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abortion, Ethics, pregnancy, prematurity

Did Irish Catholic law or malpractice kill Savita Halappanavar?

This is what is known. Savita Halappanavar was 31 years old and happy to be pregnant with her first child. Then, at 17 weeks, tragedy struck and she was “found to be miscarrying.” Her husband reports that she was in “severe pain” for three days at the hospital and a termination was requested. He says this request was denied because Ireland is “a Catholic country.” He and his late wife were led to believe that the law would only allow her to be delivered when there was no fetal heartbeat.

What does the standard of medical care say about this treatment? Without access to the chart, “miscarrying” at 17 weeks can only mean one of three things”

A) Ruptured membranes

B) Advanced cervical dilation

C) Labor (this is unlikely, although it is possible that she had preterm labor that arrested and left her with scenario B, advanced cervical dilation).

All three of these scenarios have a dismal prognosis, none of which should involve the death of the mother.

The standard of care with ruptured membranes (scenario A) is to offer termination or, if there is no evidence of infection and the pregnancy is desired, the option of observing for a few days to see if the leak seals over and more fluid accumulates. If no fluid accumulates and by some chance the pregnancy manages to go beyond 24 weeks (the vast majority of pregnancies with ruptured membranes delivery within a week), survival is unlikely given the lungs require amniotic fluid to develop. I have seen the rare case where a woman with no infection (and no fluid) elects conservative management in the hopes that might make it to at least 24 weeks in the pregnancy, however, I have never heard of a baby surviving in this scenario. Regardless, if infection is suspected at any time the treatment is antibiotics and delivery not antibiotics alone.

The standard of care with scenario B involves offering delivery or possibly a rescue cerclage (a stitch around the cervix to try to prevent further dilation and thus delivery) depending on the situation. Inducing delivery (or a D and E) is offered because a cervix that has dilated significantly often leads to labor or an infection as the membranes are now exposed to the vaginal flora. Many women do not want wait for infection. A rescue cerclage is not without risks and is contraindicated with ruptured membranes or any sign of infection. Rescue cerclage is a very case by case intervention and well beyond the scope of this post. These decisions are difficult and the mark of good medical care is that all scenarios are discussed, all interventions that are technically possible offered, and then the patient makes an informed decision. All with the understanding that if infection develops, delivery is indicated.

Not only do I know these scenarios backwards and forwards as an OB/GYN, I had ruptured membranes in my own pregnancy at 22 weeks, a rescue cerclage, and then sepsis. I know how bad it can be.

As Ms. Halappanavar died of an infection, one that would have been brewing for several days if not longer, the fact that a termination was delayed for any reason is malpractice. Infection must always be suspected whenever, preterm labor, premature rupture of the membranes, or advanced premature cervical dilation occurs (one of the scenarios that would have brought Ms. Halappanavar to the hospital).

As there is no medically acceptable scenario at 17 weeks where a woman is miscarrying AND is denied a termination, there can only be three plausible explanations for Ms. Hapappanavar’s “medical care” :

1) Irish law does indeed treat pregnant women as second class citizens and denies them appropriate medical care. The medical team was following the law to avoid criminal prosecution.

2) Irish law does not deny women the care they need; however, a zealous individual doctor or hospital administrator interpreted Catholic doctrine in such a way that a pregnant woman’s medical care was somehow irrelevant and superceded by heart tones of a 17 weeks fetus that could never be viable.

3) Irish law allows abortions for women when medically necessary, but the doctors involved were negligent in that they could not diagnose infection when it was so obviously present, did not know the treatment, or were not competent enough to carry out the treatment.

What we do know is that a young, pregnant, woman who presented to the hospital in a first world country died for want of appropriate medical care. Whether it’s Irish Catholic law or malpractice, only time will tell; however, no answer could possibly ease the pain and suffering of Ms. Halappanavar’s loved ones.

****

Since posting this piece I learned that Ms. Halappanavar’s widower reported that she was leaking amniotic fluid and was fully dilated when first evaluated. There is no medically defensible position for doing anything other than optimal pain control and hastening delivery by the safest means possible.

Discussion

167 thoughts on “Did Irish Catholic law or malpractice kill Savita Halappanavar?

  1. FWIW Irish doctors have clarified that they need legislation. My friends who are doctors have said that they need legislation. Doctors calling for legislation include:

    Dr. Rhona Mahony, Master of Holles St Maternity Hospital in Dublin
    Prof PK Plunkett, consultant in emergency medicine at St James’ Hospital, Dublin
    Dr Sam Coulter-Smith, Master of the Rotunda Maternity Hospital in Dublin

    http://www.herald.ie/news/we-need-law-on-abortion-now-doctors-3295676.html

    Posted by QoB | November 17, 2012, 11:44 am
  2. Not only should the doctors who tortured this woman to death be named, but the nurses, the aides, the administrators, the consultants, and the useless chanting nuns and priests and other professional virgins who refused to honour their oaths to first do no harm. Their heartless comments should be made public. They should be forced to recount, in public, every minute, every pain, every indignity and cruelty that any and all of them put onto this young woman. They should be forced to say why they thought she should be the blood sacrifice for a lot of perverted men who think pain is a gift to God and that by making her pain continue, God would love the torturers more. Then, perhaps, the root of this spreading hatred, which runs worldwide through the church, could be exposed for what it is.

    Posted by WA | November 17, 2012, 11:46 am
  3. I hope they all get struck off

    Posted by sarin.pk | November 17, 2012, 6:09 pm
  4. I think it might be better to wait for the investigations – clearly, the chronology is crucial. I see you have Infectious Disease experience, and it appears that the patient had DIC,organ failure several days before she died. Her husband in interview Irish radio mentions dialysis so she had renal failure. What is unclear to me is the chronology and whether the physicians were dealing with a constellation of crises trying to save the patient and when trying to prioritize it MIGHT have seemed that surgically completing the abortion was not the most urgent especially if there was a hemorrhagic diathesis.

    You might find this Link of interest from Hema Divakar,President Elect Federation OBGYN India:

    http://www.thehindu.com/news/cities/bangalore/city-doctor-defends-irish-counterparts/article4100988.ece

    “Based on information in the media, in that situation of septicaemia, if the doctors had meddled with the live baby, Savita would have died two days earlier.”

    ..“Delay or refusal to terminate the pregnancy does not in itself seem to be the cause of death. Even if the law permitted it, it is not as if her life would have been saved because of termination,” she said. “Severe septicaemia with disseminated intravascular coagulation (DIC), a life-threatening bleeding disorder which is a complication of sepsis, major organ damage and loss of the mother’s blood due to severe infection, is the cause of death in Savita’s case. This is what seems to have happened and this is a sequence which cannot be reversed just by terminating the pregnancy.”
    ________________

    I find this opinion somewhat problematic as well but in general I think it better to await more information, The “this is a catholic country..” is pretty shocking since the RC Hierarchy in Ireland would probably dispute this; about half the medical professional in University Hospitals in Ireland are not Irish so I am also anxious who made this atrocious remark.

    Posted by s branagh | November 20, 2012, 7:58 am
  5. Thank you Jen for a lucid analysis in which you rely on your own medical knowledge and knowledge of law. I am a Canadian and support the approach we have in Canada to abortions, which, in the wake of a landmark decision of the Supreme Court of Canada back in 1989 to strike down the abortion law as unconstitutional, is to permit them on demand. The wider issue that Savita Halappanavar’s tragic death highlights, then, is the extremely restrictive law regarding abortion in Ireland, a restriction that effectively means abortion is only permitted in a clear case where a pregnant woman’s life is in danger. As to the narrower question of what exactly happened in Savita’s case, as you have alluded, there may well have been medical negligence on the part of the attending physicians at the Galway University Hospital. Either that, or extreme cowardice on their part. Surely, and entirely for the sake of my argument, even if the law prevented the physicians from acting to terminate Savita’ pregnancy, the defence of medical necessity would have been available to them after the fact had they terminated the pregnancy and then were subsequently charged with violating the law. In any event, this truly is a glaring example of the law on this matter being an arse.

    Posted by Brian Seaman | November 21, 2012, 9:38 pm
  6. Where is the difference between Irish Catholic law and that of Alshabaab?

    Posted by Donald | November 22, 2012, 8:19 pm
  7. Reblogged this on Indian Lawyers Express.

    Posted by qualandar | January 5, 2013, 10:00 am
  8. I am just curious why, if she was already fully dilated and contracting she did not go on to have a spontaneous delivery?

    Posted by V boome | March 24, 2013, 11:22 am
  9. Which is exactly what they were doing. Where the doctors went wrong was in failing to read the blood tests they had ordered.
    “There is no medically defensible position for doing anything other than optimal pain control and hastening delivery by the safest means possible.”

    Posted by KV | October 21, 2016, 10:44 am
  10. This case was tragic in the extreme but one wonders if it had not been a Non National involved here with a devoted Husband would it have been ” buried” as a story.? A more recent case earlier this year in Holles St Dublin sounded horrific also insofar as an American Woman died during a supposedly routine op for an ectopic pregnancy due to rupture during surgery of a main artery. My understanding is that Irish Doctors are forbidden by Irish Law from removing a live foetus from the WOMB of a Mother ie the Doctors have to wait until it is dead and this “wait” can and does endanger lives of pregnant Women. However in both cases I am referring to there were critical signs missed or actions delayed resiltong in death. There is a movement at present to have the legal situation changed bit until then pregnant Women are in more danger in Ireland. I hear its been stopping Multi National Female employees and couples from relocating to Ireland. Both the deaths of pregnant Women referred to were non National.

    Posted by Anthony Duffy | October 22, 2016, 3:15 am

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