Tuesday, 20 November 2012

An update to my last post on Maternal death.

UPDATE:
Since posting this on the death of Savita Halapannavar, a few more things came to my attention which add more context to this story. Initially I added them at the bottom of my original post, but Mac at Mulier Fortis pointed out that it wouldn't be picked up by RSS readers and so it might be worth putting the update in a separate post. Seems like a good idea, so here it is:

This article in the Hindu Times quotes the president elect of the Federation of obstetric and Gynaecological Societies of India, Dr. Hema Divakar defending the decision of the Irish doctors as being reasonable:


 Cause of death
 Delay or refusal to terminate the pregnancy does not in itself seem to be the cause of death. Even if the law permitted it, it is not as if her life would have been saved because of termination,” she said. “Severe septicaemia with disseminated intravascular coagulation (DIC), a life-threatening bleeding disorder which is a complication of sepsis, major organ damage and loss of the mother’s blood due to severe infection, is the cause of death in Savita’s case. This is what seems to have happened and this is a sequence which cannot be reversed just by terminating the pregnancy.”

Pain and infection
Analysing the situation, Dr. Divakar said: “Based on available information, Savita would have reported pain and infection and doctors would have indicated a miscarriage as the 17-week foetus may not have grown as expected. Its growth would have been deteriorating because of the infection. Having understood that the baby was not going to make it, the couple would have asked for termination. But as Savita’s infection may have required aggressive treatment at that stage, doctors must have felt the need to prevent complications. The usual [practice] is to meddle the least till the mother is stable.”
Asserting that it is wise to wait in cases with such complications at 17 weeks, Dr. Divakar said: “As per reports, the baby’s heartbeat stopped after three days. But that was expected.” 
The blogger Thirsty Gargoyle points out significant discrepancies in the various timelines of events which are being quoted in the press.
How has the Irish Times ran two conflicting versions -- one written, one aural -- of the same story, and not noticed that they contradict each other? Did Kitty Holland not notice, the second time she interviewed Praveen, that his sequence of events had changed?
How has nobody picked up on the fact that the sequence of events as described by the Irish Times, with Praveen as a source, and RTE, dependent on the hospital's viewpoint, are completely at odds with each other?
He also posts the timeline of events from Galway University Hospital which RTE reports on here.


Sunday 21 October:
Patient presents to hospital complaining of backpain.
Patient is admitted with a threatened miscarriage to the Obstetrics and Gynaecology Unit.
Monday 22 October:
After 24 hours of admission, antibiotics are given.
Tuesday 23 October:
Patient transferred to theatre.
Spontaneous miscarriage occurs.
Wednesday 24 October: 
Post-theatre patient is transferred to Intensive Care Unit.
Patient remains unwell.
Thursday-Saturday 25-27 October:
Patient continues to deteriorate.
Sunday 28 October:
Patient dies in ICU.
Post mortem examination ordered by coroner.

One of the commenters on my last post, Katie, asked about normal management of pre term premature rupture of membranes (PPROM).
With the important caveat that I am not an expert and I don't wish to add to the speculation before the facts, here is the answer I gave Katie according to my understanding:

 The central issue here appears to be whether or not the patient was showing signs of infection. If not then it is quite typical, as I understand it, for management to be expectant. That is, to wait for labour to start, but usually within a given time frame and with close monitoring for signs of chorioamnionitis.

If infection is present, there seems to be agreement in most places that induction would be normal management. However, as the article in the Hindu Times I linked to above says, it could be that inducing a woman already in septic shock may dramatically worsen her condition.

This is why I say that crises such as these are managed on a case by case basis, taking a number of other clinical factors into account.

Here's one article I found which explains management quite clearly..
 This quote refers to PPROM in the second trimester, which was the stage of pregnancy that Savita was at. It explains that, in the absence of infection, such patients may even be managed at home ( actually, in some ways this may be safer, from an infection control point of view, because hospital environments are full of foreign pathogens):

"Chorioamnionitis occurs in 30-60% of patients with second trimester PPROM. The risk of infection increases with duration of ROM and an AFI less than 2.0 cm. Frequent exams are necessary to ensure maternal safety. Patients need to be educated about the warning signs of intraamniotic infection and need to take their temperature 3 times a day at home. These patients do not need to be cared for in the hospital if no evidence of vaginal bleeding or infection exists. They may consider admission for inpatient management at 24 weeks, which currently is considered the point of viability at most institutions."
A couple of other things. There have been frequent references to the open cervix being akin to "an open head wound". The state of the cervix is more significant in terms of the inevitability of miscarriage. It is the torn membranes that pose a risk of infection.

Secondly, many commenters have said that the doctors ought to have agreed to termination of the pregnancy because the patient asked for it. But patient request, particularly in extremis, is not always good grounds for making important decisions about clinical management.

A personal anecdote here:
In September 2007  I was in labour with twins. I had been told that Olivia, "twin one", was dead.
Because we didn't know what had killed her and whether twin two might be next, I elected to have an emergency caesarean section. The prospect of labouring naturally, knowing that I would have to birth my stilborn baby first and that the living one might be at risk, was too frightening.
Traumatised and in shock, I'm ashamed to say that at this point I begged the registrar to sterilise me.
She refused saying that I wasn't in a fit state to know my own mind on the matter..
I insisted that I did and pleaded with her again, saying that I knew for a certainty that I couldn't go through this again.
She firmly refused.
Days later I was longing with all my heart to be pregnant again and grateful beyond words for her "no".


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