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Posts Tagged ‘sepsis’

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A number of mainstream media outlets are reporting on the tragic case of a Sicilian woman, Valentina Milluzzo who became pregnant with twins following IVF treatment and then died after miscarrying them.

Scant detail has been reported, but according to reports, Mrs Milluzzo was admitted to the Cannizzaro hospital in Catania, Sicily, after falling ill and going into labour at just 19 weeks in pregnancy, on September 29 where she remained in a stable condition for a couple of weeks.

On October 15 her condition worsened and one baby was then stillborn, Mrs Milluzzo’s condition then rapidly deteriorated, her family then asked for the other baby to be aborted, doctors refused supposedly on the grounds of conscientious objection, then it appears that the other baby was miscarried, shortly after which poor Valentina Miluzzo died too.

The various media reports seem muddled. In the Daily Mail the family’s lawyer allegedly reported that one of the unborn twins was suffering from from a ‘breathing complication’. This doesn’t stack up because a baby in utero does not actually breathe through their nose and mouth, but rather exchanges oxygen and carbon dioxide with the mother through the placenta and umbilical cord. Clearly there was some kind of complication causing foetal distress which may have led to the miscarriage, but ‘breathing difficulty’ seems to be an overly-simplistic term. That said, this could simply be a translation error. But in any event the account in the Daily Mail, has the doctor refusing to abort both babies.

The BBC has a similar account, namely the doctor apparently refused to intervene to abort both babies after one got into difficulty, but the Guardian claims that having given birth to one stillborn baby, poor Valentina was in agony for 12 hours with the doctors refusing to intervene on the grounds that the other baby was still alive. The family begged for the doctors to abort the other child to save her life, the doctors refused and shortly afterwards the baby was born dead and Mrs Milluzzo died of septic shock.

The Guardian of course carries a photograph of pro-life nuns, just in case you hadn’t got with the programme about these evil Catholic types. It also runs a load of irrelevant copy with implied supposition about the recent decline in abortions in Italy being due to a shortage of doctors willing to perform them and whether or not Italy actually has enough people to carry out abortions because, shock horror, there’s a high rate of conscientious objectors. A decline in abortions, can never be seen as positive news now can it, and what this unsubtle inference fails to mention is Italy’s catastrophically declining birth rate. Maybe, just maybe, fewer women are getting pregnant and those who do actually want to keep their babies?!

First off, nobody should be blamed or jump to conclusions because the fact is that we do not know what happened. Of course the family would have been enormously distressed by the way events unfolded and one cannot blame them for wishing medics to take whatever action necessary to save the life of their beloved wife and daughter.

But in this situation, when we have the very sketchiest of facts, it is a revolting political opportunism that wishes to capitalise on a terrible tragedy of a woman, who is not yet buried, to claim, as the profiteers at International Planned Parenthood Federation (who  make money from abortion) have done, that the right of medics to conscientiously object to abortion, puts women at risk and must be removed. Medics are not disrespecting the law, they are acting in accordance with it. Italian law in common with other European laws, allows for abortion in certain specific prescribed circumstances, and also allows doctors who feel that their remit is to save lives not end them, to opt out. Freedom of conscience ought to take primacy. Nobody should be coerced by the law into carrying out acts which they find to be morally abhorrent.

In the case of a woman who has achieved a much-wanted pregnancy via IVF, one can well understand the reticence of doctors to abort the child, if there was a chance that they might survive. Secondly, and perhaps more importantly, in the case of miscarriage, the best clinical approach is to conservatively manage a miscarriage, which negates the risks and complications of surgery. It’s not clear how aborting the surviving twin would actually have saved her life – an unborn baby is not some kind of toxin, poisoning a woman’s system from within.

There seem to be several terrible parallels with the case of Savita Halappanavar going on here. Both women would appear to have died of septic shock. The HSE inquiry ruled that Mrs Halapannaver died of sepsis which went undiagnosed for too long. An abortion would not have saved her life, but prompt administration of antibiotics could well have done, though sepsis does require extremely swift diagnosis and intervention.

Dr Sam Coulter-Smith, master of the Rotunda hospital in Dublin commented that Ireland’s pro-life laws had little to do with Mrs Hlappanavar’s death and echoed the view of most gynaecologists saying

 “I think most of us who work in obstetrics and gynaecology, there may be individual differences, but the majority would be of the view that if the health is such a risk that there is a risk of death and we are dealing with a foetus that is not viable, there is only one answer to that question, we bring the pregnancy to an end.”

Here are the known facts. At 22 weeks, Mrs Milluzzo’s much-wanted child was viable and potentially had a chance of life. Abortion is not on the protocols of treatment for pregnant women with sepsis. Patients and family wishes must of course be taken into account, but the fact that they may have been understandably begging for a course of treatment which they believed was the best chance of saving this woman’s life, does not mean that aborting the baby was the correct medical solution. Wishing to save both the life of the baby and the mother, if at all possible, does not mean that the doctors were negligent, uncaring or adopting a rigourist approach.

The hospital is strongly disputing the family’s account. They have said the following:

“There was no conscientious objection on behalf of the doctor that intervened in this case because there was no voluntary termination of the pregnancy, but (the miscarriage) was forced by the grave circumstances…I rule out that a doctor could have told the family what they say he told them.”

Italian law forbids doctors to withhold life-saving treatment when a mother’s life is at risk. This has been reiterated by a national association of Catholic doctors who said that when a mother’s life is at risk, doctors must do whatever is necessary to save it.

Regardless of what may or may have been said to the family by the doctor (and I think we also have to allow for misunderstandings, especially in such a traumatic situation) there is nothing as yet, which demonstrates that doctors wilfully refused to save the life of a dying pregnant woman and sacrificed her for the sake of her unborn child. We do not have enough evidence and we should not speculate or seek to vilify the doctors, who were the ones actually dealing with the situation and who had the medical knowledge to ascertain the best course of action. Presumably when Mrs Milluzzo went into hospital she was hoping that the doctors would do everything possible to save her children. The request for an abortion was a response to ease suffering and save her life when her condition deteriorated, but chances are that by this stage it was already too late.

There are always two sides to every story, what happened to innocent until proven guilty?

But sadly, that won’t stop the pro-choice bandwagon from using this story as further proof of the uncaring pro-lifers forcing women to die for the sake of their unborn children and trying to remove the conscience rights of doctors, even though tragic cases such as these are very few and far between. With an absence of backstreet butchery upon which to hang the need for compassion, any maternal death with any possible tenuous link to abortion must be milked to ensure every drop of righteous indignation and anger is directed at those who wish to protect the lives of the unborn, who must be portrayed as uncaring misogynists. Especially if they happen to be doctors.

Valentina Milluzzo was a beautiful woman with everything to look forward to. May she and her babies rest in peace.

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Before going any further, we should all remember Savita’s husband Parveen Halappanavar in our thoughts and prayers. Today, the date that the inquest returned its verdict of medical misadventure following the death of his wife, they should have been celebrating their fifth wedding anniversary together with their newborn baby girl due to be be named Prasa. May they rest in peace.

There are already many disingenuous headlines in the press, stating that the inquest has ruled medical mismanagement, following the denial of an abortion to Savita, as if the two events are linked.

First of all, Savita was not denied an abortion, rather a termination of pregnancy. Though it may seem semantic, this is an important distinction. Though medically they both refer to the same end result, the term abortion is widely understood in the context of a woman who does not wish to have a baby. With women such as Savita, a termination of pregnancy is the more correct phrase, because the pregnancy and baby were accepted and welcomed. Savita wished for her pregnancy to be terminated swiftly when it became clear that she was miscarrying. She didn’t want to abort her unborn child, she wanted her miscarriage to be brought to a quick conclusion.

Savita’s request for her pregnancy to be terminated must be seen in the context of her miscarriage. The explanation given at the inquest, that this was not carried out because of the law, is an unsatisfactory one. The implication being that though there was a good medical reason to terminate the pregnancy, the law disallowed this.

Dr Katherine Astbury testified that on the Monday and the Tuesday, Savita did not appear to be unwell, though she was emotionally distressed. In these circumstances, Dr Astbury is quite correct, Irish law would not allow for a termination to take place, because there appeared to be no risk to Savita’s life. This is actually fairly reasonable. Poor prognosis for the foetus would not allow for a termination, because Ireland rightly places equal value on all life, born and unborn alike. That someone has a poor prognosis is not grounds to kill them. Patients who are given a diagnosis of a terminal or incurable disease are not then killed because the outlook looks bleak and neither are the elderly, much as people might agitate for euthanasia. Whilst there is life, there is always hope and when we take into account the fact that Savita’s pregnancy was a wanted one, so long as a life is not deemed to be at risk, then it is not morally acceptable to kill an unborn baby on the grounds that he or she is as likely going to die soon anyway.

The request to terminate the pregnancy from Savita, should not have determined what was in her best medical interests. All other things being equal, normal medical protocols dictate a conservative management (i.e. wait and see) approach. On a personal note, I can well imagine her distress and her physical pain. I was readmitted into hospital a week after my eldest child was born, suffering from retained infected placenta. When I apologised to the registrar in A&E for crying because I was in so much pain, his response was ‘madam, you have a uterine infection, it is going to hurt a lot’. In my case, despite my entreaties, they didn’t take me in for surgery for 4 days (it was Easter bank holiday weekend) preferring instead to administer IV antibiotics to cure the infection first and to see if the product would pass. Nine years on, I can still remember the pain vividly, but at least I was given the correct antibiotic treatment, though my desire to have a D&C and be back home was ignored. I can’t begin to imagine what Savita went through, especially when she had the ultrasound and could hear the heartbeat of her baby, whom she knew was shortly to die. It must have been awful for her and her husband, let’s not forget that.

But this question of abortion or termination is nonetheless the source of much misinformation. Speaking at the inquest Dr Astbury stated that had she known about Savita’s blood results on Monday or Tuesday, then she would have taken a different decision and terminated Savita’s pregnancy forthwith. Which begs the obvious question, why didn’t she? We know from the inquest that the blood test results taken from Savita at 6.33pm on the Sunday evening were immediately processed and were available on the hospital’s computer system at 6.37pm. They were not accessed until 5.24pm the next day, by an unidentified member of staff and Dr Astbury herself did not look at them until 11.24pm on the Wednesday morning, by which time Savita’s condition had severely deteriorated.

It is this delay that proved fatal for Savita. If a termination had been required, then Irish law allowed for this, the medical guidelines state that delivery of an unviable foetus may be expedited where there is real and substantial risk to the life of the woman. Sepsis would count as such a risk. Savita’s bloodcount was 16.9 (normal range 4.3 – 10.8) which should have rang alarm bells. She was definitely exhibiting signs of an infection which merited urgent further investigation which would have thrown up the presence of E.Coli. Real and substantial risk, are often confused with immediate. A woman does not have be in her death throes or dying for a real and substantial risk to be identified, simply that if a termination is not performed, there is a real and substantial risk that she will die.

With hindsight, this perhaps was the case with Savita, as she was at risk of chorioamnionitis (inflammation of the foetal membranes), once the membranes had broken on Sunday. Once this has happened there is a 30 – 40% risk of infection, which is why she was prescribed general oral antibiotics on the Monday evening. Had Dr Astbury thought Savita was at risk of this, or was exhibiting signs, then why were no further diagnostic tests peformed, in this case an amniocentesis would have confirmed whether or not chorioamnionitis was present. Regular monitoring to identify trends in the white blood cells count is also crucial.

What has confused the issue further is that Dr Peter Boylan, a doctor with a publicly stated position opposing abortion restrictions, testified as an expert witness stating that had Savita been allowed a termination earlier, it would have saved her life. It’s very difficult to know that with any certainty without recourse to a time machine. In any event the post mortem showed that it was the E.Coli bacteria that led to septic shock. The baby was not poisoning Savita’s bloodstream, though chorioamnionitis if diagnosed, requires delivery. If the baby had died then the placenta needed to be removed in order to halt the rapid of spread of infection spread via its dead blood cells. Bacterial chorio-amnionitis is exceedingly rare.

What we do know though, is that in 40 years there have been 5 cases of septic abortions, no patients have died and Savita’s case was very rare. Every year in Ireland there are sadly 14,000 miscarriages, many of them carrying an infection risk, and no maternal deaths on record where the obstetrician felt that the law was inhibiting them. Dr Sam Coulter Smith, master of the Rotunda Hospital in Dublin, says that he has terminated a pregnancy in four instances where women had been diagnosed with sepsis and in all of them the baby did not survive. It’s difficult to see then, how Irish law can be said to be putting women at risk.

The failure of Dr Astbury to discuss abortion outside of legal terms is what has proved troubling in this case. A surgical abortion would have carried with it real risks of further infection which could have proved fatal, and had Savita been given the drug misoprostel to induce delivery, this would not necessarily have made delivery any swifter or negated the need for surgical intervention. Faced with a fully dilated cervix and ruptured membranes, the medics could thought that delivery was imminent and there was therefore no need for further medical intervention at this point. They were therefore wholly wrong not to discuss this in medical terms with Savita and her her husband. Anyone would be cross if their request for a certain type of medical treatment was refused purely on legal grounds.

What is important is that today’s inquest ruled that there was medical mismanagement in the death of Savita Halappanavar. The jury had the option to deliver an a narrative verdict which would not have attributed a cause. Despite the verdict which implies failures in medical care, the judge, Dr McLoughlin, has thrown further confusion into the mix by stating the verdict did not mean that deficiencies or systems failures in University Hospital Galway contributed to Ms Halappanavar’s death; these were just findings in relation to the management of her care.

That seems to imply that there was nothing wrong with the general systems in place at University Hospital Galway, simply that the management of Savita’s individual care was unsatisfactory as we can see. One cannot help but wonder whether or not this is about offloading any legal liability that the hospital may incur in terms of compensation that might be due? After all, it was a galloping sepsis that killed Savita, stemming from the E.coli, ESBL bacteria that entered her bloodstream from the urinary tract and one that is antibiotic resistant. No-one can say with any certainty whether, even had the care been perfect, she would have survived this. Perhaps that is what the coroner is trying to convey, medical misadventure was a factor in relation to her care, but not necessarily in her death. It’s no wonder Parveen is still in the dark.

What urgently needs to be addressed is the factors behind the poor care. Did the law really make Dr Astbury too afraid to check blood results, which needed further analysis or carry out further diagnostic tests? Was the law behind the lack of regular observations, the lack of communication and the failure to realise that paracetamol administered as a painkiller could mask other symptoms? Did the law cause staff to forget that infection requires a low burden of proof? Or was it the effects of austerity measures on an already overstretched hospital struggling with lack of resources? What caused the glaring omissions and can any law be expected to cover every single permutation that might arise in the management of pregnancy or childbirth, or is this simply that medical guidelines need to be more precise and explicit?

Here is the list of the coroner’s recommendations which the jury all unanimously and strongly endorsed

* The Medical Council should say exactly when a doctor can intervene to save the life of a mother, which will remove doubt or fear from the doctor and also reassure the public;

* Blood samples are properly followed up;

* Protocol in the management of sepsis and guidelines introduced for all medical personal;

* Proper communication between staff with dedicated handover set aside on change of shift;

* Protocol for dealing with sepsis to be written by microbiology departments;

* Modified early warning score charts to be adopted by all staff;

* Early and effective communication with patients and their relatives when they are being cared for in hospital to ensure treatment plan is understood;

* Medical notes and nursing notes to be kept separately;

* No additions or amendments to be made to the medical notes of the dead person who is the subject of an inquiry.

Savita’s request for a termination to have been accepted and acted upon, simply by dint of her wishes. would have required Ireland to have legislation which is much more liberal than even that in the UK, which in practice, allows abortion on demand.
It’s no wonder that the clamours for a repeal of the Eight Amendment of the Irish Constitution, (which defends the right to life of the unborn) have already started. None of which addresses the reasons behind the catastrophic failures in care.
Savita’s treatment timeline can be accessed here.

Postscript

One thing that should be emphasised is how rare it is to have a miscarriage at 17 weeks. 0.5% of single pregnancies in women with no history of recurrent miscarriages end in spontaneous second trimester foetal loss. Sepsis is still thankfully rare. Whilst it should be on the radar as a possibility, most maternity staff will not be panicking about the possibility of sepsis when a pregnant woman presents with a UTI. In the incidence of a UTI, blood samples are tested and antibiotics administered. A normal reaction to a UTI would not be to terminate the pregnancy as a precautionary measure. UTIs are serious if left untreated but no medical protocols would consider them as a real and substantial risk to life. Even with a suspected UTI there was no reason (in the absence of blood results) for medical staff to believe that Savita was dying.

I would be seriously concerned if any medic proposed termination of pregnancy as being necessary as a precautionary measure, unless it was in the most serious and grave of circumstances. Nowhere in NICE guidelines is termination mentioned as a treatment for a bacterial infection. Savita’s death should not prompt pregnant women diagnosed with a UTI to seek abortion and neither should they worry about contracting sepsis. One thing that should be remembered is the importance of scrupulous personal hygiene in terms of preventing the spread of bacteria such as E.coli.

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