Last October, Savita Halappanavar became a household name around the world in both prochoice and antichoice circles as news of her tragic death spread.
Ms. Halappanavar was a 31-year-old dentist in Belfast, who emigrated from India. She was 17 weeks pregnant with a very much wanted pregnancy when she began to miscarry. She and her husband went to the hospital where, despite their requests for a termination, they were denied and forced to wait to miscarry “naturally.” During this waiting process, Savita became incredibly ill, developing chorioamnionitis after her membranes ruptured, which progressed to sepsis, and then septic shock. She later died from a cardiac arrest, a week after being admitted to the hospital.
Her death sparked off vigils and protests around the world and calls for a change to Ireland’s draconian laws which prohibit abortion in all but the most extreme cases.
Just this week, however, the Prime Minister of Ireland, Enda Kenny, presented the new Protection of Life During Pregnancy Bill of 2013 – drafted in large part as a response to Savita’s death – which lays out ground rules for when abortions may be performed to save women’s lives in Ireland.
Unfortunately, since her tragic death, antichoice advocates have continued to claim that lack of access to abortion care was not a factor in Savita’s death. For instance, in response to a reblogged tumblr post that I tweeted, the antiabortion gang made the following remarks:
Well, antiabortion gang, yesterday the experts DID tell us what happened. Yesterday the Irish Health Service Executive published its full investigative report into her death.
A summarized timeline of the relevant medical facts in her case (from the report) is as follows:
Sunday, 21 Oct 2012, 9:35AM
Savita, 17 weeks pregnant, arrives at the hospital complaining of back pain (though it is noted she has a history of back pain due to sacral disc problems). Her vitals are taken and a urinalysis is performed. Neither show any signs of infection.
Sometime after 11:15 am, she is discharged from the hospital with the suggestion to take an OTC pain medication for her back pain.
Sunday, 21 Oct 2012, 3:30 PM
Savita returns to the hospital and informs staff that she “felt something come down” and pushed it back in. A midwife reported that she believed Savita would immediately miscarry and conducted a visual inspection.
Later, a senior house officer conducts a speculum examination and notes that her gestational sac (aka membranes) are bulging.
Sunday, 21 Oct 2012, 2:20 PM (This time has come into question as this entry was made AFTER entries made at 3:30 PM)
The Obstetrics and Gynecology Specialist Registrar (O&G Spr) performs a speculum examination, noting that Savita’s membranes are bulging almost to the entrance of her vagina, but are not cloudy (indicating no infection). The reviewing doctor notes that a miscarriage is imminent, and a “await events” approach is ordered and explained to Savita and her partner. No other treatment options are offered or explained.
Savita complains of pain that is “unbearable.”
A full blood panel is ordered due to the risk of infection associated with bleeding during miscarriage.
NB: Pain during a miscarriage, particularly severe pain, may indicate intrauterine sepsis and should have warranted further investigation.
Monday, 22 Oct 2012, 12:30 AM
Savita vomits copiously as her membranes spontaneously rupture. She is helped back to bed and told to rest.
Monday, 22 Oct 2012, 8:30 AM
The O&G Consultant 1 discusses the risk of infection and sepsis with Savita, and reiterates that the treatment plan is to “await events.”
Monday, 22 Oct 2012, 6:00 PM
Savita’s pulse rate begins to go above normal. (102 bpm)
Monday, 22 Oct 2012, 10:00 PM
Savita is administered a first dose of 250mg of erythromycin, to be delivered every six hours. The rationale given was ruptured membranes.
NB: Concerning the administration of erythromycin in this case, the investigators stated that:
Erythromycin is indicated for use prophylactically in preterm pre-labour rupture of the membranes in the absence of signs such as a faster pulse or lower blood pressure or raised temperature (Green-top Guidelines No 44 (2006 with amendment Oct 2010)). Erythromycin has also been shown to delay delivery which is beneficial in the management of preterm pre-labour rupture of the membranes but not in cases of inevitable miscarriage. However, in cases of preterm pre-labour rupture of the membranes where signs of sepsis occur, best practice guidelines promote that delivery is expedited.
Tuesday, 23 Oct 2012, 8:20 AM
Savita is continued on a course of erythromycin.
Savita and her husband ask about the possibility of using medication to induce a miscarriage, but are informed that, “Under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart”. They were informed that if risk to Savita’s life were to increase, a termination would have been possible, but it would have to be based on an actual risk and not a theoretical risk of infection as, “we can’t predict who is going to get an infection”.
Tuesday, 23 Oct 2012, 7:00 PM
Savita’s pulse rate increase to 114 bpm.
Tuesday, 23 Oct 2012, 9:00 PM
It is noted that Savita has been complaining of weakness.
NB: Weakness is an indication of infection / sepsis.
Wednesday, 24 Oct 2012, 4:15 AM
Savita is found shivering and with chattering teeth in her room. Her temperature has increased to 37.7 Celsius (99.86 Fahrenheit). Savita is given an extra blanket, and medication to lower her temperature.
NB: Shivering and chattering teeth are a sign of sepsis.
Wednesday, 24 Oct 2012, 4:20 AM
NB: Vomiting can be a sign of early toxic shock.
Wednesday, 24 Oct 2012, 6:30 AM
Savita’s complains of weakness and general body aches. Her vitals were as follows:
→ Temperature 39.6 degrees Celsius (103.28 Fahrenheit). ABNORMAL
→ Pulse rate 160 per minute ABNORMAL
→ Blood pressure 94/55mmHg, ABNORMAL
→ Respiratory rate 15 per minute
→ Oxygen saturations 97% on room air. ABNORMAL
Wednesday, 23 Oct 2012, 7:00 AM
Savita’s medical notes indicate nausea and vomiting, fever of 39.6 C with chills and rigors, palpitations, and tachycardia (160 bpm).
Her medical examination revealed extreme sensitivity upon examination of her suprapubic regions, and a significant amount of foul smelling brownish vaginal discharge.
The Senior House Officer diagnosed her as suffering from chorioamnioitis at this point, with possible sepsis.
An additional antibiotic was ordered administered at this point (Augmentin) as well as medication to reduce her fever. Blood samples were ordered, as well as a serum lactate test (due to concern about hypoperfusion that might indicate sepsis).
NB: the the suprapubic sensitivity and foul-smelling discharge are indicative of intrauterine infection.
Wednesday, 24 Oct 2012, 7:00 AM
Savita’s vitals continue to deteriorate. Her temperature remains high, her blood pressure continues to drop, her heart rate remains high, and she is placed on 40% oxygen supplementation.
Wednesday, 24 Oct 2012, 8:25 AM
Savita’s vitals continue to decline. Chorioamniotis is officially documented and she is started on another IV antibiotic: Metronidazole. A high vaginal swab and a mid urine stream are collected and sent to determine what infection is present. The medical team decide to wait on the results of the earlier blood test to change treatment plans.
Savita’s consultant OB/GYN inform she and her husband that if the source of the infection cannot be determined, a termination may have to be considered.
Wednesday, 24 Oct 2012, 12:00 PM
Savita’s blood count returns with a white cell count of 1.7 x 109/L at 8:29 AM. A normal range for a white cell count in a second trimester pregnancy is between 6.2 – 14.8 x 109/L.
NB: A low white blood cell count or an elevated blood cell count outside the normal range in the second trimester is indicative of sepsis.
Wednesday, 24 Oct 2012, 1:20 PM
Savita’s condition continues to deteriorate rapidly. Her blood pressure has dropped to 81/40 mm/Hg, while her pulse rate has increased to 150 bpm. She is suffering from hypotension, dyspnoea and myalgia.
A diagnosis of septic shock is made, with the cause queried as chorioamnionitis.
Wednesday, 24 Oct 2012, 2:09 PM
Tazocin (an antibiotic) is added to Savita’s antibiotic regimen.
Wednesday, 24 Oct 2012, 3:00 PM
Savita’s condition deteriorates even further. An ultrasound is carried out and shows no movement of the fetal heart.
Wednesday, 24 Oct 2012, 3:15 PM
During insertion of a central venous line for monitoring and medication dispersal, Savita spontaneously miscarries the fetus and placenta.
Swabs of the maternal and fetal surfaces of the placenta are sent for culture and analysis.
After this point, Savita’s condition RAPIDLY deteriorates.
Thursday, 25 Oct 2012, 9:00 AM
Savita’s condition is still rapidly deteriorating. Diagnoses of severe septic shock, acute respiratory distress syndrome (ARDS), and disseminated intravascular coagulation are made.
Thursday, 25 Oct 2012, 12:00 PM
Based on preliminary results from placental swabs, the microbiologist recommends a change to Savita’s antibiotic regimen, removing the Tazocin and replacing Meropenem, and adding Gentomicin.
NB: The local Guidelines for the management of sepsis recommend using Tazocin and Gentomicin.
Friday, 25 Oct 2012, 12:00 PM
Cultures from placental swabs are complete, indicating the bacteria in question is ESBL E.Coli, proven susceptible to Tazocin and Meropenem.
Savita is continued on an antibiotic regimen of Meropenem, Gentomicin, and Metronidazole.
Sunday, 28 October 2010, 12:45 AM
Despite continued treatment, Savita condition continues to rapidly and severely deteriorate, and she suffers a cardiac arrest. Resuscitation efforts are made, but she is pronounced dead at at 1:09 AM.
I included the above timeline not only to provide readers with a background to the case that has been largely hidden from the public prior to now, but to highlight just how glaring the errors in her medical treatment were.
In addition to providing a complete timeline of events, The investigative team laid out three causal factors for Savita’s death, with the first being:
Inadequate assessment and monitoring that would have enabled the clinical team to recognise and respond to the signs that the patient’s condition was deteriorating due to infection associated with a failure to devise and follow a plan of care for this patient that was satisfactorily cognisant of the facts that: (1) the most likely cause of the patient’s inevitable miscarriage was infection and (2) the risk of infection and sepsis increased with time following admission and especially following the spontaneous rupture of the patient’s membranes.
While second trimester miscarriages are rare (occurring in only 1 – 2% of pregnancies), when they do occur, 77% are the result of infection, and, with chorioamnionitis, 0.5% will develop sepsis, and 0.1% will die.
A wide variety of bacteria is naturally present in the normal vaginal flora of pregnant women, including anaerobes and E.coli. However, these bacteria can also cause ascending infections, such as the one experienced by Savita, usually after membranes rupture, resulting in chorioamnionitis.
Chorioamnionitis, in turn, can lead not only to preterm labor, but to maternal and fetal morbidity. While maternal mortality in Ireland is normally listed at about 1 in every 10,000, the risk for women with chorioamnionitis increases to 1 in every 1,000. As the infection progresses to sepsis and septic shock, the risk increases exponentially.
To summarize Savita’s case, Savita presented at the hospital on Sunday, miscarrying an unviable fetus. In the middle of the night between Sunday and Monday, her membranes ruptured, opening her up to the risk of infection. Tuesday morning, she and her husband asked for medication to induce the miscarriage, but were denied. Instead, her medical team administered an antibiotic – erythromycin – that has been proven to prelong pregnancy with preterm prelabor rupture of membranes, a useful medical tool for viable pregnancies, but the exact opposite of what doctors should have been doing when faced with Savita’s inevitable miscarriage.
By Tuesday evening, she was already showing signs of sepsis, which were missed (or ignored) by her medical team. By Wednesday morning, her septic symptoms were severe, and she was diagnosed with chorioamnionitis, yet still the medical team forced her to continue with an “await events” approach to her miscarriage. Savita then naturally miscarried the fetus and placenta Wednesday evening. Afterwards, she became even more ill, dying from a cardiac arrest on Sunday.
While it is not clear exactly when Savita’s condition of severe sepsis progressed to septic shock, based on all available evidence, the investigative team felt it most likely that this happened sometime between the hours of 4:15 to 10:30 AM on Wednesday, 24 October 2012.
As Dr. Sabaratnam Arulkumaran, a London professor of obstetrics and gynecology, and author of the investigative report has stated: “When sepsis sets in, it is difficult to say who is going to live and who is going to die. We are just guessing here.” He also described the death rate from severe sepsis as 40 percent and septic shock as 60 percent, and said that if Halappanavar had received an abortion and aggressive doses of antibiotics early into her hospitalization, “the risk [of her death] would be much less.”
At the point at which chorioamnionitis was discovered, and most likely sooner, a termination should have been IMMEDIATELY performed. A woman who was miscarrying a nonviable fetus, had been lying in a hospital room for more than 48 hours with ruptured membranes (when clinical literature shows that the risk of infection – and therefore the need to empty the uterus – greatly increases after 24 hours), was showing signs of sepsis, and had been diagnosed with chorioamnionitis.
Had Savita received the termination she requested on Tuesday (more than 24 hours after her membranes had ruptured), and had swabs of the placenta been sent for analysis THEN instead of waiting the 30+ hours for her to miscarry naturally, Savita would have had 30 additional hours of aggressive antibiotic therapy, and 30 fewer hours for the infection in her uterus to spread throughout her body.
There was NO chance of saving Savita’s fetus. NONE. Fetal demise is a certitude in an inevitable miscarriage at 17 weeks with ruptured membranes. This fetus was not viable, and could not be saved. From the moment Savita stepped foot into the hospital, her fetus was not viable. But there WAS a chance of saving Savita, a chance that grew smaller and smaller each moment hospital staff waited, as first infection, then sepsis, then septic shock set in.
Unsurprisingly, the investigative body agrees with this assessment. Their investigation of the circumstances surrounding Savita’s death led them to state that another “key causal factor” in Savita’s death was the, “Failure to offer all management options to a patient experiencing inevitable miscarriage of an early second trimester pregnancy where the risk to the mother increased with time from the time that membranes were ruptured,” and that:
International best practice includes expediting delivery in this clinical situation of an inevitable miscarriage at 17 week with prolonged rupture of the membranes and infection in the uterus because of the risk to the mother if the pregnancy is allowed to continue. Expediting delivery (either medically or surgically as appropriate or feasible, and within the law) at the earliest signs of infection in the uterus is a critical part of management to reduce the risk of progression to sepsis, severe sepsis and septic shock and maternal morbidity and death.
Additionally, the team stated that:
Different management options needed to be considered – including termination of the pregnancy – as removal of the source of infection reduces the potential risk of sepsis thereby potentially avoiding rapid deterioration in the patient’s clinical condition due to progression to severe sepsis and septic shock with an associated high mortality rate.
That? All of that above, antiabortion gang (and other antis), is experts clarifying that the fact that termination of Savita’s pregnancy was NOT expedited even though she was miscarrying a nonviable fetus, had prolonged premature rupture of membranes, and an infection in her uterus, increased the risk of, if not directly caused, her death.
So antis, STFU about there not being a need for access to abortion services to save the lives of women. This case proves otherwise, as do many, many, MANY other cases around the world.
Finally, though this post has focused on the need for abortion care in situations where a woman’s life is at risk, I want to be careful to iterate that when it comes to abortion care, it SHOULD NOT MATTER whether a woman’s life or health is at risk from the pregnancy. What matters, ALL that should matter, is whether or not a woman wants to continue with her pregnancy. The reasons a woman wishes to access abortion care are of concern to her, and to her alone.
While Savita Halappanavar represents the ultimate tragedy of death that can befall a woman denied access to care, women who are denied access to abortions suffer many other consequences. Some turn to butchers like Gosnell when they cannot access safe and legal care, other attempt to perform abortions on themselves, and many others are coerced into carrying their pregnancies to term with devastating consequences. Focusing solely on life and health exceptions creates a false dichotomy between “good” and “bad” abortions. There are no “good” and “bad” abortions; only abortions which are safe and healthy for women, and those that are not.
Rest in peace, Savita Halappanavar. I hope that your family is finding peace, as well.
Till next time,
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© Heather Parker and Antigone Awakens, 2012-2013.