Doctor ‘not entitled’ to suggest drug to end pregnancy

A gynaecologist has said a doctor at the heart of a Medical Council inquiry was "not entitled" to recommend medication that would end a mother's early pregnancy.

Methotrexate – a drug used to end an ectopic pregnancy – should only be advised if a consultant is completely certain of this diagnosis, expert witness Dr Philip Owen told the inquiry in Dublin on Thursday.

The hearing is looking into claims a consultant obstetrician and gynaecologist working at South Tipperary General Hospital – referred to as Dr A – wrongly diagnosed an ectopic pregnancy in the case of mother-of-three Laura Esmonde, when she presented at the hospital on January 6th, 2013 with a swollen leg.

Dr A advised methotrexate to end the pregnancy, which the 38-year-old took on January 8th.

Dr Owen, an obstetrician and gynaecologist based in Glasgow, said on Thursday he believed an ultrasound taken of Ms Esmonde on January 7th, 2013 by Dr A's registrar indicated a fluid-filled cyst on the right ovary, rather than an ectopic pregnancy.

Following this scan, Dr A conducted a transvaginal scan, at which point, according to Ms Esmonde, he told her she had “an ectopic pregnancy of unknown location”. He then recommended the methotrexate.

Dr Owen said on Thursday that Dr A did not have enough information to confirm a diagnosis of an ectopic pregnancy, and should therefore not have recommended that Ms Esmonde take methotrexate.

“In my opinion, he did not have enough information to advise methotrexate,” said Dr Owen. “He didn’t have enough information to exclude an intrauterine pregnancy – quite the opposite, in fact.

“If everything fits, you can make a diagnosis with confidence, but if everything doesn’t fit, you can’t make a diagnosis with confidence. What it boils down to is this: the entitlement to recommend the administration of methotrexate – have you met this criteria? No [in this case].”

‘No going back’

Dr Owen said methotrexate is deliberately intended to be lethal. “There’s no going back [with methotrexate] and everybody knows there’s no going back. That’s it. The ship has sailed,” said Dr Owen.

“And that’s why a consultant gynaecologist has to be 100 per cent before they recommend the administration of methotrexate. There has to be a zero possibility of a viable intrauterine pregnancy.”

Dr Owen pointed out that Dr A did not note Ms Esmonde’s lack of symptoms for an ectopic pregnancy, nor discuss her potential risk for these pregnancies with her.

“This is important because ectopic pregnancies account for 1 per cent of pregnancies,” he said, adding that 90 per cent of women who do have ectopic pregnancies show symptoms, such as bleeding or abdominal pain.

Earlier on Thursday, Dr John Coulter, a consultant gynaecological oncologist at Cork University Maternity Hospital (CUMH), told the inquiry he performed abdominal and vaginal exams on Ms Esmonde on January 27th, 2013. These exams showed no symptoms of an ectopic pregnancy, he said.

Mr Coulter’s evidence concurred with earlier evidence given by his colleague, consultant Keelin O’Donoghue, a leading expert in early pregnancy.

On Tuesday, Ms O’Donoghue said she found evidence of an intrauterine gestational sac, when she performed a scan on Ms Esmonde at CUMH on January 27th.

On Thursday, Mr Coulter said Ms O’Donoghue performed the ultrasound on Ms Esmonde in his presence, and he concurred with her that the scan appeared to show a pregnancy within Ms Esmonde’s womb.

Both consultants, however, were unsure of the viability of the pregnancy.

On January 29th, a radiographer performed a scan which also indicated a gestational sac in the uterus, although there appeared to be no foetal heartbeat.

Dr Coulter prescribed Ms Esmonde folic acid, just in case the pregnancy was viable, and arranged for a scan the following week.

However, before this scan took place, Ms Esmonde returned to hospital, on February 2nd, 2013, suffering from a miscarriage.

Pathologist Peter Kelehan, who examined a sample of tissue from Ms Esmonde's miscarriage, also gave evidence on Thursday, which appeared in contrast to Dr Coulter's testimony.

Dr Kelehan, who is based in Barringtons Hospital in Limerick, only found evidence of tissue from the lining of the womb, but no evidence of chorionic, or placental, tissue. A lack of chorionic tissue often signals an ectopic pregnancy, but does not completely exclude an intrauterine one, Dr Kelehan said.

Under cross-examination, Simon Mills, BL, who is representing Dr A, asked Dr Kelehan whether there was any evidence of an intrauterine pregnancy, at a pathological level.

“No,” Dr Kelehan responded.

Dr A denies the allegations against him.

The inquiry was adjourned until November.