Key issue will be whether doctors followed guidelines

Protocols:As investigations begin into the tragic death of Savita Halappanavar, when she was 17 weeks pregnant, at University Hospital Galway, one of the main issues to be examined will be whether doctors followed guidelines on how to deal with a woman who presents to the hospital with an inevitable miscarriage.

Spontaneous miscarriage is the commonest complication of pregnancy. It occurs in up to 20 per cent of pregnancies, which means there are approximately 14,000 miscarriages in the Republic every year. An inevitable miscarriage occurs when on medical examination the neck of the woman’s womb is found to be open. Even if there is still a sign of foetal life, there is no chance of the pregnancy continuing to term. In many cases the foetus will die and be evacuated naturally from the womb, which is why the initial management is often one of “watch carefully and wait”.

In a published guideline on the management of early pregnancy miscarriage the Institute of Obstetrics and Gynaecology at the Royal College of Physicians in Ireland says: “Conservative management is an effective and acceptable method to offer women who miscarry provided there are no signs of infection (vaginal discharge), excessive bleeding, pyrexia or abdominal pain.” It says that in early pregnancy (less than 12 weeks gestation) the management policy of watch and wait for an incomplete miscarriage results in evacuation of the uterus in almost eight out of 10 cases.

Complications

The Royal College of Obstetricians and Gynaecologists (RCOG) in the UK, in a guideline on the management of bacterial sepsis (infection) in pregnancy, published earlier this year, notes that between 2003 and 2005 there were five maternal deaths from sepsis related to pregnancy complications prior to 24 weeks gestation in Britain. “Sadly substandard care was identified in many of the cases, in particular lack of recognition of the signs of sepsis and a lack of guidelines on the investigation and management of genital tract sepsis,” the guideline states.

It recommends the use of a score system called the Modified Early Obstetric Warning Score, which uses measurements of items such as the patient’s temperature, pulse and blood pressure to calculate whether the person is deteriorating or not. It also calls for an urgent referral to a critical care team “in severe or rapidly deteriorating cases”.

Survival rates

A separate RCOG guideline deals with the management of maternal collapse in pregnancy. Referring to the work of the Saving Sepsis Campaign, the document says “the speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcome with early resuscitation improving survival rates. A multidisciplinary team approach is required including midwives, consultant obstetricians, consultant anaesthetists, consultant haematologists, consultant intensivists and consultant microbiologists.”

A key issue to be examined is whether the decision to bring Ms Halappanavar to theatre for a surgical evacuation of her uterus was delayed.