Savita: Some more facts (For the hard of understanding)

There’s a fabulous phrase from Blackadder goes Forth, that would make for a very witty inscription on a tombstone and which I employ on frequent occasions when discussing pro-abortion advocates. Uttered by General Melchett (Stephen Fry before he manifested the symptoms of irrepressible smugness) whilst discussing the progress of the Great War, he tragically and comically sums up the attitude of those directing the war, thus:

If all else fails, a total Pig-Headed unwillingness to look facts in the face will see us through

I’m thinking in particular of the continued propagation of the idea that Catholic dogma played its part in the death of Savita Halappanavar, and the insistence that a timely abortion would have saved her life.

I’m going to spell this out very simply for the terminally hard of understanding.

Sunday 21st October 2012.

Savita was admitted to Galway University Hospital. She was suffering from backache and during the day had experienced some distressing blood and fluid loss. The hospital took bloods and examined her. The blood results that would have indicated that she had an infection were never followed up on, and Savita did not manifest obvious signs of infection. Sepsis is a deadly disease with a rapid progression which medical staff need to be hyper-vigilant about when dealing with pregnant women. Its symptoms can easily be masked by other symptoms in pregnancy, such as backache, raised temperature and generally feeling unwell. Savita had a history of back problems and had herself misdiagnosed her pain earlier in the day.

Savita would appear to have been suffering from a Urinary Tract Infection, (UTI) which are very common in pregnancy, need antibiotics to treat them, but are not necessarily life threatening. Let’s add into the mix that University College Hospital Galway, was over-stretched in terms of staffing and resources, this report in 2011 names it as the worst performing hospital in Ireland for the second consecutive month with calls for the Health Minister to intervene. The hospital seems to have been suffering from chronic shortages, which is something we should bear in mind before pointing the finger.

There is no reason at this point, to believe that Savita needed an abortion, let alone that her life might be at risk.

Upon examination it appears that Savita’s membranes are bulging and her cervix can’t be felt, meaning that a miscarriage is sadly imminent. There is no reason to believe that she is at risk of infection or that she needs an abortion. Later on, in the early hours of Monday morning, her membranes rupture. Again, there is no need to think that she may need unnecessary surgery, this seems like a regular miscarriage.

Monday 22nd October 2012

By 10pm on that evening, Savita’s waters had been ruptured for a full 22 hours. She was on antibiotics every six hours. It’s not clear when these were started, it should however have been from the moment the membranes ruptured and ideally based on the results of the blood culture taken on Sunday evening.

Tuesday 23 october 2012

At 8.20 am Savita is seen by Dr Astbury who informed her that ‘that the legal position in Ireland did not permit me to terminate the pregnancy in her case at that time.’ Savita is, at that point very distressed and requesting an abortion to put an end to her ordeal. No-one can blame her. She knows that she is miscarrying her baby and wants the whole thing to be over.

My take on this, is that Dr Astbury obviously sympathises. I think that she doesn’t want to take personal responsibility, or appear harsh and uncaring, nor does she want to cast the hospital in a bad light, there is no medical reason, or so it would seem, for an abortion, this isn’t life or death, they probably didn’t have a theatre or staff available at short notice and so she fell back on the letter of the law as an explanation. It’s fair to say that the law would not allow for an abortion in these circumstances, the foetal heartbeat is present, the patient seems comfortable and stable and no doubt many of the staff would have felt uncomfortable, given that this was not medically necessary, but it seems that there was no discussion as to why the hospital were taking the conservative management approach, one that would be taken in hospitals around the world. Hospitals do not deliver pregnant women the moment their membranes rupture, they can very often be sent home to get some rest in comfort, before being readmitted within the next 48 hours, depending on protocols and individual circumstances. It seems very remiss that Dr Astbury explains this in such a perfunctory and legalistic way. Surely Savita was owed more of an explanation?

If there was a clinical need for an abortion, why did Dr Asbury not consult with any of her colleagues? In any event, Savita was described as being “upset, but not unwell”.

Later on Dr Astbury testified that had she had access to Savita’s blood results earlier, then she would have taken theraputic intervention, i.e, an abortion, earlier. So how does this delay in terms of diagnosis and identifying the infection, equate with being the fault of Catholicism or uncertainty surrounding the legal situation?

But what does not make sense, is that if an infection is present or suspected, it is a contraindication for surgery – why invade a sterile uterus with instruments and risk flooding the body with further infection? Conservative management is always the default option in the treatment of miscarriages.

Wednesday 24 October 2012

This is the day that things begin to unravel for poor Savita. At 7am her pulse is 160 per minute (normal resting heart rate is usually between 60 and 80). Her blood pressure is 100/60 mm (normal is 120/80). Her temperature is 39.6 and in addition foul smelling discharge is present, suggesting infection. The doctor on duty concurs she is suffering from probable sepsis.

An hour and half later, 8.25 am, Dr Astbury and team see Savita on their ward rounds. Swabs are taken to determine what exact infection is present. According to the Irish Times, Dr Astbury testifies thus:

At this point her temperature had come down to 37.9 degrees and her pulse to 144bpm. She said she discussed with Ms Halappanavar the concern that she had inflamed foetal membranes due to infection.

“I also informed Ms Halappanavar that if we did not identify another source of infection or if she did not continue to improve we might have no option but to consider a termination regardless of the foetal heart.”

Mr Halappanavar has said he had no knowledge this discussion had taken place. In his statement he said he was at the hospital with his wife throughout Wednesday.

Subsequent to this, Savita deteriorates further, Dr Astbury consults with a colleague who agrees that delivery is medically necessary, a scan confirms that the baby has died, she is taken into theatre where she delivers, is subsequently transferred to HDU and then ICU and dies following further subsequent deterioration just after midnight on Sunday 28 October 2012.

Savita’s husband has no recollection of the conversation that a termination might be needed regardless of the presence of a foetal heartbeat.

Let’s leave aside the comments from the midwife, who was discussing abortions in a cultural context, Ireland’s Catholicism in relation to India’s Hinduism, in response to Savita’s request for an abortion. These obviously do not dictate care. Also Savita’s request for abortion should not be considered a factor. Patients’ wishes, whilst often taken into account, do not dictate what is best medical practice, as I learnt when I was refused the option of being able to deliver my youngest baby naturally. The doctors understood, they sympathised, they could see I was distressed and terrified and they did what they could to help me be comfortable, but ultimately they would not agree to the course of action that I requested, because it was deemed to be unsafe, and interestingly more unsafe for the baby than for me. I could not force them to act against my best medical interests.

Why would an abortion be required if the Dr could not find the source of the infection? It is clear that the baby could not have been the source of the infection. This is biologically impossible. A baby would not suddenly become infected and pass this onto the mother. The baby is in a sterile environment, even after the membranes have ruptured. The inflamed foetal membranes referred to, or to give it the correct medical term, chorioamnionitis, had not been identified. If this was the concern, which would require delivery, why wasn’t this possibility examined for sooner? It all seems like amateur guesswork. Finding the source of the infection, and treating the infection is a wholly different issue as to why the baby would need to be delivered. Plus we know that Savita presented with infection at the hospital, prior to the rupture of the membranes.

And here’s the absolute crunch. Four key failures. The blood test results performed on Savita on the Sunday evening admission, were ready at 6.37pm that evening, but not read until 5.25pm the next day. They were not then accessed again until after sepsis had been diagnosed and Savita’s condition was rapidly deteriorating, two days later. When Savita started shivering at 4.15am on the Wednesday morning, the first obvious signs that sepsis was raging through her body, her vital signs should have been checked. They were not. The blood culture sample taken from Savita at 8:29 am on Wednesday 24th October was processed onto the computer system by microbiology at 9.54 am but not reviewed by Dr Astbury until 11:20am. The lab also reported that the 2nd key sepsis test should have been performed on the ward, it was not. This a lactate serum test which could have definitively confirmed the presence of sepsis. The sample was taken at 6am on the Wednesday morning and stored in an inappropriate bottle before being sent to the lab who could not process it. The lab would not, in any event have carried out this test which should have been performed at a point of care unit on the ward.

The antibiotic treatment administered to Savita between 7am and 1pm was ineffective as it was erythromycin, a variant that is resistant to E-coli, the infection that pathology determined killed her. Broader spectrum antibiotics would have been a better choice.

The indications that Savita had sepsis were subtle and overlooked, by staff who were not deliberately negligent, but who were overstretched and under-resourced.

Catholics and pro-lifers have been writing today of the horrors of Kermit Gosnell. Pro-choicers have been calling his case an exception from which no broader conclusions can be drawn. Why then, in the case of Savita Halappanavar, and in the face of all evidence to the contrary in this one-off extraordinary case, under which Irish law allowed for an abortion, are they claiming that this is evidence that the law is causing women to die in droves?

Savita died from an E.coli infection, which the likelihood is, entered her urinary tract and bloodstream, causing her to miscarry. It was this bacteria that killed her and prompt identification of it, along with the correct antibiotics that could have saved her life. Aborting her baby would have made no difference to the progress of the disease and would have risked further infection and hastened death.

As well as holding the hospital to account, Parveen should be asking questions of the pro-choicers who have chosen to cynically exploit this tragedy for their own ends. The baby did not kill Savita, the E.Coli did.

7 thoughts on “Savita: Some more facts (For the hard of understanding)

  1. I agree and have written something similar, in more general terms. The debate needs to be about WHY the systems failures ocurred and if linked to auserity and cutbacks (which it is bound to be) then that needs to be highlighted the length and breath of Europe. Well, Germany at the very least….

    1. Overall conclusion sound? I’d be interested in your perspective re the detail. This is all testimony from the inquest in terms of what happened.

      Or is it the conservative management approach that you would not necessarily advocate?

  2. Sorry I made a typo in the last sentence. Basically I agree with you; if the facts are as you say, there was never any medical indication for abortion here. (As we know, there can never be any moral justification.)

    It’s great you’ve taken this freedom the inquest. Is all this published online? I would really like to read it.

    In terms of the detail, I would not necessarily consider the failure to check on the result of the bloods (presumably a Full Blood Count) as being a critical event in the chain. It certainly represents very poor care but whether this was crucial in the outcome depend on the degree of abnormality. Mild or even moderate leucocytosis may not have altered the management, for the reason that bloods alone don’t form the diagnosis but contribute to the overall picture. So if you suspect sepsis early then raised white blood cells may support this; whereas if you don’t suspect sepsis, a slightly raised result would not necessarily change your mind. Degree is important here. I would also be interested in knowing if they checked CRP, which is another marker. Perhaps there is more detail in the inquest material?

    Just from what I’ve read in your piece, it seems to me that the critical events took place on the Wednesday morning. It sounds like she had rigors at 4.25am. Where are the observations? At 7am, her heart rate is 160bpm? This lady is in SEPTIC SHOCK. She is critically ill. In emergency medicine they call the first hour of shock, the Golden Hour because it is interventions in this period that make the biggest difference to outcomes. She should have had lactate done, also arterial blood gases. She needed blood cultures taken then started on broad spectrum antibiotics – erythromycin was a terrible choice. (Incidentally the blood cultures probably wouldn’t grow anything for days anyway unless there was something to see on Gram staining.) The intensive care team should have been notified at that stage. This kind of situation doesn’t wait for the consultant’s ward round.

    So that’s my general take on what I’ve read. Just a caveat, I’m a GP, not a gynecologist. Though I have spent a few years of my training in A+E and general medicine where we see a fair bit of sepsis.

  3. I am sure Savita would have been tachypnoeic (breathing rapidly) in response to her septicaemia, which should have triggered a MEWS alert, with arterial blood gases and lactate measurement, and urgent referral to the critical care team. It would have done in my little hospital. Basic recording of observations and acting upon them is so important, but is commonly ignored and trivialised, sadly.

    Was she on erythromycin because she was allergic to penicillin? Was there any metronidazole given? Intravenous antibiotics rather than oral might have made a difference. The speed with which sepsis goes is truly frightening. I have seen a patient go from well to dead in 12 hours because of a missed dose of prophylactic gentamicin before a flexible cystoscopy.

    Bacterial chorio-amnionitis is pretty rare – I haven’t seen or heard of a case in my 25+ years of UK practice, though “puerperal fever” was the big killer of mothers pre- modern obstetrics/antibiotics. Rare conditions are hard to diagnose, but this sounds like her death was due to poor basic care, as it so often is. The coroner’s recommendations sound good to me. All hospitals must practice by such standards nowadays.

    (I am an ITU Consultant/Anaesthetist)

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