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.

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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.