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Expert in Savita inquiry confirms Irish women get lower standard of care with chorioamnionitis

article-2306301-192A17E9000005DC-388_306x466As the inquest into Savita Halappanavar’s death continues we have heard about delays and errors, all of which most likely contributed to her terrible outcome. However, along the way those who have tried to pass off her death as medical negligence and nothing to do with Irish law or Catholic ethos have rested on the assertion that she wasn’t sick enough to need a termination.

One of the experts at the inquest, Dr. Susan Knowles, a microbiologist at the National Maternity Hospital in Dublin is reported in the Irish Times as saying there wasn’t a substantial risk to Ms. Halappanavar’s life before Wednesday at 6:30 am. While she admits to what she calls “subtle indicators” of sepsis and chorioamnionitis (infection of the fetal membranes), she asserts these findings were just not enough to warrant a termination.

She is wrong.

By the Monday morning, less than 24 hours after admission, Savita had a white blood cell count of 16.9 and ruptured membranes. She also had pain. This would be enough to prompt every OB/GYN I know in the United States and Canada to discuss evacuating the uterus, or at least gather more evidence to say it is safe not to hold off and watch and wait. The standard of care in North America is “expeditious delivery” and antibiotics when chorioamnionitis is diagnosed, not wait until this get worse.

By Tuesday evening Savita had shaking chills and an elevated heart rate. This means the infection had now spread from the uterus to her blood stream. This is what happens when chorioamnionitis is inadequately treated. At this point my colleagues and I would be panicking about Ms. Halappanavar’s health. Not so in Galway. Dr. Knowles didn’t think things were bad enough until the next day.

If the diagnosis of chorioamnionitis is in doubt there are ways to be more certain, although keep in mind, Savita’s risk of infection was 30-40% the second her membranes ruptured early Monday morning so the burden of proof for infection in such a setting is low. Her white blood cell count (WBC, a marker of infection) was apparently 16.9, which is very suspicious, but looking at specifics of the white blood cell count (the neutrophil count and the presence of bands, which are immature neutrophils) could have provided more about the possibility of a bacterial infection. An elevated neutrophil count or a bandemia would all but confirm chorioamnionitis in this clinical setting. An amniocentesis could also be performed if the diagnosis of chorioamnionitis were in doubt.

 

One could argue that the diagnosis of chorioamnionitis wasn’t in doubt as the team started antibiotics on the Monday evening, although say, just for the sake of argument, that the antibiotics were started as prevention. In this case, as infection was obviously suspected why wasn’t more done to confirm the diagnosis or rule it out? Was the maternity ward at Galway that much of a fuck up that no one, from nursing student all the way up to senior staff, could possibly conceive of the idea that a woman with ruptured membranes at 17 weeks might actually have an infection? Or didn’t it matter, because Savita was pregnant with a 17 weeks fetus that had cardiac activity but a 0% chance of survival. If Savita had to be sick enough to have a termination why bother confirm a diagnosis that no one could do anything about? Did the staff feel the only treatment that they could legally give was antibiotics so there was no point in knowing more?

Dr. Knowles’ testimony confirms for me that the law played a role, because her statements indicate the standard of care for treatment of chorioamnionitis is less aggressive in Ireland. This can only be because of the law as there is no medical evidence to support delaying delivery when chorioamnionitis is diagnosed. Standard of care is not to wait until a woman is sick enough to need a termination, the idea is to treat her, you know, before she gets sick enough. An elevated white count and ruptured membranes at 17 weeks is typically enough to make the diagnosis, so Dr. Knowles needs to testify as to what in Savita’s medical record made it safe to not recommend a delivery.

By the way, I also disagree with Dr. Knowles about her interpretation of Savita’s medical record, the chart doesn’t have “subtle indicators” of infection, it screams chorioamnionitis long before Wednesday morning.

In North America the standard of care with chorioamnionitis is to recommend delivery as soon as the diagnosis is made, not wait until women enter the antechamber of death in the hopes that we can somehow snatch them back from the brink.

If Irish law, or the interpretation thereof, had nothing to do with Savita’s death no expert would be mentioning sick enough at all.

 

 

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Discussion

37 thoughts on “Expert in Savita inquiry confirms Irish women get lower standard of care with chorioamnionitis

  1. Dr Knowles is a microbiologist, not an obstetrician; she ought not to give “expert” evidence outside her specialist field.

    Posted by Korhomme (@Korhomme) | April 13, 2013, 12:26 pm
  2. Antibiotics started on Monday were definitely prophylactic. Just wondering about amnio as standard in the States to rule out infection in a threatened miscarriage. If more viable pregnancy would that not be too invasive?

    Posted by Caledonia | April 13, 2013, 1:47 pm
  3. Some inaccurate assumptions. Poor analysis.

    Posted by docshamrock | April 13, 2013, 2:03 pm
    • I am an OB/GYN board certified in 2 countries and did an infectious diseases fellowship. I’ve been in practice for 17 years. I draw my conclusions based on that knowledge and experience. What are your qualifications?

      Posted by Dr. Jen Gunter | April 13, 2013, 3:52 pm
      • Top ten replies

        10) I have a degree in theology from Bob Jones university.
        9) Last week I touched a pregnant lady.
        8) I own the entire series of ER
        7) My father is a doctor. In fact he is the only podiatrist in the five counties.
        6) I know all the words to Baby by Justin Beiber.
        5) As an avid bird watcher I am well aware of the migratory habits of storks.
        4) Have you ever heard of wikipedia?
        3) I read the bible.
        2) In tenth grade I took an entire semester of microbiology.
        1) I watch Glenn Beck every day.

        Posted by Kevin Lyda (@lyda) | April 15, 2013, 11:36 am
  4. Are you serious? The maternal mortality rate in the US is way higher than in Ireland? The management of Savita’s infection was disgraceful and led to her death, but, please, clean up your own back yard before attacking Ireland. And face up to the montrosity of Kermit Gosnell – the kind of ‘care’ that the abortion industry produces – while you are at it.

    Posted by Sail | April 13, 2013, 2:15 pm
    • The post is not about US maternal mortality. Changing the subject is not a valid form of debate.

      I wrote on Gosnell, I suggest you read the post.

      Posted by Dr. Jen Gunter | April 13, 2013, 3:54 pm
      • all they got is Look over there!! & tu quoques….bc they cant answer the questions, very telling….

        Posted by Sgaile-beairt | April 13, 2013, 7:49 pm
      • Good article link below re interpretation of the current law and the outrageous ’51 %’ judgement by the team in GUH by m McDowell (as a barrister). The problem however is that the outcome of ‘death’ (the outcome of risk ‘to the life’) is so serious in any risk analysis that even a very small probability is unacceptable, and to many should not be left to doctors to decide but should be chosen by women themselves. This is the issue (negligence aside) and I am glad that you finally seem to be nailing it Jen.
        If you don’t want tu quoques arguments on your page then I would suggest asking others to refrain from other forms of ad homomem argument such as that all irish md get their qualifications from cereal top boxes – or maybe you think this is valid debate and will generate reasoned posts…

        http://www.independent.ie/opinion/analysis/michael-mcdowell-termination-should-not-come-down-to-percentages-29194818.html

        Posted by Roedole | April 14, 2013, 7:32 am
      • Thanks for the link.

        I typically don’t censor what’s replied unless it’s a personal attack and then I block the ip address.

        I think when people stoop to the kind of cereal box top comments it says a lot about the person who left the comment.

        Posted by Dr. Jen Gunter | April 14, 2013, 9:05 am
    • The rate might be lower on paper, but that’s because of some “creative” certification. Women don’t die in labour, they die of “MI”, they don’t die because of chorioamnionitis, they die of “septicaemia”.

      In short – the figures are massaged in the same way as you massage a steak to tenderise it. Viciously, and with a blunt object.

      Posted by neverdefiled | April 15, 2013, 7:16 am
    • Saying that there are more maternal deaths in the United States doesn’t the facts surrounding Savita’s death.

      I’m calling out your red herring.

      But since you were kind enough to mention the US, I would like to point out to you that the highest cases of teen and unwanted pregnancies – the leading causes of abortions – are in the Bible Belt, where state sex education is limited to abstinence-only programs.

      Thank you for bringing up the US’ maternal deaths – the Church has much to answer for that.

      Posted by Antonio Pe Yang III | April 19, 2013, 4:48 pm
  5. When Dr Knowles says the risk was not enough to warrant a termination, I take it she means that at that point (early Wednesday) Savita fell short of the standard required by Irish law, which is “a real and substantial risk to the life, as distinct from the health of the mother.” Of course that phrase is open to a wide range of interpretations. Unfortunately it seems the medics read it as meaning, at death’s door.

    The Irish medics evidently agree that under US or UK standards a termination would have been warranted earlier. So yes, it’s partly about the law, although plain negligence stands out as the main culprit.

    Posted by Kevin Donoghue | April 13, 2013, 3:00 pm
    • Correct me if I’m wrong, but isn’t a systemic infection always “a real and substantial risk to the life, as distinct from the health of the mother”?

      Posted by Feminerd | April 13, 2013, 7:30 pm
      • I would consider it to be, but whether that meets the Irish definition is unknown. Considering the testimony, it would appear it does not.

        Posted by Dr. Jen Gunter | April 13, 2013, 7:39 pm
      • She died because of medical errors but would still be alive if our abortion laws were different.
        The consultant didnt realise how sick she was on Wed morning- didn’t read chart – or would have done an abortion sooner. She was restricted by the law at the point when Savita requested a termination.
        Chorio set in during the night/Wed am, and was diagnosed and acted on at 6.30am by an oncall doc.

        Aside from this issue, the health system is over stretched here but generally is much better than it is in the U.S.
        If there was universal cover in the States do you not think that increased errors would occur?
        There is free primary and secondary cover for 40% of the population. Insurance is relatively affordable for those who don’t get free cover- $1000 per year on average. For the 100,000 who don’t have either the max you will be charged if diagnosed say with cancer is €750 per year- no matter how long you are in hospital, how much chemo you need.
        Aside from the exception on abortion where they are constrained by the law, doctors here practise evidence based medicine – patients are not over-investigated.
        Patients here don’t routinely die two years post transplant cos they can afford antivirals.

        Posted by Caledonia | April 14, 2013, 4:02 am
      • @caledonia so as long as you arent a woman of childbearing years its great!!

        of course thats half the population at one time or another…..

        Posted by Sgaile-beairt | April 14, 2013, 6:14 am
      • @Caledonia, Sgaile-Beairt: I think a broader discussion of the relative merits of US and Irish health care is something of a diversion here, especially if the WHO stats for each are collected on a different basis (whether for legitimate reasons or “juking the stats”). Each may have different problems that make direct comparisons difficult. The US has notorious “access” issues, though Ireland’s “two-tier” system is not without those, either. The “legal and ethos” considerations are also hard to compare: it’s been pointed out that many Catholic-run hospitals are distinctly doing their own thing as regards best practice in this area.

        Because of the lack of legal clarity in Ireland, there seems to be massive confusion between different practitioners, and huge obfuscation about what current practice actually is. In one interview with the medical director of Ireland’s “Pro Life Campaign” she asserted that a termination was legally and ethically available, and even that it was “not abortion”. Semantics, certainly, and hindsightitis, very probably, but it’s a clue that the hard line Astbury is trotting out isn’t one that her profession is going to stand behind.

        Posted by alaimacerc | April 16, 2013, 5:08 pm
    • AFAIK, there is no legal definition of an “abortion” beyond the everyday meaning, nor for “termination”. It might be a sophist play on words, but rather than a “termination”, Savita might have been better served by a “completion of an inevitable miscarriage”.

      Posted by Korhomme (@Korhomme) | April 14, 2013, 5:35 am
      • @sgaile-beairt: No, it’s not great, it is generally fairer and better and more evidence-based than med in the U.S. but it is over-stretched. There are mistakes happening that shouldn’t happen. There is a lack of co-operation/communication between doctors and nurses. Nurses in some acute hosps are not doing first doses of antibs/first bloods as per hospital policy, they just say No knowing the INO will back them so doctors are running around doing ‘rubbish’ tasks with less time to spend on clinical stuff.
        At least in obs, shifts are limited for medics to 24 hours- still way too long, in general med they routinely work 36 hours without sleep. I don’t know the system that Dr Jen is working in, is it private med in the States where patients are over investigated and there isn’t much evidence based medicine..she suggests amnio to rule out the risk of infection, speaking to docs here even in the aftermath of Savita that would be way too invasive; a weird way to treat a threatened miscarriage.

        Posted by Caledonia | April 15, 2013, 12:52 am
  6. Reblogged this on Feminist Ire and commented:
    The furious attempts by anti-choicers to portray Savita’s death as an issue of negligence rather than Ireland’s abortion law overlooks some very simple facts. The law is the reason Savita’s request for an abortion was denied. The law is the reason Savita’s medical team were forced to assess her illness by reference to whether she met some vague and ill-defined threshold of sick enough before they could accede to her request. The law is the reason preservation of her foetus was given such priority.

    Here, an OB/GYN with expertise in infectious diseases, practicing in a jurisdiction without such a law, describes how she would have assessed Savita’s condition – not being constrained by the threat of prosecution to look for any possible chance, however remote, that a (clearly unviable) foetus could be saved.

    Posted by Wendy Lyon | April 14, 2013, 12:48 am
  7. ‘Or didn’t it matter, because Savita was pregnant with a 17 weeks fetus that had cardiac activity but a 0% chance of survival. If Savita had to be sick enough to have a termination why bother confirm a diagnosis that no one could do anything about? Did the staff feel the only treatment that they could legally give was antibiotics so there was no point in knowing more?’

    I think this is a very pertinent question. During my first pregnancy in the UK I attended ante-natal appts which included blood tests to detect risk of spina-bifida (can’t remember medical term – 20 years ago). Having re-located to Ireland I queried my GP about this blood test (as he hadn’t mentioned it and first scans were a lot later in Ireland than UK). His reply, verbatim, was: “Why would you want that blood test when there’s no abortion in this country?” I was shocked by this response as I was innocently enquiring about a blood test that I presumed was routine in pregnancy, due to my experience in the UK. I don’t know what my reaction would have been if the blood test had been positive, but I very much doubt it would have been as cold as his reply to me. So I do think you may be correct in your assertion Jen.

    Posted by Marie | April 14, 2013, 11:43 am
  8. For further understanding of what happened –

    Savita’s final hours set out by ICU nurse

    http://webcache.googleusercontent.com/search?q=cache:HMDMOmTrlaQJ:www.irishtimes.com/news/health/savita-s-final-hours-set-out-by-icu-nurse-1.1357707+&cd=2&hl=en&ct=clnk&gl=us

    Timeline: Savita Halappanavar’s last days

    http://www.irishtimes.com/news/health/timeline-savita-halappanavar-s-last-days-1.1357554

    This is exactly why I questions the midwives at my first pre-natal and their back up doctors about their views on abortion, just in case something unforeseeable were to happen to my pregnancy I wanted to ensure that my life would take priority and that my husband and I would be able to have a choice in the care I would receive if something tragic with the pregnancy happened. The husband thought I was being a nutty, nosy uber pro-choicer but after keeping him informed about Savita he know understands why I would demand to know what their policies and personal beliefs are about abortion. Everyone one in the office was tolerant of my questions and assured me that my life would always take precedence and that hospital policy would protect me over my pregnancy.

    Posted by Oubli | April 16, 2013, 4:17 pm
    • This is the advice I would now give to all the women and girls I know – to be highly wary of any catholic medical establishment and to probe the beliefs of their medical caregivers. Women’s lives are too cheap too often.

      Posted by mirax | April 18, 2013, 6:44 am
  9. Katherine Astbury, the consultant treating Savita said that

    “If someone has chorioamnionitis you only get the chorioamnionitis out by delivering the foetus”

    (bottom of http://www.irishexaminer.com/breakingnews/ireland/obstetrician-admits-system-failures-to-savita-inquest-590844.html)

    So if they’d realized earlier that she had chorioamnionitis, they presumably would have been able to terminate the pregnancy? According to the following timeline, http://www.irishexaminer.com/archives/2013/0413/world/alarming-communication-breakdown-228260.html, chorioamnionitis and sepsis were first diagnosed on Wednesday, and at this point, the decision was made to terminate, but they then found out that the foetal heatbeat had already stopped.

    I’m not trying to defend the law, because maybe there are dangerous conditions that aren’t deemed sufficiently dangerous to warrant a termination, but according to the above, this doesn’t seem to be the case for chorioamnionitis?

    Posted by Dave | April 17, 2013, 1:21 pm
  10. You seem to suggest that Chorioamnionitus should have been diagnosed earlier yet according to testimony at the Savita Halappanavar inquest by Dr Peter Boylan the patient had non of the classic symptons of Chorioamnionitus until Wednesday namely:

    High temperature and fever
    Rapid heartbeat
    Sweating
    A uterus that is tender to the touch
    A discharge from the vagina that has an unusual smell

    On Monday and Tuesday all that was noted was a high white blood cell count which would not indicate that there was a “real and substantial risk” to the patient’s life which is the legal test under Irish law for legal termination. While it may be possible to terminate in states without a personhood law, would you accept that Doctor Astbury and Dr Boylan assessment that there was no “Real and Substantial Risk” to the patient’s life on Monday and Tuesday was correct and therefore the pregnancy could not legally be terminated?

    Posted by Patrick Martin | April 23, 2013, 9:18 am
    • The diagnosis was clear on the Monday. She had a 30-40% chance the second her membranes ruptured. A white blood cell count of 16.9 and pain is confirmatory.

      Posted by Dr. Jen Gunter | April 24, 2013, 6:57 am
      • Do you mean 30-40% chance of developing Chorioanmionitus?

        The link below is a transcript of a radio interview with Dr Peter Boylan (Dr Peter Boylan Consultant Obstetrician/Gynaecologist and former Master of Holles St Hospital, Dublin) and a Pro Life activist Breda O’Brien from an ultra-catholic organization. Dr Boylan you might remember was the expert witness called at the inquest. He seems to be adamant that the risk to Ms Halappanavar’s life on Monday or Tuesday was not “real and substantial” enough. Pro Life groups here are accusing him of protecting the Doctors in Galway University Hospital by blaming the law. They claim that there is no need for a change in the law and in particular Ireland’s personhood 8th Amendment to the Constitution. I know it’s difficult to imagine yourself faced with the same legal constraints as Irish doctors but if you can, would you broadly agree with Dr Boylan assessment as to when the risk to Ms Halappanavar’s life became “Real and Substantial?

        http://www.broadsheet.ie/2013/04/21/dr-peter-boylan-and-breda-obrien-the-transcript/

        Posted by Patrick Martin | April 24, 2013, 9:01 am
  11. thank you for your post, I wish we could have sane discussion about this in Ireland, but instead its an entrenched debate about ideology and religion, and rants mainly from prolifers in the Irish Times. People have been quick to blame Ireland’s law for Savita’s death. True, it plays a part, but this obfuscates the fact that she received an absolutely appalling standard of care from her medical team – they spent more time monitoring the stricken baby’s heart than they did the condition of the mother, as if it were not enough of a distress for her to know that she would inevitably lose her first baby at just over 4 months. This was not a “capricious” request for a termination as a substitute for birth control, this was a woman who wanted her child very much, but knew – unlike the doctors tasked with caring for her – that her child was now unviable and her pregnancy was doomed. Her request for a termination – no doubt not an easy request to make – fell upon deaf ears. They simply did not monitor her deteriorating condition – at one point I remember reading they gave her paracetamol. Seriously??? She should have been on intravenous antibiotics by then.

    You may also find this article of interest – about another Indian woman who died in Ireland because of appalling medical care. This time, not tied up with the morals or otherwise of abortion law, but just plain shockingly bad care. Anyone knows how dangerous pre-eclampsia is, let alone HELLP, yet it took 2 DAYS to deliver her over-term baby… http://www.independent.ie/irish-news/husband-calls-for-inquest-into-how-his-wife-died-days-after-giving-birth-29246506.html

    What is going on with Irish maternity care???? I am due to give birth here later this year and am frankly terrified about what lies ahead.

    Posted by LB | May 9, 2013, 5:22 am

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