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Apr 09 2013

Left untreated, the outcome is maternal death

Dr Jen Gunter has weighed in; I was hoping she would. She was informative and passionate about it last fall.

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.

What I want to know is, what are OB_GYNs taught in Irish medical schools? What are they taught is the treatment for chorioamnionitis? Are they really taught it’s to delay unless the fetal heart has stopped?

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.

And yet they dawdled. Still.

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.

That’s not the legal position here in the US, but it is the de facto position in many Catholic hospitals.

17 comments

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  1. 1
    Argle Bargle

    I sincerely hope Mr. Halappanavar sues the hospital and attending staff for wrongful death.

  2. 2
    Claire Ramsey

    Jennifer Gunter, MD’s post is excellent. While I was there I read another post, about the Duggar Circus/reality show and the 20 children and their costs to the people of their state and the nation. Her blog is fabulous! Thanks for linking to it. (The Duggar post is from 2011 but well worth reading).

  3. 3
    Giliell, professional cynic -Ilk-

    Oh, there are other gems in Mr. Halapavannar’s testimony, like telling them that the bloodwork takes two days.
    Bloodwork takes two days when I have a routibe check-up at my GP who’ll send it to an external lab.
    Important life and death bloodworks take the time the machines need, more or less.
    My mum used to work as a lab technician. Yes, some things are done by external labs. And the hospital she worked for was actually two hospitals. Some tests could only be done by one of the labs. There was a routine taxis that would transport samples once a day. And in an emergency a taxi would transport that one sample, making a 20 min delay.
    2 days are absolutely inacceptable for a woman with an accute condition.

  4. 4
    miraxpath

    The latest testimony from Dr astbury is mind boggling! Her understanding of what is life-threatening is effectively anything etremely dangerous and unrelated to pregnancy! WTF?

    ” Dr McLoughlin quoted from Medical Council guidelines on obstetric complications, which state that it may be necessary to intervene to protect the life of the mother while making every effort to save the baby’s life.

    Asked if she felt she had scope to intervene under these guidelines, the witness said she didn’t believe she could. Her understanding was that these guidelines applied to situation where a mother had been diagnosed with cancer or another life-threatening illness not related to her pregnancy. ”

    http://www.irishtimes.com/news/health/savita-halappanavar-s-consultant-acknowledges-hospital-systems-failures-1.1355804

  5. 5
    mildlymagnificent

    Her understanding was that these guidelines applied to situation where a mother had been diagnosed with cancer or another life-threatening illness not related to her pregnancy. ”

    Uh, oh. This woman is sounding more and more to me as though she’d be a problem whether or not she was RC or in Ireland.

    It’s not just the crunchy granola earth mothers who go in for this “mother nature knows what she’s doing” crap. There are far too many so-called professionals whose medical education merely puts a high gloss on some very shabby unscientific, non-medical shoes. The ‘beauty’ and ‘wonder’ of pregnancy and childbirth. It’s all natural, you know. It’s not that modern countries have medical systems and expert professionals to save women and babies from death and injury. Women like this seem to take their attitudes from those advertisements for moisturisers for the skin of those magnificent protruding bellies.

    It’s just nature at its purest and finest. (In this case, it sounds as though this woman really truly thought that if the baby wasn’t “meant to be” then the pregnancy would miscarry without problems.)

    She could also be an intransigent ideologue whose blinkers won’t let her see the woman dying before everyone’s eyes.

  6. 6
    dianne

    The more I read about Dr. Astbury the worse she sounds. She says that one reason she didn’t intervene earlier is that she didn’t have the results of lab tests showing that her wbc was elevated. Fine, so the system failed to get those results to her. But what sort of incompetent physician sits on a patient at high risk for sepsis for 4 days and doesn’t demand that the labs be drawn in all that time? This isn’t an exotic test that has to be sent out of country to the one lab in the world that does it and takes a month to come back, it’s a fucking CBC! She should have had the results within hours of Ms. Halappanavar’s admission and if she didn’t she should have been reordering it, calling the lab for results, and, if necessary, drawing the test herself and taking it to the lab.

  7. 7
    dianne

    Although maybe I’m being too hard on Dr. Astbury personally. It appears that the whole system is full of miseducated and incompetent practitioners. Another doctor is quoted as saying that when he saw Ms. Halappanavar for a fever and a pulse of 160, he drew some blood tests. Excuse me? Drew blood tests? In a patient with probable sepsis and a pulse of 160? What about starting broad spectrum antibiotics, transfer to the ICU, and getting in the surgeons’ faces until they agree to remove the nidus of infection? That’s the right way to treat sepsis, not just draw a few labs and stick the patient in a corner to die.

  8. 8
    miraxpath

    It is unbelievable that a senior doctor can be this irresponsible and intransigent. Dr Astbury does not concur with the admitting doctor that miscarriage was inevitable :

    Dr Astbury told the inquest that had she delivered at the stage when the membranes had ruptured there was no prospect of the baby’s survival.

    She told the inquest she did not agree with the view of her colleague who has said the pregnancy loss was “inevitable” when he reviewed her. Dr Astbury insisted there was a “very small prospect” of the pregnancy remaining viable.

    “If the membrane ruptures under 20 weeks there is a 12 to 18pc chance of the foetus reaching viability,” she said.

    A bloody motherfucking 12 to 18% chance of foetal viability!! So she dragged her feet for 2 days – didn’t order another blood test or ask to see the results of the one taken on Sunday.

    http://www.independent.ie/irish-news/courts/savita-doctor-law-was-factor-in-termination-decision-29187443.html

    Sha has to gall to say this : Speaking about Ms Halappanavar’s condition on the Tuesday, after the young woman had requested a termination, Dr Astbury described her patient as being “emotionally distressed”. When asked if emotional distress was as far as it went, she replied, “Yes, She’s not physically unwell.”

    So it appears that in an Irish hospital , you have to literally show signs of near death before a nurse or doctor accepts you are physically unwell. Fluid loss, a dilated cervix, an elevated white blood count , a heart rate of 114, increased body temperature , ruptured membranes all mean nothing much in themselves until the patient goes into septic shock on wednesday morning.

    Savita had no chance.

  9. 9
    Giliell, professional cynic -Ilk-

    Asked if she felt she had scope to intervene under these guidelines, the witness said she didn’t believe she could. Her understanding was that these guidelines applied to situation where a mother had been diagnosed with cancer or another life-threatening illness not related to her pregnancy. ”

    Well, clearly, if you’re dying of baby-making, then god wants you too. Remember, catholic women who die in childbirth are martyrs.
    But it also shows clearly why they need, need, need to legislate for X. Because it leaves woma-killers like Dr. Astbury wriggle-room.

  10. 10
    Walton

    That’s so tragic and awful.

  11. 11
    miraxpath

    Well it appears that the good little catholic doctor neglected to read her patient’s ‘case notes on wed morning. Savita had a medical emergency at about 630 am on wednesday morning and Dr Ast would have seen her after 830 am.

    Dr Astbury earlier told the inquest that she would have prepared to terminate Ms Halappanavar’s pregnancy five hours than she did had she read Ms Halappanavar’s notes on her ward round on the morning of October 24th.

    The notes indicated her life was by then at risk.

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

  12. 12
    dianne

    @Gilell: In the very partial defense of the doctor in that case, it’s possible that they were talking about blood cultures. Blood cultures do take 3 days to be confirmed as negative-the bacteria have to have time to grow (though in this case, they’d likely turn positive in less than one day). But if he meant a CBC…not so much. A CBC is a routine test that can be run in any hospital and quite a few outpatient labs. In about 10 minutes. The proper way to deal with the need for a CBC in a potentially septic patient is for the house officer or attending to draw the blood, run it to the lab him or herself, and stand there glaring at the techs until the results come back. Guaranteed to get results in fewer than 2 days.

  13. 13
    dianne

    @miraxpath: Again, in Dr. Astbury’s very partial defense, the house officer should have paged her as soon as he saw that Ms. Halappanavar was having difficulties and was likely septic. Just dropping a note in the chart to that effect is substandard care. Assuming, of course, that Dr. Astbury didn’t simply ignore a page from the house officer.

  14. 14
    miraxpath

    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.

  15. 15
    miraxpath

    #13 apparently another doctor had the case notes – the house doctor dropped the ball on this case. He told another doctor who promised to look in on Savita but did’nt. He didn’t intervene as strongly as he should have. We dont know why the ob/gyn in charge was not informed. So many staff failed Savita right from the start.

    From her husband’s testimony, it appears that even as she was dying, the husband was left hanging by the doctors who either didn’t turn up to brief him or chose the time to talk about clinical trials to a man whose wife was dying rapidly.

  16. 16
    miraxpath

    She told Mr Gleeson that once the membranes had ruptured there was a 30 to 40 per cent likelihood of Ms Halappanavar contracting an infection.

    “That is serious from a patient’s point of view? It’s a significant risk to her health?” he asked.

    “If you consider 30 to 40 per cent significant, yes,” Dr Astbury replied. She agreed the longer a woman with ruptured membranes remains undelivered, the greater the risk of infection.

    “If you consider 30 to 40 per cent significant, yes,” This ob/gyn is somewhat mathematically challenged.

  17. 17
    Ophelia Benson

    omigod. She’s terrifying me.

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