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abortion, doctor-patient relations, Ethics, evidence based medicine, war on women

Savita Halappanavar’s inquest: the three questions that must be answered

Savita Halappanavar was admitted at on a Sunday to Galway hospital at 17 weeks into her pregnancy with ruptured membranes, a dilated cervix, and an elevated white blood cell count (a marker of infection). It is clear that her diagnosis was chorioamnionitis, an infection of the fetal membranes. When left untreated the bacteria of chorioamnionitis march across the umbilical cord into both the maternal and fetal circulation. Left untreated, the outcome is maternal death.

Just walking through the door with ruptured membranes at 17 weeks Ms. Halappanavar baseline risk of chorioamnionitis was 30-40%. Her presentation should not have posed a diagnostic dilemma, not even for an intern. She was a perfect set up.

In Canada and the United States, once chorioamnionitis is diagnosed the treatment is antibiotics and delivery. An “expeditious delivery…regardless of gestational age,” according to the guidelines of the American Congress of Obstetrics and Gynecology (ACOG). If the fetus is not viable there is no waiting for the fetal lungs to mature or waiting for the fetus to succumb. The recommendation is delivery. This is because chorioamnionitis kills women and if a fetus is on the cusp of viability it has a far greater chance of survival without an infection than with one. The infection helps no one, neither the mother nor the fetus.

To not deliver a woman in such a high risk situation requires proof that she does not have an infection. This can only be accomplished with an amniocentesis, which is extracting amniotic fluid from around the fetus and testing it for signs of infection. The results take 1-2 hours.

Savita Halappanavar’s medical team tells a different story. The testimony of the consultant obstetrician was that Ms. Halappanavar was not sick enough to be allowed a termination on Tuesday according to the Irish legal position. However, there is clear evidence that she was rapidly deteriorating on the Tuesday evening. Ms. Halappanavar’s heart rate was 110 beats/minute and her widower reports that she was shivering and her teeth were “chattering.” Tachycardia (a rapid heart rate) and shaking chills and clear clinical signs that she was gravely ill.

To figure out how a woman could die from such an obvious diagnosis with clear treatment recommendations, the inquest into Savita Halappanavar’s death must answer these three questions:

1. When did the medical team make the diagnosis of chorioamnionitis?

If it wasn’t until Tuesday then that’s negligence. Ruptured membranes at 17 weeks, an open cervix, back pain, and an elevated white blood cell count means chorioamnionitis. The diagnosis was likely clear on Sunday evening, Monday at the absolute latest. By Tuesday evening she was beyond sick, she was gravely ill.

2. Considering there was a delay in delivering Ms. Halappanavar, what tests were done to support the safety of the “watch and wait” therapy? 

Say the team was on the fence about chorioamnionitis. Maybe there was reason to believe that her white cell count was elevated? In this scenario, an amniocentesis would be required to prove the amniotic fluid was not infected. In my opinion watching and waiting could only be supported with a negative amniocentesis. If an amniocentesis wasn’t done then either A) the team were certain she had an infection B) the team had no idea that she could have an infection C) the team was on the fence, but the results wouldn’t matter anyway because the fetus had cardiac activity.

3. What is the treatment for chorioamnionitis?

If the answer is delivery then the delay must be explained. One obvious explanation is the swiss cheese effect, where several things are missed culminating in a very bad outcome. It shouldn’t happen, but it does.  This problem can be fixed with better staffing, education, and specific protocols.

If the answer is, as the consultant obstetrician suggests, that Ms. Halappanavar was simply not sick enough to warrant delivery then it appears that the current “legal position” in Ireland is that a woman must be left brewing her infection until the stench is bad enough that Death himself gets a whiff and comes calling.

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Discussion

43 thoughts on “Savita Halappanavar’s inquest: the three questions that must be answered

  1. What do you think of one doctor’s testimony that an elevated white cell count is ‘normal in pregnancy’ ?

    “The SHO [Senior House Officer] told the coroner this [raised white cell count] would be normal in pregnancy and would not have altered her management in any way.”

    http://www.rte.ie/news/2013/0409/380412-savita-halappanavar-inquest/

    Posted by QoB | April 9, 2013, 11:19 am
    • It can be normal, it depends on the count and the % of neutrophils and the situation.

      With ruptured membranes and an open cervix if the plan were not to induce labor one would need proof that the white count wasn’t concerning. That proof could only cone from an amniocentesis

      Posted by Dr. Jen Gunter | April 9, 2013, 11:46 am
  2. The current legal position in Ireland would permit the delivery of a non-viable foetus in these circumstances.

    The coroner’s inquest opened yesterday, Monday; already it seems that there are major differences in the stories that we are hearing via the newspapers. Even the “this is a catholic country” comment is disputed.

    The inquest is expected to last a week, or perhaps a bit longer. Other inquiries are also ongoing.

    Posted by Korhomme (@Korhomme) | April 9, 2013, 11:21 am
    • the midwife has admitted the catholic country comment….the doctor doesnt think a 40 per cent chance of woman dying is enough of a risk to warrant abortion….and doesnt know that a 17 wk fetus is nonviable!! apparently obgyns in ie get their mds by mailing in box tops….

      Posted by Sgaile-beairt | April 10, 2013, 6:14 pm
    • oh and prolifers lie and are ignorant but we knew that, already….

      Posted by Sgaile-beairt | April 10, 2013, 6:15 pm
      • Actually “ie” is a safer place for women to give birth than USA check your facts please! Obviously this is a case of serious negligence but it is rare and does happen in other places even the USA. And we ie drs have no difficulty passing your us exams and getting jobs there if we want so get your facts straight re standard of ‘ie’ education also.

        Posted by Roedole | April 11, 2013, 2:26 pm
      • @roedole like cracking pelvises instead of doing c-sections?? yeah right…

        Posted by Sgaile-beairt | April 11, 2013, 3:01 pm
      • ‘Cracking pelvises’ was clearly wrong when it used to be done but irrelevant to standard of ed and similar things happened in us etc etc.. Shame you need to use a tragic case to just be insulting to a whole nations doctors. Oh and by the way many of us are ‘pro choice’ and though this is irrelevant to your childish comments should give you pause to consider what point it is you really need to make here. I am not even an obs/gyn but knew the minute I heard this story months ago that the bloods not followed up on the Sunday night plus the mild tachy were the main issue – but that the legal situation still needs to be made crystal clear so that no one can ever again add such an interpretation of it into an already dangerous situation. The fact is that even most so called ‘pro life’ people in Ireland would not expect a woman to die on the off chance that a 17 week old foetus might survive another few weeks until delivery.

        Posted by Roedole | April 11, 2013, 3:27 pm
      • actually no your tu quoque is not very impressive just denial wo any evidence, you want links about symphs I can spam u w links but if yr really a dr shld already be aware that that was not ‘a few bad apples’ & yes it was church-influencing medical policy….dont yell at us, clean house if drs astbury & o’dwyer (who was a teacher & is still v v active in yr prolife obgyn education, running conferences etc) arent to be deemed representative of yr competence!!

        ….or do you think astbury is right & a 17 wk fetus w chorio etc is viable???

        Posted by Sgaile-beairt | April 11, 2013, 4:57 pm
      • Uh no these particular people in this particular case not to be deemed rep of competence or don’t you use stats etc but would rather draw inferences from single cases or single issues. Yes Catholic Church had big influence still does have a bit and its wrong. Not my point made above. I also don’t see anywhere that anyone involved thought a 17 week old foetus was viable, if you have inferred that from the newspaper articles you need to check how you interpret what journalists write and re-read them. Maybe you’re not an md so don’t realise how off the wall it would be for the drs involved to think that and maybe dont get it re what how what was done appears to have been negligent. Am going to sign off here. Ciao.

        Posted by Roedole | April 11, 2013, 5:38 pm
  3. Reblogged this on Activism and Agitation.

    Posted by Sharrow | April 9, 2013, 2:05 pm
  4. The current legal position in Ireland would permit the delivery of a non-viable foetus only when there is a clear and immediate risk to the woman’s life, not her health her life. They have to wait until your life is at risk before expediting the end of a pregnancy, to do so other wise medical professionals risk prosecution under the Offences against the Person Act from, and I kid you not 1861.

    Posted by Sharrow | April 9, 2013, 2:09 pm
  5. And this happens at Catholic hospitals IN THE US too. I’ve had 2 people report similar experiences (though with non-fatal outcomes for the mothers) on my blog in just the past few hours.

    Posted by Ophelia Benson | April 9, 2013, 3:13 pm
  6. She didn’t present with ruptured membranes; this didn’t happen until the following day.

    Posted by Caledonia | April 9, 2013, 3:20 pm
    • That is not my understanding of the situation reading multiple accounts as well as information from the HSE report.

      Posted by Dr. Jen Gunter | April 9, 2013, 3:47 pm
      • From the Irish Times today:’ Ms Dunleavy,(midwife) who worked on the ward where Ms Halappanavar was treated last October, said she didn’t contact a doctor after her membranes ruptured the day after admission. She said it wasn’t an emergency but a natural progression of her condition and if she had called a doctor, she would have been told to keep an eye on the patient.’

        Posted by Caledonia | April 9, 2013, 4:36 pm
  7. Hm. According to Fergal Barrow’s reporting for RTE, “Astbury said that she had requested an ultrasound on Monday 22 October after Mrs Halappanavar’s membranes ruptured.” That sounds as if the membranes ruptured on Monday rather than Sunday. Does that make any difference? Does it make the inaction on Sunday any less appalling?

    http://www.rte.ie/news/2013/0409/380412-savita-halappanavar-inquest/

    Posted by Ophelia Benson | April 9, 2013, 3:49 pm
  8. I think a timeline would be useful as several doctors were involved and a number of crucial things seem to have been missed. My understanding of the timeline from what has been reported to the inquest so far is :

    Sunday 21 : Dr H first saw Dr Olufoyeke Olatunbosun who initially diagnosed Mrs Halappanavar with back pain and discharged her. Dr Olufoyeke ordered the blood tests but the results of the test showing the elevated white blood count were either not available or referred to until Wednesday. No vaginal examination was carried out.

    Sunday 21: Savita returns to hospital within several hours, highly distressed with complaints of something hard trying to push itself out.

    Dr Andrew Gaolebale, a specialist registrar in obstetrics who was called for a second opinion, diagnosed that the pregnancy was being lost and tells inquest that he expected this miscarriage to occur within 24 hours. Dr G knows of dilated cervix but unaware of blood test results.

    Monday 22 : 12.30 am . Savita’s membranes rupture but Dr Gaolebale (who is still on duty at that time) is not told of this by nurse Miriam Dunleavy who tells coroner that she did not tell doctors this as “it was a natural progression and not a medical emergency.”

    Dr G insists to inquest that he would have not done anything even if aware of blood test results.

    “The white cell count was 16 and the normal pregnancy range in the first trimester was 15,” he said about her notes. “I would have repeated them.”

    It appears that Savita was basically left to get sicker all of Monday.

    Praveen H testifies that he and his wife asked for a termination on Monday but the medical staff dispute this.

    Tues 23 : Morning. Dr K Astbury examines Savita. Testifies she refused termination on grounds of legality and because she felt life of Savita was not compromised. May have suspected sepsis as antibiotics were apparently administered for the first time that morning, while the husband was absent.

    Night at about 930 pm. Miriam Dunleavy testifies that Savita’s pulse was elevated at 114. it is not clear if any doctor was informed of this. Dunleavy’s opinion was that Savita was one of the healthiest women in the ward that night!
    Notes by midwife Ann Maria Burke, who will give evidence, claimed a senior house officer was told on Tuesday evening that Mrs Halappanavar was weak and had a high heart beat of 114 beats per minute.

    “I was told vital signs were stable,” Dr Uzockwu replied. “I wasn’t told of an elevated pulse.”

    He said he went to check on Mrs Halappanavar at 1am but she was sleeping. He got the emergency call at 6.30am.

    Wed 430 am. Savita shivering, elevated temperature, given a blanket and a couple of paracematol by Dunleavy.

    630 am Savita seriously ill. Examined by Dr Ikechukwu Uzockwu who said he got an emergency call to attend the patient before 7am one morning, 54 hours after her waters had broken, and found her heart rate was almost double from when she was admitted three days earlier.

    Her temperature had soared to 39.6C and she was producing a foul smelling discharge from her vagina, and he thought she was suffering from sepsis due to chorioamnionitis, an infection of the foetal membrane, he said.

    The medic, said he called a more senior colleague but he believed she never reviewed the patient.

    Wed morning. Dr Astbury begins to realise that her patient is seriously ill and termination of the pregnancy is in order. Consults colleagues, one of whom agrees to write a medical note to that effect.

    1pm goes to Savita to take ultrasound scan but discovers foetus finally dead.

    3-4 pm Savita delivers naturally but very ill from that point onwards.

    Posted by mirax | April 9, 2013, 11:55 pm
    • Thank you for the time line

      Given her white count was 16 there would be little difference between rupturing membranes Sunday evening (which is when I thought it happened) and Monday am just after midnight.

      With a dilated cervix and an elevated white count an infection is almost certain. Brushing a WBC of 16 off as normal is not ok. You would really need an amniocentesis to say everything was ok.

      The consultant OB should have been able to piece all this together on Monday.

      Her care was atrocious. Why delivery was not recommended on Monday with ruptured membranes is inconceivable to me.

      Posted by Dr. Jen Gunter | April 10, 2013, 7:00 am
      • The WBC was apparently 16.9. The OB’s most recent testimony to the inquest is bloodcurdling. She actually says that she disagrees with Dr Gaolebale, the admitting doctor that the pregnancy was lost! She saw a 12-18% chance of foetal viability even after ruptured membranes and thus felt a termination was not in order. She says that Savita was only emotionally distressed on tuesday , but physically not unwell.

        Posted by mirax | April 10, 2013, 7:26 am
      • Fetal survival with ruptured membranes at 17 weeks is 0%, this is from prospective study.

        Posted by Dr. Jen Gunter | April 10, 2013, 8:32 am
      • After the medical emergency Savita had on wed morning at 630 – pulse rate 160, fever, vaginal discharge, – Dr Astbury didnt read Savita’s case notes later that morning at 830 am. Apparently another doctor had them. The Ob/gyn would have terminated the pregnancy 5 hours earlier if she had read the notes then. Read this and weep for poor Savita.

        http://www.irishtimes.com/news/health/savita-halappanavar-s-obstetrician-denies-using-term-catholic-country-1.1355895

        The doctor actually told savita on Monday that the foetus had some small chance of viability. Did she tell the prospective parents that a dilated cervix and ruptured membrane had a much greater chance of infection of 30-40% ? I would so ask that question if I was cross-examining her.

        Posted by mirax | April 10, 2013, 7:57 am
      • “Mr Gleeson [the coroner] asked the witness if she discussed with an obstetric colleague whether to offer or perform a termination when Ms Halappanavar’s health was deteriorating. Dr Astbury [the consultant obstetrician]replied that there had been no need to as there had been no “evidence of a real and substantial” risk to Ms Halappanavar on Tuesday, October 23rd.”

        “real and substantial risk” to the woman’s life is what is required by the Irish constitution to terminate a pregnancy, *whether or not the foetus is viable*.

        I feel sick.

        Posted by QoB | April 10, 2013, 8:14 am
      • That is just wrong.

        Posted by Dr. Jen Gunter | April 10, 2013, 8:31 am
      • Further details here: http://www.rte.ie/news/health/2013/0410/380613-savita-halappanavar-inquest/

        The (then dead) foetus was only delivered when they brought her into theatre to put in a central line.

        Posted by QoB | April 10, 2013, 8:20 am
      • Yes the risk to the life of the woman must be 51% no matter the viability of the fetus even if the miscarriage is unavoidable. This is due to this horrendous addition to the Irish Constitution

        http://en.wikipedia.org/wiki/Eighth_Amendment_of_the_Constitution_of_Ireland

        “The Amendment inserted a new sub-section after section 3 of Article 40. The resulting Article 40.3.3° reads:

        The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right. ”

        Which was put in place 30 years ago after a fear that a ruling on privacy in marriage which made contraception legal might be used to return to the courts to justify abortion like the Roe V Wade ruling. It was warned at the time it was ambiguous and would lead to legal challenges and the loss of women’s lives, but it is still in effect and while it is, women are not equal citizens.

        Posted by Sharrow | April 10, 2013, 9:34 am
      • one of the things that came out in the wake of protests, is that the ethical, responsible health care provders in ie, quietly tell women who are in this situation, to go to the uk….even if theyre not legally supposed to, they say things like ‘if you were my daughter” etc….so maybe its possible that these drs like astbury & o’dwyer dont have enough xp with miscarriages to know how dangerous it is?? at least, not enough to overide their RTL ideology??

        Posted by Sgaile-beairt | April 11, 2013, 4:13 am
  9. I dont know know what conclusion you make, as a medical professional, of that sequence of events, Dr Gunter, but it sounds scarily incompetent to me, almost criminally negligent. They didnt look at the result of the first blood test until wednesday and didnt even order another blood test until Wednesday when Savita was almost certainly seriously ill.

    Posted by mirax | April 10, 2013, 12:02 am
  10. Jen, Could you amend where you state that membranes had ruptured on presentation, for accuracy? It is still true that appropriate action was not taken on Monday.
    The main point is that our abortion laws influenced treatment/delayed intervention but it is important that the facts are reported accurately.
    The ‘alteration to the medical notes’ which caused consternation yesterday is thought to have been a bracket/underline for emphasis done by someone in the ICU as they reviewed her chart when trying to save her.

    Posted by Caledonia | April 10, 2013, 4:45 am
  11. Hi Jen – Your first question seems to be answered now : “What is not in doubt is when the diagnosis of chorio-amnionitis was first made – on the Wednesday morning at about 6am”, see http://www.irishtimes.com/news/midwife-s-statement-raises-possibility-infection-spread-with-extraordinary-speed-1.1355298

    Posted by Rachel | April 10, 2013, 7:40 am
  12. Hi – thanks for this clear and reasoned blog post on Savita Hallapanavar’s treatment. I’m currently writing an article on the issue, and I would so very much appreciate it if I could ask you a medical question via e-mail. Would this be possible?

    Posted by Emer | April 11, 2013, 3:14 am
  13. Even if you take termination out of the picture altogether, sadly, none of this is surprising. Irish maternity wards are a mess. They’re understaffed and overcrowded. Women are left to labour on their own, if they’re even believed to be in labour in the first place. The stories of women delivering in the hallways or car parks are in the hundreds, because these midwives didn’t have time for one more mother and fobbed them off. The early pregnancy units are equally a joke. I was told bluntly on two occasions that I was miscarrying just from a cursary examination, those children are now 6 and 1. They don’t want to hear it, they want you in and out and off their docket. It’s an absolute disgrace. I am heartbroken for Savita’s family and I just hope that the system steps up and takes notice. The government just keep cutting spending, I wonder how many more people have to die before something is done? This is severe medical incompetence and the worst part is, it’s par for the course in Irish hospitals, but if no one dies, no one notices. When will enough be enough?

    Posted by Avery | April 11, 2013, 5:17 am
    • there was a lot of talk in blogs back during the protests, about how records were routinely fudged, women who had seen their records were saying how falsified they were….and there were rumors of even deaths, being attr to other causes, to keep their “wonderful’ maternity record….

      Posted by Sgaile-beairt | April 11, 2013, 2:52 pm
  14. Would amniocentesis not be v invasive for someone with threatened miscarriage as a standard treatment?

    Posted by Caledonia | April 12, 2013, 1:13 pm
  15. Irish Hospitals are a complete filthy disgrace, they hire medics without even checking references, even though some of these people have come from countries known for their flagrant forgeries and corrupt practices, some of these so called doctors know less than nurses aids. case in point, a Romanian doctor who was recently working in an Irish hospital was found not to know how to take a pulse, use a stethoscope, or take a temperature, but she was sent for further training and later assumed into the system, May God Almighty save us from this incompetence.
    I now hitch hike to a hospital in Northern Ireland when I feel sick.

    Posted by bostonfast | April 13, 2013, 8:01 am
  16. It seems like the timeline offered by multiple accounts now is showing that the infection is what caused the abortion. Not the other way around. I think that is important in declaring what actually killed this young woman is the infection – not her lack of receiving an abortion.

    Of course, part of the treatment of the infection would have been an immediate termination of the pregnancy because the membrane had ruptured, but that does not mean the lack of the immediate termination caused the infection.

    Posted by GLove | May 15, 2014, 4:11 pm

Trackbacks/Pingbacks

  1. Pingback: Left untreated, the outcome is maternal death » Butterflies and Wheels - April 9, 2013

  2. Pingback: Dr Jen on Savita – Charioteering - My Telegraph - April 10, 2013

  3. Pingback: Woman dies in Galway Hospital after being refused termination - Page 934 - April 10, 2013

  4. Pingback: Expert in Savita inquiry confirms Irish women get lower standard of care with chorioamnionitis | Dr. Jen Gunter - April 13, 2013

  5. Pingback: HIQA Report into the Death of Savita Halappanavar Published - Page 122 - November 5, 2013

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