A procedure to remove a miscarried foetus was halted when scans showed the embryo was still alive.
Just moments before undergoing a dilation and curettage (D&C), a woman requested a final scan of her uterus, which showed she had been mistakenly told she had miscarried.
New Zealand Health and Disability Commissioner Anthony Hill released a report on Monday that found a sonographer and a radiologist were in breach of the Code of Health and Disability Services Consumers' Rights for services provided to the woman. The names of those involved have been suppressed, as has the location of the incident.
The woman in question had a transabdominal scan, after her GP became concerned about her pregnancy, which was in its first trimester. The sonographer found no observable yolk sac, fetal pole or heartbeat, and concluded that she miscarried the embryo. He did not offer the woman a transvaginal scan, but noted that he did not believe the pregnancy was viable.
After the scan, the woman and her family met with an obstetrician, gynaecologist and a midwife, and she was told she had suffered a miscarriage. She chose to wait a few days in case the tissue would be expelled without medical intervention. During this time the woman was "very distressed", and drank alcohol, ate unsafe food and took medications that were potentially harmful to a foetus, she told the Health and Disability Commissioner.
She returned five days later to undergo the D&C, which would empty her uterus, but requested a final ultrasound for her own peace of mind. Her doctor concluded a repeat scan was appropriate, because her hormone levels were consistent with an ongoing pregnancy. Much to the surprise of the woman and her doctor, a viable embryo of 17.6mm was detected by the ultrasound.
In his report, Mr Hill found that it was wrong for the sonographer to deny the viability of the pregnancy, based on just one scan. He was also critical of the sonographer's decision not to offer the woman a transvaginal scan. Mr Hill recommended the NZ Medical Radiation Technologists Board consider a review of the sonographer's competency. He also recommended the sonographer make an apology to the woman, arrange an audit of his first-trimester viability scans and report on his learnings from a professional development programme.
The report also criticised the radiologist for failing to report that no transvaginal scan had been performed. Mr Hill recommended that the radiologist also carry out an audit.
He also recommended that the district health board use the woman's situation as a case study to highlight the importance of communication between sonographers and radiologists. The district health board was also required to update the sonographer worksheet to declare it was a provisional report, pending the review of a radiologist.
The patient, sonographer and radiologist were unnamed in the report, as was the location of the district health board.