How sick must a pregnant woman be in Ireland for her doctor to say her life is at risk?

While a full analysis of the tragic case of Savita Halappanavar’s death from sepsis at 17 weeks in her pregnancy is not possible without access to her medical records, there is a key piece of information provided by her husband that supports his claim that a termination was not allowed or was delayed because of the law. It is the fact that the medical staff were checking fetal heart tones. Not just once a day as is sometimes done during a previable induction so the mother knows which day her baby died, but several times a day.

Fetal heart tones are not checked with any medical purpose in mind until viability (around 23-24 weeks). The presence of fetal heart tones was irrelevant because survival of a baby at 17 weeks with ruptured membranes and/or advanced cervical dilation is impossible. Ms. Halappanavar was not 22 weeks pregnant where there might be a 3% chance of survival (depending on weight, sex of the baby, gestational age, whether it is a singleton or a multiple gestation etc). At 17 weeks with ruptured membranes, regardless of cervical dilation, this pregnancy could only end in with a fetal demise. In a study from 2006, when membranes ruptured at 21 weeks or less the outcome was “dismal.” In fact, in this study there were no survivors when membranes ruptured between 18 and 19 weeks. Whether a fetus has cardiac activity at 17 weeks with ruptured membranes and a dilated cervix is simply not part of the medical decision making tree.

Then of course there is the matter of infection. When membranes rupture at 17 weeks the risk of infection just walking in the hospital door is 30-40% and, according to the American College of Obstetrics and Gynecology (ACOG), “At any gestational age, a patient with evidence of an intrauterine infection….is best cared for by an expeditious delivery.” By her husband’s account, she had abdominal pain on or shortly after arrival, a potential sign of infection. On the Tuesday, two days after she was admitted, he reports that she was shaking and complaining of chills. In this scenario those symptoms can only mean infection. And when a woman with a previable fetus has an intrauterine infection the treatment is not antibiotics and watch the fetus, it’s antibiotics and expeditious delivery.

I’m told that while Irish law technically allows abortion to save the life of the mother, many practitioners fear recrimination and exactly when the life of the mother is “at risk” is a murky question. I can easily argue that Savita’s life was at risk the moment her membranes ruptured at 17 weeks. However, does Irish law mean a different kind of risk? And if so, how would doctors judge that risk to be present? Ruptured membranes and fever? Shaking chills? Bacteria in the amniotic fluid? Positive blood cultures? Sepsis? Cardiovascular collapse? How sick must a pregnant woman be in Ireland be for a doctor to state that her life is at risk?

Whether the delay in Ms. Halappanavar’s care was fear of criminal repercussions or personal dogma, both of these scenarios are permitted to exist because of laws that trounce evidence based medicine. Her husband’s claim that Irish law played a role rings true because the team was checking for fetal heart tones when the only vital signs that mattered were Savita’s.