A pregnant woman in Michigan ruptured her membranes weeks before viability. She is not offered a termination (standard of care in the scenario) and suffers an infectious complication. This case from Michigan has eerie similarities to the Savita tragedy in Ireland. The only difference being Ms. Means did not die and Savita Halappanavar did.
This case happened at Mercy Health Partners,, a Catholic hospital in Muskegon, Mich. What makes it even worse is that Ms. Means is one of four women to suffer the same negligent care with ruptured membranes before viability at Mercy Health Partners who were denied adequate care. The cases were apparently discovered by a federally funded infant and fetal mortality project.
The ACLU, in an heretofore untested legal strategy, is suing the Catholic bishops. An interesting take, one that will undoubtedly wind its way to the higher courts. I hope the Supreme Court Justices weighing in on contraceptive coverage case under the ACA are watching this case unfold in Michigan, because the two cases are just a hop skip and a jump apart. If you can deny contraception to your employees based on your own personal religion, then why can’t you deny lifesaving care to your patients?
While there is a lot of press over this legal tactic, we must not lose sight of a crucial fact. If the events as reported are supported by the medical record Ms. Means was the victim of medical malpractice.
It is standard to care to offer termination at 18 weeks with grossly ruptured membranes. This is because the risk of infection is 30-40% just walking in the door with ruptured membranes at 18 weeks (meaning 30-40% of the time membranes ruptured because of an infection). If an infection isn’t there initially, it almost always develops. This is because once the membranes ruptured there is no barrier preventing the vaginal bacteria from ascending into the uterus. Regardless of gestational age. Regardless of viability. This kind of infections kills women. One needs to look no further than the Savita tragedy for a terrible reminder. And so, because the risks are very great, it is standard of care to include the discussion of termination at 18 weeks with ruptured membranes.
The facts tell us that with grossly ruptured membranes at 18 weeks subsequent prolongation of the pregnancy with the hopes of getting to viability is essentially non-existent. A study from 2006 looking at this exact scenario found no surviving fetuses with ruptured membranes up to 19 weeks. It is important to remember that at 22 weeks viability, meaning the percentage of babies who will survive to go home, is around 3%.
So what is the standard of care with ruptured membranes at 18 weeks?
- Confirmation that the membranes have ruptured
- Evaluation for infection
- If infection is present, recommend delivery (either a dilation and evacuation or an induction). Infection = delivery. Full stop.
- If no evidence of infection, discuss odds of fetal survival (reported as <1% with prolongation of the pregnancy) and overall risk that with each day infection becomes more of a concern. Some women, once fully informed, and who have no evidence of infection, do chose expectant management. It is very hard to make a decision to end a wanted pregnancy no matter how medically indicated the decision might be. In this scenario the patient requires extensive education about the signs of infection and must know when she should return to the hospital. If an infection develops, delivery is indicated.
There are several medically troublesome parts of Ms. Means care.
1) Reports that she was given medication to stop her contractions. If she had contractions she had an infection. If she received a tocolytic, medication to try to stop contractions, that is gross negligence. If she received a pain medication, that is standard of care. However, if she had pain, then she likely had an infection.
2) How did the doctors rule out an infection at her first ER visit? To safely send a patient home this must happen. Again, if she had contractions at 18 weeks with ruptured membranes infection is almost always a given.
3) The fact that she returned to the hospital two more times, delivering spontaneously the third time. What symptoms brought her two the hospital the second time? How did the doctors rule out infection at this visit?
4) Why wasn’t Ms. Means told that the odds her fetus would survive grossly ruptured membranes at 18 weeks* is essentially unheard of and offered a termination or transfer to a facility where one could be performed?
Without seeing Ms. Means chart the first three points I raised could have valid explanations.
It is also highly likely no doctor at Mercy Health Partners had the skill to do a dilation and evacuation, although as they have a birth center and a full-time laborist they have the ability to give oxytocin or misoprostol to induce labor. So, the technical ability to deliver Ms. Means at Mercy Health Partners existed.
It medically acceptable to deny to perform a non-emergent procedure based on personal beliefs. It is, however, medically unacceptable to refuse to refer a women who needs medical care to someone else who can.
Doctors can choose to work where there like. They can choose to not do procedures for a variety of reasons. They can even chose to work in hospitals that do not allow abortion and they can certainly feel that abortion is unethical and refuse to provide perform these procedures. However, it is malpractice to have a patient who requires a medically indicated procedure and to not arrange a transfer to a physician or facility where she can get that care or, at the very least, inform her of her options if you are unable to render that care yourself.
A bishops cassock is no acceptable defense against malpractice.
*ruptured membranes after an amniocentesis has a different prognosis.