Savita Halappanavar case

MrCreosote

Presumably everyone has seen the recent case in Galway.

One thing that seems to have been overlooked is the fact that the E coli sepsis seems to have been caused by ESBL E coli. Is this common in Ireland? Possibly was a contributing cause if the antibiotics that were presumably given didn't work.

I don't want to debate the rights and wrongs of abortion law in Ireland (seems to be on plenty other forums), except to say that if a necessary medical procedure was delayed on non-medical grounds then there are serious ethical questions to be answered.

Withholding a termination on a foetus that is never going to survive is similar to delaying treating an ectopic pregnancy because it has a heart beat.

OMD

MrCreosote wrote: »

Presumably everyone has seen the recent case in Galway.

One thing that seems to have been overlooked is the fact that the E coli sepsis seems to have been caused by ESBL E coli. Is this common in Ireland? Possibly was a contributing cause if the antibiotics that were presumably given didn't work.

I don't want to debate the rights and wrongs of abortion law in Ireland (seems to be on plenty other forums), except to say that if a necessary medical procedure was delayed on non-medical grounds then there are serious ethical questions to be answered.

Withholding a termination on a foetus that is never going to survive is similar to delaying treating an ectopic pregnancy because it has a heart beat.

The problem is we don't know the relevance or not of the termination. Would the termination have increased her chances of survival?

opinion guy

There is an interview with the husband here - he gives alot of details on the time course of the case etc. I've not listened to the whole thing however.
http://www.irishtimes.com/audio/2012/11/savita.mp3

MrCreosote

OMD wrote: »

The problem is we don't know the relevance or not of the termination. Would the termination have increased her chances of survival?

I'm sure the investigations ongoing will clarify this. Going on what's in the media already, I think the answer is pretty clear.

Could a mod change the title from "Sativa" to "Savita" as well please? Sorry-misspelling.

frfintanstack

Tragic case.....

Agree with this point...

MrCreosote wrote: »

Withholding a termination on a foetus that is never going to survive is similar to delaying treating an ectopic pregnancy because it has a heart beat.

surely this case is about management of an "inevitable miscarriage" and has nothing to do with abortion?

3 options; expectant, medical or surgical management. Nothing to stop medics using any of these options.

Expectant management is a perfectly valid method.

Suppose we wont know until its investigated fully.

I'd wonder about the husbands assertion that he was told that because the foetal heartbeat was still present and they were told, “this is a Catholic country”.

Sounds bizarre to me.

OMD

MrCreosote wrote: »

I'm sure the investigations ongoing will clarify this. Going on what's in the media already, I think the answer is pretty clear.

I don't think the answer is remotely clear but as you say an enquiry may give the answer. I think a lot of people have jumped to conclusions that sound to me like the wrong conclusions

RacoonQueen

OMD wrote: »

I don't think the answer is remotely clear but as you say an enquiry may give the answer. I think a lot of people have jumped to conclusions that sound to me like the wrong conclusions

I was thinking this as well. Seems to be a lot of bandwagon jumping and everyone automatically assuming that it is an abortion issue.

We know very few facts of the case other than what the media have publicised(sensationalised?). Is there a certain protocol in cases of this nature? When did they know she had an infection? Is it against the rules to 'abort' the foetus while it still has a heartbeat even though it's clear it won't survive?

MrCreosote

frfintanstack wrote: »

3 options; expectant, medical or surgical management. Nothing to stop medics using any of these options.

Expectant management is a perfectly valid method.

Unless there are complicating factors like heavy bleeding and particularly infection. In that case urgent surgical management is mandatory. Antibiotics might buy time, but as it seems ESBL E coli was involved they won't be effective.

OMD wrote: »

I don't think the answer is remotely clear but as you say an enquiry may give the answer. I think a lot of people have jumped to conclusions that sound to me like the wrong conclusions

If the husband's account is accurate in terms of timing, and there's nothing to suggest it isn't, then it is pretty clear what happened (or more accurately, didn't happen). If this was as a result of a clinician's religious views, then it's an ethical disaster.

RacoonQueen wrote: »

We know very few facts of the case other than what the media have publicised(sensationalised?). Is there a certain protocol in cases of this nature? When did they know she had an infection? Is it against the rules to 'abort' the foetus while it still has a heartbeat even though it's clear it won't survive?

If there is a direct threat to the mother's life then it is legally allowed. If there isn't only a threat to her health, as opposed to her life, then it is illegal. This is bullsh*t legal black-and-white speak though which is almost impossible to apply to the real world. Almost everything that has a threat to "health" has a threat to life as well- so you're entering a grey area where it's not clear where the legal lines are drawn. My feeling is that very few clinicians want to be the test-case to see where the boundaries are set, and as for the politicians legislating for this...well, we've only been waiting 20 years.

seamus

MrCreosote wrote: »

If there is a direct threat to the mother's life then it is legally allowed. If there isn't only a threat to her health, as opposed to her life, then it is illegal. This is bullsh*t legal black-and-white speak though which is almost impossible to apply to the real world. Almost everything that has a threat to "health" has a threat to life as well- so you're entering a grey area where it's not clear where the legal lines are drawn. My feeling is that very few clinicians want to be the test-case to see where the boundaries are set, and as for the politicians legislating for this...well, we've only been waiting 20 years.

+1

I think this sums up the entire issue very well. The clinicians involved no doubt recognised the danger to the poor woman's health but didn't feel that they could legally justify aborting the foetus on the basis of risk to life. Obviously there reaches a point where a risk to health becomes a risk to life, but without any firm law on it clinicians are always going to err on the side of caution and action won't be taken until the danger has been allowed to go further than it should have.

OMD

MrCreosote wrote: »

If the husband's account is accurate in terms of timing, and there's nothing to suggest it isn't, then it is pretty clear what happened (or more accurately, didn't happen). If this was as a result of a clinician's religious views, then it's an ethical disaster.
.

At what stage was the septicaemia diagnosed? From what I can gather it was after the miscarriage.

At what stage would a reasonable doctor have concluded that an abortion was necessary?

Did the consultant feel an abortion was necessary but refused to do it in either legal or moral grounds? From my reading of it the answer is no but as I say we don't yet know.

We need answers to these questions and many more before we jump to conclusions

OMD

Just in addition to the above I saw this in the Irish Times. I am not sure if Simon Mills knows any more about this case than the rest of us but he is quoted as saying:
"As barrister Simon Mills points out, on the available facts, it does not appear Ms Halappanavar was facing a substantial threat to her life until after her baby was delivered."
This is pretty much what I have been saying and is an important point to be clarified.

opinion guy

OMD wrote: »

Just in addition to the above I saw this in the Irish Times. I am not sure if Simon Mills knows any more about this case than the rest of us but he is quoted as saying:
"As barrister Simon Mills points out, on the available facts, it does not appear Ms Halappanavar was facing a substantial threat to her life until after her baby was delivered."
This is pretty much what I have been saying and is an important point to be clarified.

I think this is worth a read:
http://drjengunter.wordpress.com/2012/11/14/did-irish-catholic-law-or-malpractice-kill-savita-halappanavar/

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.

_Whimsical_

frfintanstack wrote: »

surely this case is about management of an "inevitable miscarriage" and has nothing to do with abortion?

3 options; expectant, medical or surgical management. Nothing to stop medics using any of these options.

Expectant management is a perfectly valid method.

I was just wondering about this point. Obviously it is impossible to answer any questions with regard to this case as so few of the facts are apparent. I presume "expentant management" is not intervening and allowing nature take it's course?

Is it very unusual for miscarriage to take place over a course of days? Is "expectant management" an uncommon approach? Generally in a physicians mind is this course of action seen as more potentially life threatening than another?

It's such a dreadfully sad case and the growing hysteria around it is quite frightening when there are so few facts. It is sad that the media and public won't afford such a tragic situation the reflection it deserves and wait for more of the facts without hijacking it as fuel to the fire of their own agenda.

frfintanstack

_Whimsical_ wrote: »

Is it very unusual for miscarriage to take place over a course of days? Is "expectant management" an uncommon approach? Generally in a physicians mind is this course of action seen as more potentially life threatening than another?

It isn't at all uncommon for a miscarriage to pass over a few days.

Expectant management is used commonly. Although its not suitable if there is heavy bleeding or infection present. But we don't know when the infection started here.

There are risks to all 3 methods,

maternal mortality during ERPC (surgical removal of foetus) is quoted at 14/100,000 so its not without risks either.

Its hard to work out what happened when we have so few facts about this case.

I'm amazed by the public reaction, mostly about the outpouring of self loathing about us Irish being somehow backward.

Something went wrong here but IMO it had nothing to do with Irish abortion law....

There was nothing in irish law to stop the doctors managing this miscarriage medically or surgically......it happens everyday!

MrCreosote

frfintanstack wrote: »

It isn't at all uncommon for a miscarriage to pass over a few days.

Expectant management is used commonly. Although its not suitable if there is heavy bleeding or infection present. But we don't know when the infection started here.

There are risks to all 3 methods,

maternal mortality during ERPC (surgical removal of foetus) is quoted at 14/100,000 so its not without risks either.

Its hard to work out what happened when we have so few facts about this case.

All the facts are in the original article. If they are accurate then I think it's clear the way things went:

http://www.irishtimes.com/newspaper/frontpage/2012/1114/1224326575203.html?via=mr

There were systemic signs of severe infection (fever, rigors and collapse) on the Tuesday. The ERPOC was delayed until the Wednesday afternoon after the foetal heart was checked again. It should have been performed immediately, regardless. How someone can say there is only a threat to the mother's health as opposed to life from sepsis is beyond me. All the arguments about other forms of management are moot at this point- if there is sepsis the correct treatment is surgical and antibiotics.

I'd agree that this seems to be a question of correct medical management rather than some challenge to abortion law, but for one reason- if what her husband says about medical staff saying "Abortion is banned" and "This is a Catholic country" is true then it immediately becomes about the need for proper legislation.

frfintanstack

MrCreosote wrote: »

I'd agree that this seems to be a question of correct medical management rather than some challenge to abortion law, but for one reason- if what her husband says about medical staff saying "Abortion is banned" and "This is a Catholic country" is true then it immediately becomes about the need for proper legislation.

Having been adjacent to a couple of stories that made it into the papers one should be careful calling the details in newspapers "facts". Especially when we only have a one sided story.

I cant believe that there is an obstetrician working in Ireland today who would say things like that.

For some reason it doesn't ring true to me (call me cynical)....but if they did they should be up in front of the medical council ASAP.

10000maniacs

india.png

I kind of agree with The India Times today (See Link above). The Catholic doctrine is still running this country.
It can be argued that The Catholic Church has claimed another victim. They have to be stopped before they do any more damage.

Jessibelle

The lack of clarity regarding abortion here is not a religious decision, it's a legal one. Purely government driven. If it was religious, abortion wouldn't be possible anywhere that there's organised religion. Legislative cowards are hiding behind convenient scape goats for this, to hide they've had nearly twenty years to legislate for this eventuality since the X case, which they have failed to do.
Also, blaming it on any religious institution runs the risk of enveloping any further legal decisions in more smoke and mirrors and then another delay on clarification.
I'm also curious as to the E.coli infection (I'm just a student at this point so don't know too much about how common that type of infection would be), any one know anywhere I couldl look for this information?

Truman Burbank

MrCreosote wrote: »

All the facts are in the original article. If they are accurate then I think it's clear the way things went:

http://www.irishtimes.com/newspaper/frontpage/2012/1114/1224326575203.html?via=mr

There were systemic signs of severe infection (fever, rigors and collapse) on the Tuesday. The ERPOC was delayed until the Wednesday afternoon after the foetal heart was checked again. It should have been performed immediately, regardless. How someone can say there is only a threat to the mother's health as opposed to life from sepsis is beyond me. All the arguments about other forms of management are moot at this point- if there is sepsis the correct treatment is surgical and antibiotics.

I'd agree that this seems to be a question of correct medical management rather than some challenge to abortion law, but for one reason- if what her husband says about medical staff saying "Abortion is banned" and "This is a Catholic country" is true then it immediately becomes about the need for proper legislation.

A bit of both, more of one and less of the other. The Irish Times audio in particular is harrowing. Her husband does not appear to realise that being brought to The HDU (after an ERPC) is not reassuring. Current link (make take a few minutes to load);

http://46.4.230.144/web/UpToDate.v19.2/contents/f31/26/32591.htm

http://www.uptodate.com/contents/midtrimester-preterm-premature-rupture-of-membranes?source=see_link

It's awfully quiet around here.

ballsymchugh

Truman Burbank wrote: »

A bit of both, more of one and less of the other. The Irish Times audio in particular is harrowing. Her husband does not appear to realise that being brought to The HDU (after an ERPC) is not reassuring. Current link (make take a few minutes to load);

http://46.4.230.144/web/UpToDate.v19.2/contents/f31/26/32591.htm

http://www.uptodate.com/contents/midtrimester-preterm-premature-rupture-of-membranes?source=see_link

It's awfully quiet around here.

empty vessels make the most noise. this may only be the second page, but it's the best thread on the situation on this site.

Truman Burbank

Jessibelle wrote: »

T
I'm also curious as to the E.coli infection (I'm just a student at this point so don't know too much about how common that type of infection would be), any one know anywhere I couldl look for this information?

http://www.cdc.gov/ecoli/
Also pubmed for article searches

Jessibelle

Truman Burbank wrote: »

http://www.cdc.gov/ecoli/
Also pubmed for article searches

Thanks. I've been to Pubmed but the quantity of research there is a bit vast for what I'm looking for. I was looking more for any good review papers if anyone knew of them, that said, my own fault for not being more precise. Thanks again.

Truman Burbank

ballsymchugh wrote: »

empty vessels make the most noise. this may only be the second page, but it's the best thread on the situation on this site.

Indeed. Was referring to the conspicuous absence of regular posters. But there's no need to jump to conclusions here. This tragedy is not difficult to decipher. There was no legal impediment to performing surgery at an earlier date. This is looking black and white, not grey.

MrCreosote

Apparently ESBL organisms are not too uncommon in Ireland:

http://www.biomedcentral.com/1471-2334/12/116

The only recent study I could find, no true incidence figures unfortunately.

A Neurotic

Truman Burbank wrote: »

A bit of both, more of one and less of the other. The Irish Times audio in particular is harrowing. Her husband does not appear to realise that being brought to The HDU (after an ERPC) is not reassuring. Current link (make take a few minutes to load);

http://46.4.230.144/web/UpToDate.v19.2/contents/f31/26/32591.htm

http://www.uptodate.com/contents/midtrimester-preterm-premature-rupture-of-membranes?source=see_link

It's awfully quiet around here.

Can't access uptodate (poor student) - but I'm just wondering how common/foreseeable septicaemia is as a complication of PPROM?

Is this a situation where the medical team knowingly put the patient at increased risk of serious complications due to legal constraints?

Tree

MrCreosote wrote: »

Apparently ESBL organisms are not too uncommon in Ireland:

http://www.biomedcentral.com/1471-2334/12/116

The only recent study I could find, no true incidence figures unfortunately.

The HPSC track ESBL incidence, their 2010 report seems to indicate they account for 6.1% of isolates :-/

http://www.hpsc.ie/hpsc/AboutHPSC/AnnualReports/

Truman Burbank

A Neurotic wrote: »

Can't access uptodate (poor student) - but I'm just wondering how common/foreseeable septicaemia is as a complication of PPROM?

Is this a situation where the medical team knowingly put the patient at increased risk of serious complications due to legal constraints?

I've linked the uptodate article, in its entirety, above it. A number of these are downloaded. The intro for every one is available - that's the second link. As a student this is a great resource because not only does it give you a basic summary of the topic, it also provides the references below for further reading. There are several summaries, including a general one, I've only referenced the mid-trimester one here. Uptodate should be on your hospital, and Health Sciences library, desktop.

I would not think anyone would think like that. The patient is your raison d'etre.

panda100

frfintanstack wrote: »

Having been adjacent to a couple of stories that made it into the papers one should be careful calling the details in newspapers "facts". Especially when we only have a one sided story.

I cant believe that there is an obstetrician working in Ireland today who would say things like that.

There are very outspoken catholic conservatives in the medical profession. It wouldn't suprise me to heqr them say somethng like this.

Also,our hospitals are still run by religious orders,with members of the clergy sitting on the boards of most majory hospitals. It is up to them to uphold the Catholic doctrine in Irish hospitals. I remember it was for that reason, the morning after pill could not be prescribed in the Mater hospital, and you would have to send people to their gp for it.

partyatmygaff

ballsymchugh wrote: »

empty vessels make the most noise. this may only be the second page, but it's the best thread on the situation on this site.

Nearly every other thread on boards has descended in to a frenzy of people repeating and rewording the following opinion and thanking each other:
"Abortion would have definitely saved her life. It's all the Catholic church's fault, we're just an awful nation and should take criticism and make national apologies to the likes of India."

Suggesting the possibility that it's a legal and not a religious issue and/or that an abortion could very well have had no effect on the final outcome seems to fall on deaf ears. Everyone seems to just want a sensational story they can get worked up over and talk about.

Agnieszka_88

partyatmygaff wrote: »

Nearly every other thread on boards has descended in to a frenzy of people repeating and rewording the following opinion and thanking each other:
"Abortion would have definitely saved her life. It's all the Catholic church's fault, we're just an awful nation and should take criticism and make national apologies to the likes of India."

Suggesting the possibility that it's a legal and not a religious issue and/or that an abortion could very well have had no effect on the final outcome seems to fall on deaf ears. Everyone seems to just want a sensational story they can get worked up over and talk about.

I definitely agree that the responses found everywhere on the internet are very emotional and that people seem to just accept everything as it's given without asking questions. But I do not agree that you can differ between legal and religious in this (and any similar) case. The fact is, that the only other European country with such a strict anti-abortion law is the obsessively catholic Poland (I spent a big part of my childhood there and trust me when I say that I know everything there is to know about the catholic doctrine being forced on people, whether it comes to lawmaking or education).
Whether abortion would have had an effect on the final outcome is important and should definitely be cleared, together with the procedures, but this case shows something else- that people feel that the archaic Irish abortion law should be reviewed, and that the church has no place in a democracy, indeed it shouldn't have such a huge influence on the law of a autonomous country. Some might say that the Health Sciences forum isn't the right place for such a discussion, but then where else?

Stheno

Agnieszka_88 wrote: »

The fact is, that the only other European country with such a strict anti-abortion law is the obsessively catholic Poland (I spent a big part of my childhood there and trust me when I say that I know everything there is to know about the catholic doctrine being forced on people, whether it comes to lawmaking or education).

Polands laws are more liberal than ours allowing for it in the case of
When the woman's life or health is endangered by the continuation of pregnancy,
When the pregnancy is a result of a criminal act, or
When the fetus is seriously malformed

Malta has a complete ban on abortion.