Legal Briefs

Abstract

Twins (31 3/7 weeks) were born to a 31-year-old healthy mother with a pregnancy remarkable for an accidental administration of epinephrine at 10 3/7 weeks. The mother was experiencing severe hyperemesis gravidarum for which her physician ordered intravenous (IV) dolasetron mesylate (Anzemet®, sanofi-aventis, Bridgewater, NJ), but the outpatient nurse unintentionally administered epinephrine instead. The nurse gave the mother 1 mL of the 1:1,000 concentration of IV epinephrine. In adults, the dose of epinephrine for anaphylaxis is 1 mL of 1:1,000 solution intramuscularly or subcutaneously, and for cardiac arrest, it is 1 mL of 1:10,000 intravenously. The plaintiff experts pointed out that this mother received a concentration of epinephrine 10-fold higher than that used for cardiac arrest; for the 10-week fetuses, they were likewise exposed to a mega-dose. The mother immediately became pale and dizzy and developed chest pain, shortness of breath, tachycardia, and hypertension. An electrocardiograph showed a subendocardial myocardial infarction. A perinatologist closely observed the twins before and subsequent to this event. The twins were diamniotic monochorionic (DiMo) males as a result of in vitro fertilization (IVF). A week after the epinephrine administration, the mother experienced vaginal bleeding and an ultrasound showed a “possible subchorionic hematoma.” At 14 5/7 weeks’ gestation, 30 days after the epinephrine mishap, discordance was noted in the twin size (121 g and 96 g). The larger twin had polyhydramnios, for which 220 mL of red-brown amniotic fluid was removed. Both bladders were visible. No further amnioreduction was needed for the remainder of the pregnancy. The twin-to-twin transfusion syndrome (TTTS) met the least severe grade of the Quintero grading system (I of V). At 30 4/7 weeks’ gestation, the mother experienced a mild brownish discharge. On external monitoring, regular uterine contractions were occurring. The mother was admitted for IV tocolysis and antenatal steroids, …