.
• One important issue was exactly when the patient’ s period started and whether the administration of the injection was in accordance with the manufacturer’ s recommendations.
• Given the calculated dates determined by the ultrasound, conception could be consistent with the patient’ s statement that she had not had sexual relations in the month prior to the date of the injection.
• The manufacturer recommends the first injection be given in the first five days of the patient’ s menstrual cycle.
• It appeared likely the patient was beyond day five of her menstrual cycle when she attended her GP and so the injection administered on that date did not suppress ovulation. As a consequence when she had sexual intercourse a few days later, ovulation occurred normally.
• If an injection of depot progesterone was given within the first seven days of the start of the patient’ s menstrual cycle, this would be widely accepted by peers as competent, even though not consistent with the manufacture’ s recommendations.
Outcome The claim was reviewed by the GP’ s MDO and it was agreed it should be settled because back-up contraception had not been recommended and a pregnancy test had not been performed when the patient presented with nausea. The settlement was achieved for a moderate sum inclusive of costs, with terms not to be disclosed. ●
Dr Lilienthal is a GP and medicolegal adviser in Sydney, NSW.
Tech Talk
Geir O’ Rourke
The curious case of digital self-harm
THE case of English teen Hannah Smith, who took her own life in 2013 after being called“ a slut” and told“ to die” on social media, made newspaper headlines across the UK. But not for the reasons you might expect.
Hannah’ s family was convinced the 14-year-old had been driven to suicide by a gang of internet trolls. However, the truth was far stranger. The horrible messages had all come from just one computer— Hannah’ s.
After a long investigation, a coroner ruled that there was no evidence to suggest the teenager had been the victim of cyberbullying.
Instead, the coroner said the campaign of abuse“ would all have been at Hannah’ s own hand”.
“ Why she did it, I don’ t know,” the coroner said in her summation.
In Hannah’ s case, it will likely remain a mystery, but new research is beginning to shed light on the phenomenon of‘ digital self-harm’.
Data published in the Journal of Adolescent Health last month suggested that as many as 6 % of teens had written or shared something hurtful about themselves online.
Criminologists from the University of Wisconsin and Florida Atlantic University asked 5593 US high school students if they had ever“ anonymously cyberbullied” themselves or posted something online about themselves that was“ mean”.
More than 7 % of the boys and 5 % of the girls reported posting something unkind about themselves online, with 13 % saying they had done it many times. The students, aged 12-17, were also asked to record why they had done so.
The reasons varied, with many reporting they were seeking attention, while others described being motivated by self-hate or to find an outlet for depressive symptoms.
Beyond that, there was a strong correlation between digital self-harm and being bullied at school.
For example, a 16-year-old girl wrote:“ After this happened at school and online, I became very depressed. I didn’ t like myself very much. I felt like I deserved to be treated that way, so I thought I would get in on the‘ fun’.”
Professor Marilyn Campbell, a psychology researcher at Queensland University of Technology specialising in cyberbullying, said it could be very similar to physical self-harm.
“ It’ s harder to detect and there is less immediate physical danger, but that doesn’ t mean it’ s not serious.”
Young people play out so much of their lives online that in some ways, it should be no surprise that self-harm, too, migrates to the digital space, she added. Journal of Adolescent Health 2017; online.
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