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.