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.
To not deliver a woman in such a high risk situation requires proof that she does not have an infection. This can only be accomplished with an amniocentesis, which is extracting amniotic fluid from around the fetus and testing it for signs of infection. The results take 1-2 hours.
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.
To figure out how a woman could die from such an obvious diagnosis with clear treatment recommendations, the inquest into Savita Halappanavar’s death must answer these three questions:
1. When did the medical team make the diagnosis of chorioamnionitis?
If it wasn’t until Tuesday then that’s negligence. Ruptured membranes at 17 weeks, an open cervix, back pain, and an elevated white blood cell count means chorioamnionitis. The diagnosis was likely clear on Sunday evening, Monday at the absolute latest. By Tuesday evening she was beyond sick, she was gravely ill.
2. Considering there was a delay in delivering Ms. Halappanavar, what tests were done to support the safety of the “watch and wait” therapy?
Say the team was on the fence about chorioamnionitis. Maybe there was reason to believe that her white cell count was elevated? In this scenario, an amniocentesis would be required to prove the amniotic fluid was not infected. In my opinion watching and waiting could only be supported with a negative amniocentesis. If an amniocentesis wasn’t done then either A) the team were certain she had an infection B) the team had no idea that she could have an infection C) the team was on the fence, but the results wouldn’t matter anyway because the fetus had cardiac activity.
3. 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.