Opinion ID: 1058434
Heading Depth: 1
Heading Rank: 2

Heading: doctors' appeal

Text: In February 2002, Julie met with Dr. Solos-Kountouris for pre-conception counseling and a gynecological examination. Dr. Solos-Kountouris discussed the risks associated with conceiving a child when the mother is past the age of 35, in particular the risk of having a fetus with a chromosomal abnormality. [3] According to Dr. Solos-Kountouris, she emphasized the importance of screening tests, including CVS and amniocentesis, [4] and explained how such procedures are performed, the risks associated with them, and the time frame during a pregnancy when the mother can undergo the tests. Julie's testimony about the initial appointment differed from that of Dr. Solos-Kountouris. Julie stated that Dr. Solos-Kountouris discussed and recommended only amniocentesis. Julie testified about how she explained to Dr. Solos-Kountouris that, since amniocentesis is performed 16 to 18 weeks into the pregnancy, she felt the pregnancy would be too far along to terminate if the procedure revealed an abnormality. According to Julie, after the first trimester she would feel and look pregnant, and it's a baby, not a fetus at that point. To Julie, anything past the first trimester is ... when my responsibility is to manage the pregnancy. Julie further testified that Dr. Solos-Kountouris told her amniocentesis was the only way to determine whether a fetus has a chromosomal abnormality. Moreover, Julie insisted that no one at the Doctors' office mentioned CVS during either her initial appointment or her subsequent appointments. Soon after the pre-conception counseling visit, Julie became pregnant and returned to the Doctors in March 2002 to confirm her pregnancy. At that appointment, she saw Dr. Fruiterman, who, like Dr. Solos-Kountouris, recommended that Julie undergo amniocentesis. According to Julie, she again rejected amniocentesis because, in her view, it is performed too far along in the pregnancy. Throughout her pregnancy, Dr. Fruiterman and Dr. SolosKountouris also recommended that Julie receive genetic counseling. Despite their recommendations, Julie never attended genetic counseling. Additionally, she never underwent amniocentesis, despite a positive alpha-fetoprotein blood test result in June 2002. The result signaled that the fetuses had a high risk for Down syndrome. In September 2002, Julie gave birth to identical twin girls, both of whom are afflicted with Down syndrome. At trial, Julie insisted that, if the Doctors had advised her about the availability of CVS either before or during the first trimester of her pregnancy, she would have undergone the test. Julie stated she would not have bonded with her fetuses before the test could have been performed. She further testified that, if the test result had been positive, meaning her twin fetuses were afflicted with Down syndrome, she would have to have had a double abortion. The Granatas presented testimony from two medical expert witnesses. The first witness, John Williams, III, M.D., an expert in the field of obstetrics and gynecology, testified to the standard of care for an obstetrician to inform his patients about the availability of CVS. In forming his opinions, Dr. Williams relied upon medical literature, one of which described amniocentesis and CVS as definitive diagnostic test[s]. During cross-examination, Dr. Williams admitted that there is a possibility of receiving a false result from CVS, but claimed such a result is extremely rare. When asked if there are instances of positive CVS results that have been disproved by later tests indicating a fetus is normal, Dr. Williams explained that there are occasions when there is a mixture of normal and abnormal cells, and in that situation better than 90 percent of the time the fetus is not affected. He also stated that about 1-in-100 patients would require a follow-up amniocentesis to sort things out after receiving a positive CVS. At no time during his testimony did Dr. Williams state his opinion as to whether CVS would have been positive for Down syndrome if Julie had undergone that test. Similarly, the Granatas' other medical expert witness, Ronald J. Wapner, M.D., also an expert in the field of obstetrics and gynecology, expressed no opinion on that particular issue. Dr. Wapner, like Dr. Williams, acknowledged that one of the risks associated with undergoing either CVS or amniocentesis is the possibility of having false positives and false negatives, and sometimes information that just won't be interpretable at all. One of the Doctors' witnesses, Mary E. D'Alton, M.D., who testified as an expert in the field of obstetrics and gynecology, stated there is a problem in using CVS in the case of twin fetuses because of the potential for cross-contamination ... between the placentas or two samples from only one fetus. Thus, in her opinion, a 1-in-20 chance exists that a CVS in a pregnancy with twin fetuses will provide mixed information, thereby requiring further testing such as amniocentesis. Additionally, Dr. D'Alton testified that there is a potential for misdiagnosis with CVS that is not there with amniocentesis.
In addressing the Doctors' challenge to the sufficiency of the evidence to prove that, if Julie had undergone CVS, the result would have shown the chromosomal abnormality associated with Down syndrome, we apply established principles of appellate review. A plaintiff who is [a]rmed with a jury verdict approved by the trial court, ... stands in `the most favored position known to the law.' Bitar v. Rahman, 272 Va. 130, 137, 630 S.E.2d 319, 323 (2006) (quoting Ravenwood Towers, Inc. v. Woodyard, 244 Va. 51, 57, 419 S.E.2d 627, 630 (1992)). When a trial court has refused to strike a plaintiff's evidence or to set aside a jury verdict, the well-established standard of appellate review requires this Court to determine whether the evidence presented at trial, taken in the light most favorable to the plaintiff, was sufficient to support the jury verdict in favor of the plaintiff. Id. at 141, 630 S.E.2d at 325-26. We will not set aside a trial court's judgment sustaining a jury verdict unless it is plainly wrong or without evidence to support it. Code § 8.01-680; see also Bitar, 272 Va. at 137, 630 S.E.2d at 323. In Julie's wrongful birth case, as in any medical malpractice action, one of the elements that a plaintiff must prove is a causal connection between the breach of duty and any claimed injury or damage. Naccash v. Burger, 223 Va. 406, 414, 290 S.E.2d 825, 829 (1982); see also Bryan v. Burt, 254 Va. 28, 34, 486 S.E.2d 536, 539-40 (1997) ([A] plaintiff must establish not only that a defendant violated the applicable standard of care, and therefore was negligent, the plaintiff must also sustain the burden of showing that the negligent acts constituted a proximate cause of the injury.); Brown v. Koulizakis, 229 Va. 524, 532, 331 S.E.2d 440, 446 (1985) (same). Although the issue of proximate causation is normally a question of fact for the jury to determine, a court may decide the issue when reasonable persons could not differ. Jenkins v. Payne, 251 Va. 122, 128, 465 S.E.2d 795, 799 (1996); accord Hadeed v. Medic-24, Ltd., 237 Va. 277, 285, 377 S.E.2d 589, 593 (1989). Expert testimony is generally required to establish not only the appropriate standard of care and a deviation from the standard, but also `that such a deviation was the proximate cause of the claimed damages.'  Perdieu v. Blackstone Family Practice Ctr., Inc., 264 Va. 408, 420, 568 S.E.2d 703, 710 (2002) (quoting Raines v. Lutz, 231 Va. 110, 113, 341 S.E.2d 194, 196 (1986)); accord Bitar, 272 Va. at 138, 630 S.E.2d at 323. In the case before us, Julie claimed the Doctors breached the standard of care by failing to inform her about the availability of CVS either prior to or during her pregnancy. She further alleged that, if she had known about CVS at a time during the pregnancy when she could have had the test, she would have done so and would have terminated her pregnancy if the result had been positive for Down syndrome. Julie, however, did not prove to a reasonable degree of medical probability that, if she had undergone CVS, the result would have shown the chromosomal abnormality indicative of Down syndrome. None of Julie's medical expert witnesses opined about what the result of CVS would have been if Julie had undergone the procedure. Moreover, the Granatas acknowledged before the circuit court that no such evidence existed in the record. Thus, Julie failed to establish that the Doctors' breach of the standard of care was a proximate cause of the wrongful birth of her twin daughters. Julie, nevertheless, contends Dr. Williams' testimony, read from medical literature that classified CVS as a definitive diagnostic test, provided the requisite proximate cause. Julie argues on appeal that the term definitive means CVS results would have been positive if she had undergone the procedure. We are not persuaded by her argument. The term definitive means serving to supply a final answer, solution, or evaluation and to end an unsettled unresolved condition. Webster's Third New International Dictionary 592 (1993). The term does not signify that a certain answer will be provided; it indicates only that some answer will be ascertained. Because her twin daughters unquestionably have Down syndrome, Julie also contends she is entitled to an inference that if she had undergone CVS, the result would have been positive for Down syndrome. This is so, according to Julie, because in CVS, the laboratory technician has only to count the number of chromosomes to determine whether there is an extra copy of chromosome 21, meaning the presence of Down syndrome. Again, we do not agree. This wrongful birth case is not one of those rare instances in which expert testimony is not required to prove, among other things, that breach of the standard of care was a proximate cause of the claimed damages. Beverly Enterprises-Virginia, Inc. v. Nichols, 247 Va. 264, 267, 441 S.E.2d 1, 3 (1994); see also Coston v. Bio-Medical Apps. of Va., 275 Va. 1, 5, 654 S.E.2d 560, 562 (2008). Whether the result of CVS would have been positive for Down syndrome if Julie had undergone that procedure is not a matter within the common knowledge and experience of a jury. See Perdieu, 264 Va. at 420-21, 568 S.E.2d at 710-11. Furthermore, the Granatas' evidence from their medical expert witnesses showed that many patients require a follow-up amniocentesis after receiving a positive CVS. The Granatas, through their medical experts, also presented evidence about the risks of false positive and false negative results with CVS. Thus, we conclude that the circuit court erred in refusing to set aside the jury verdict in Julie's favor. [5] The judgment was without evidence to support it. Code § 8.01-680.