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Cognitive Error: The Implications of Anchoring Bias and the Framing Effect in the Diagnosis of Intrauterine Fetal Demise (IUFD) in the Setting of Undiagnosed Concealed Placental Abruption
Abstract Number: F-13
Abstract Type: Case Report/Case Series
A 37yo G3P1011 at 32 weeks, presented with moderate abdominal pain and no noted fetal movement for >2 days. Fetal heart tones were absent and IUFD was confirmed by ultrasound. IOL and delivery of the fetus was planned. Anesthesiology was consulted, finding a pale and ill-appearing patient, but attributed the patient’s condition to the stress and grief of a newly diagnosed IUFD. Options for labor analgesia were discussed. Later, while obtaining IV access, the patient was noted to be diaphoretic and lethargic. Repeat ultrasound exam suggested retroplacental clot and abruption. Laboratory values confirmed DIC, and significant vaginal bleeding began during her exam. An arterial line was placed, large bore PIV access established, and a massive transfusion protocol was activated in preparation for an emergent cesarean section.
General anesthesia was induced without complication, followed by a repeat cesarean section. Approximately 2L of blood clot, placenta, and fetus were removed from the uterus. Significant hemorrhage necessitated uterotonics, B-Lynch sutures and bilateral uterine artery ligation. Total blood loss was approximately 5.5 L and 20 units of blood products were required for resuscitation. The patient was transferred to the surgical ICU, extubated the next day and discharged home on POD #4.
Multiple types of cognitive error contributed to a delay in diagnosis of placental abruption, DIC, and the urgency of cesarean delivery. More specifically, anchoring, or fixation, bias played an important role. Attention is focused on one feature of a diagnosis exclusively, at the expense of a more comprehensive understanding.(1) Cognitive errors in decision making may cause more than two thirds of missed or delayed diagnoses according to some estimates.(2) Reports from the ASA closed claims registry suggest that >50% of diagnosis-related adverse events in obstetric anesthesia were related to a delay in diagnosis or treatment.(3) Heuristic decision making and an initial focus on the diagnosis of IUFD delayed the recognition of worsening physical signs and eventual diagnosis of abruption.
This patient was discussed by three different care teams: OB, Anesthesia, and Nursing. The framing effect clouded each team’s impression of the clinical situation. The patient was described to be experiencing significant grief, erroneously providing an explanation for her organic clinical picture. Placental abruption was the likely etiology for this IUFD, and should be immediately considered as a possible diagnosis in the setting of IUFD, hypertension, and abdominal pain.(4) In addition to those discussed, other types of cognitive errors played significant roles in this case. Hindsight analysis can enable practitioners to better evaluate their clinical decision making abilities and biases in the future.
1. Anesthesiology 2014; 120:204-217
2. Arch Intern Med 2005; 165:1493–9
3. Anesthesiology 2009; 110:131–9
4. Obstet Gynecol 2006; 108:1005