The Ghost of Savita Halappanavar Comes to America : Obstetrics & Gynecology

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Contents: Personal Perspectives

The Ghost of Savita Halappanavar Comes to America

Wall, L. Lewis MD, DPhil

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doi: 10.1097/AOG.0000000000004979
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In Brief

If you are pregnant, how ill must you be to receive a therapeutic abortion to save your life? How high does the risk of dying have to be, and how imminent the expectation of death, for you to qualify to have your pregnancy terminated?1 In the aftermath of the recent Supreme Court ruling that overturned the constitutional right to abortion previously guaranteed by the 1973 decision in Roe v Wade, the country will be facing these questions. The answers will likely be inconsistent and confusing—and deadly.

The antiabortion laws that are pouring out of the legislatures of conservative states threaten clinicians with lengthy prison sentences, stiff fines, and loss of licensure for violating poorly written, unclear, and vaguely phrased laws prohibiting abortion. These laws are being written by legislators who are committed to ending access to abortion but who are woefully ignorant of the clinical complications of human reproduction. Worse still, these laws will be enforced capriciously and unpredictably by grandstanding, politically ambitious attorneys general and local prosecutors who are likewise poorly informed about complications of pregnancy and how best to manage them.2 A cloud of uncertainty is descending over the clinical practice of obstetrics and gynecology in the United States.

Most Americans have not heard of Savita Halappanavar, but in Ireland she is a household name (Fig. 1). She was a 31-year-old dentist from India, a practicing Lingayat Hindu, who was living in Ireland when she became pregnant in 2012. She died from inappropriate medical care after having been denied an abortion at 17 weeks of gestation after developing serious complications during her much-wanted pregnancy.

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Fig. 1.:
Savita Halappanavar, victim of the medical mismanagement of her inevitable abortion at 17 weeks. Photo courtesy of The Irish Times, used by permission.

The case made headlines around the world. The India Times screamed, “Ireland Murders Pregnant Indian Dentist,” a sentiment also expressed by Indian demonstrators outside the Irish embassy in New Delhi as well as by many other commentators and protestors.3–9 Her death provoked widespread demonstrations in Ireland against the government and its abortion laws.10–14 More than 10,000 people marched through Dublin to the Irish Parliament in outraged protest over Savita's death and the Irish abortion laws that had led to it.11 The Indian Ambassador to Ireland, Debashish Chakravarti, bitterly declared to the press (to the Irish government's great embarrassment) that Savita Halappanavar would still be alive had she been treated in an Indian, not in an Irish, hospital.13 Her death was the subject of a coroner's inquest, two extensive governmental health inquiries, at least one book, and much commentary, which form the basis of this essay.15–20 In death she became a major force for the subsequent reform of the Irish laws governing abortion, which were overturned by an amendment to the Irish Constitution in 2018.21,22 Savita's family enthusiastically embraced the abortion-reform movement and gave permission for campaigners to use her picture as part of the campaign for Irish abortion reform23,24 (Fig. 2).

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Fig. 2.:
With her family's permission and encouragement, Savita Halappanavar became the face of the campaign for Irish abortion reform, which backed an amendment to the Irish Constitution to allow abortion. The campaign spurred a huge voter turnout, and the amendment passed overwhelmingly with 66% of the popular vote. Photo courtesy of The Irish Times, used by permission.

What happened to Savita—and what can American obstetrician–gynecologists (ob-gyns) learn from her tragic case?

Savita Halappanavar became pregnant in the summer of 2012 with her first child and registered promptly for prenatal care with her general practitioner and the antenatal clinic at University Hospital Galway in Galway, Ireland. She had an ultrasound examination at her initial visit on October 11, which confirmed her menstrual dates (about which she was certain). Her gestational age was 15 weeks and 5 days. The only finding of clinical note was an Rh-negative blood type.15

Ten days later, on Sunday, October 21, she presented to the gynecology ward at University Hospital Galway with lower back pain, radiating anteriorly. She had increased urinary frequency but no bleeding or vaginal discharge. Urinalysis was negative. Because she had a past history of sciatica, she was told to go home and rest and was given an appointment for physical therapy. No pelvic examination was performed, but fetal heart tones were present.15

Her pain worsened, and she returned several hours later, upset and crying. She reported that she had “felt something coming down” and that she had “pushed a leg back in.” Speculum examination revealed membranes bulging almost to the vaginal introitus but no apparent loss of amniotic fluid. She was informed that she was miscarrying and would probably lose her pregnancy within a few hours.15

Savita was admitted to the hospital and given analgesia and antiemetics. She had an elevated white blood cell count of 16,900/microliter (a laboratory value that was overlooked by the clinical team caring for her). Praveen Halappanavar, her husband, an engineer working for Boston Scientific in Ireland, remained with her. Shortly after midnight on October 22, she vomited and had spontaneous rupture of her membranes. She soon started bleeding. Intravenous fluids were started.15

When Savita was seen on rounds the following morning by the attending ob-gyn, she was told that it was very unlikely that the pregnancy would reach viability. She was given a plan only for expectant management. No other choice was given to her. Even though, at 17 weeks of gestation, the pregnancy was previable, the presence of fetal cardiac activity (confirmed by ultrasonography) prohibited more aggressive management. She was started on oral erythromycin 21 hours after her membranes ruptured. She continued to have moderate bleeding. Soon she became tachycardic.15

The next morning, October 22, Savita's blood pressure began to decrease. She and Praveen were still quite emotional, having been told that the pregnancy was not viable. They asked if there was medication she could take to expedite completion of the miscarriage, because they saw no point in waiting unnecessarily for the inevitable bad outcome, especially because Savita was in significant pain. One of the midwives told them that such actions would constitute an abortion, and this was not possible because, “Ireland is a Catholic country.”25–27 The Halappanavars told the midwife that they were Hindus from India and did not see why this should apply to them. In their view, they were being denied necessary, appropriate medical care. On rounds that morning, the attending ob-gyn told them, “Under Irish law, if there's no evidence of risk to the life of the mother, our hands are tied so long as there is a fetal heart.” Furthermore, they were told, the decision to terminate the pregnancy had to be based on “actual” risk as opposed to “theoretical” risk, and, because “we can't predict who is going to get an infection,” they were stuck with expectant management, irrespective of their preferences.15

In the early morning of October 24, Savita complained of being cold. The midwife thought the room was chilly and provided extra blankets but also noted that Savita's teeth were chattering. In retrospect, she was having rigors. Soon she vomited, and, at 6:30 AM, she spiked a fever to 39.6 °C (103.3oF). Her pulse was now 160 beats per minute, with a blood pressure of 94/55 mm Hg. Her abdomen was diffusely tender, and a foul-smelling vaginal discharge was also present. Supplemental oxygen was started, and Savita was given intravenous acetaminophen. Her fluids were increased, blood cultures and serum lactate were drawn (the latter subsequently lost), and intravenous amoxicillin–clavulanate was started.15

She did not improve. Intravenous metronidazole was started, and a urine culture was sent. Savita and Praveen continued to press to have her pregnancy terminated, but fetal heart tones were still present and their requests were refused. A repeat white blood cell count was notably depressed at only 1,700/microliter. Her blood pressure continued to fall, and she remained tachycardic. In her chart, it was noted that she was “very unwell,” complaining of muscle soreness and difficulty breathing. After microbiologic consultation (the first), her antibiotics were changed to piperacillin–tazobactam and gentamicin, along with metronidazole.15

Arrangements were made to transfer Savita to the high dependency unit (a tier below intensive care), but the wards were full, staff were busy, and the transfer was delayed. She was taken to the gynecology operating theater for insertion of a central venous line. The fetal heartbeat was no longer present, and, shortly thereafter, she spontaneously delivered a stillborn female fetus along with the placenta, which appeared to be intact. Her blood cultures returned positive. She was then finally admitted to the high dependency unit.15

That night (October 24–25), Savita’s condition continued to deteriorate, and was transferred to the intensive care unit. Her oxygen requirements soared, and she required vasopressors to maintain her blood pressure. She was intubated when she arrived in intensive care, with a diagnosis of septic shock complicated by disseminated intravascular coagulopathy. She was now critically ill, requiring constant adjustments in her antibiotic regimen, vasopressors, ventilator settings, fluids, and a polypharmacy of supportive medications.15

On October 26, Savita’s blood cultures grew extended-spectrum beta-lactamase–producing Escherichia coli. A transesophageal echocardiogram showed a dilated right ventricle, severe tricuspid regurgitation, a hypokinetic left ventricle, and a possible pulmonary embolism. She was anticoagulated with heparin.15

At 12:45 AM on October 28—less than a week after she was admitted to the hospital—Savita Halappanavar had a cardiac arrest in the intensive care unit. She was pronounced dead after failed resuscitation at 1:09 AM.15 Both she and her husband had known that she needed immediate delivery because of her clinical circumstances. They had pleaded repeatedly with the clinical care team to deliver the fetus, but the system denied her this care, and she died.

A postmortem examination was performed on October 30. The coroner's inquest subsequently concluded that the cause of death was “fulminant septic shock from E. coli bacteremia, ascending genital tract sepsis, and miscarriage at 17 weeks' gestation associated with chorioamnionitis.” There were no other comorbidities. An otherwise healthy young woman had died unnecessarily from a septic (spontaneous) abortion.15

A distraught, grieving Praveen Halappanavar took Savita's body home to India for burial. His Irish friends were in a state of shock. The Indian community in Galway was stunned and outraged by what had happened. Praveen and Savita were well-known in the community, and she was deeply engaged in teaching Indian dance lessons to children and in organizing the local Diwali festival each fall. Members of the Indian community approached the Irish Times to voice their concerns about the care she had received at University Hospital Galway.18 On November 14, 2012, a little more than 2 weeks after her death, Irish Times reporters Kitty Holland and Paul Cullen broke the story, titled “Woman ‘denied a termination’ dies in hospital,” noting especially that she had been told it was because, “Ireland is a Catholic country.”25,26 Savita's picture, supplied by the family, was on the front page of the newspaper. A firestorm of outrage swept through Ireland and India, soon spreading around the world.2–13

Government investigations into this case lasted nearly a year, and the results of those investigations—all in the public record—were damning.15,16 The Irish Health Information and Quality Authority found 13 “missed opportunities” in Savita's care, which, had they been acted on, could have changed the tragic fatal outcome of her case.16 The Authority stated quite bluntly that, “The doctors in charge of and caring for Savita Halappanavar, despite a diagnosis of chorioamnionitis with probable sepsis being made, did not appear to recognize the significance of this diagnosis and the continuing deteriorating clinical signs.”16 This despite the Royal College of Obstetricians & Gynaecologists having published a specific Green-top Guideline on bacterial sepsis in pregnancy less than 6 months previously that warned, “Severe sepsis with acute organ dysfunction has a mortality rate of 20–40%, which increases to 60% if septic shock develops.”28

The Irish Health Service Executive investigation was just as blunt and was even more damning. They identified three main causal factors in the death of Savita Halappanavar: 1) she received inadequate assessment and monitoring, during which there was a failure to develop and adhere to a coherent plan of management; 2) there was a 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” (ie, no offer to terminate the pregnancy was made); and 3) nonadherence to clinical guidelines led to dilatory and ineffective management of sepsis, severe sepsis, and septic shock, leading to her death.15

Concisely, the report concluded, “…it is imperative that any infective focus should be identified with removal of the source of infection to be completed as quickly as possible. In this clinical context, that would be termination of the pregnancy.”15 The reason this was not done was due to the medical–legal environment created by the Irish abortion laws. “The investigation team considers that there was an apparent over-emphasis on the need not to intervene until the fetal heart stopped together with an under-emphasis on the need to focus appropriate attention on monitoring for and managing the risk of infection and sepsis in the mother.”15 In short, the nonviable fetus was given precedence over the woman carrying it.

Savita Halappanavar was sacrificed on the altar of fanatical adherence to the antiabortion religious orthodoxy that had been enshrined in the laws of the country in which she lived.

Her distraught husband, Praveen, sued the Irish Health Service Executive for aggravated, punitive, and exemplary damages for negligence, breach of constitutional rights, breach of duty, and failure to vindicate Savita's constitutional rights, among which was her right to her own life. The Health Authority, faced with two damning government reports, admitted that her death was wrongful. The case was settled, but terms were not disclosed; nonetheless, it was apparent that Praveen Halappanavar probably received “a substantial sum” in compensation.29

What lessons can American ob-gyns learn from this case? The most obvious lesson is that political and legal interference with the practice of obstetrics and gynecology that is spurred by antiabortion fanaticism clouds clinical judgment, instills fear in practitioners, and leads to tragic, unnecessary, and preventable maternal deaths. Previable premature rupture of the membranes is not an infrequent occurrence. There will be many cases similar to that of Savita Halappanavar in the United States in the foreseeable future.30 Every patient who presents in similar circumstances should be offered immediate delivery by induction of labor or dilatation and evacuation of the uterus (irrespective of the presence of a fetal heartbeat); if expectant management is undertaken (if and only if fully informed consent has been obtained from the patient), should signs of chorioamnionitis or sepsis develop, delivery under broad-spectrum antibiotic coverage should be undertaken immediately.30,31 The maternal morbidity rate for expectant management in previable premature rupture of the membranes is 3.5 times higher than for cases in which immediate delivery occurs, and the risk of death from septic shock is not negligible.32,33

In Charles Dickens's famous 1843 novella A Christmas Carol, a series of ghosts appears to warn Ebenezer Scrooge of the dismal fate that awaits him if he does not change his ways. Similarly, the ghost of Savita Halappanavar now stands before us making an urgent plea for the reform of abortion policy in the United States. The people of Ireland heard her message and acted on it in 2018. The question remains, will we?

REFERENCES

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