Prudente baby had ‘a chance, not a great one, that it could live’
Mater Dei doctors tell court that Andrea Prudente was not at risk of death when her baby’s amniotic sac ruptured
Andrea Prudente had insisted on being discharged from Mater Dei Hospital, while specialists explained that the health risks she faced from her baby’s ruptured amniotic sac were minimal.
The Constitutional case filed by Prudente, an American citizen, against the Maltese state over Mater Dei Hospital’s refusal to terminate her 16 week-old pregnancy during a stay in Malta, began on Friday before Madam Justice Miriam Hayman.
The judge is hearing testimony from all medical personnel who dealt with the case, in a sitting expected to last several hours.
First on the witness stand this morning was Professor Yves Muscat Baron, an obstetrician and gynaecologist who chairs the Maternity and Gynaecology Department at Mater Dei Hospital, who faced questiones from lawyer Lara Dimitrijevic, for Prudente.
Muscat Baron explained that when a mother’s membranes are ruptured and amniotic fluid is lost, a baby could survive in just 2cm of fluid. “To be detected on ultrasound, 10 to 14 days are needed for a rupture to be detected. The baby can survive this.”
“As soon as the waters break we give intravenous antibiotics,” he said, explaining that the membranes may re-seal themselves, likening them to self-sealing fuel tanks introduced in WW2 fighter planes. “When they rupture, the membranes overlap and close the tear.”
He said that if all amniotic fluid were to be lost, it would form again – depending on the patient – “because the kidneys are still working and the membranes also secrete water themselves.”
In the Prudente case, Muscat Baron said the patient had suffered a prolapse of the umbilical cord protruding from her cervix. Mr Alberto Vella, the consultant treating Prudente, said he was “worried, because he had been contacted by Prof. Isabel Stabile, who had told him that the patient was potentially in danger, and had told him that ‘you know what you should do.’”
“He [Vella] appeared uncomfortable so I convened a case conference with two other specialists, to discuss the case and the file. We decided that the management was the same as we had been doing for the past 35-40 years, without incident.”
Antibiotics were administered but before the rupture occurred, Prudente had a urinary infection, so she was placed under observation for drowsiness and inflammatory markers in her blood.
While doctors expected the foetus’s heart to stop due to the umbilical cord prolapse, a next-day ultrasound showed the cervix to be closed and no cord was visible. “It could be that this happened because we ordered her to rest in bed… many times, this solves the problem.”
Muscat Baron said the membranes had not been destroyed. “Just torn. If rested, they will heal”, and shown the patient file, confirmed a white blood cell count that had never exceeded 14. “So there was no infection.”
“When you have a strong infection, your white blood cell count won’t be 11 – it’ll be 20-25 and CRP – an inflammatory marker – 140-150, not 9.”
Muscat Baron said bereavement midwife had been asked to assist the patient as standard practice. “If there is a danger of losing the baby, she begins to start a relationship with the mother… Perinatal mental health services don’t stop at outpatients but also assist patients at emergency.”
The judge asked the witness at what point the decision, if any, had been taken that the pregnancy had to be terminated. “At that time there was no indication for this to take place,” Muscat Baron said.
“And after?” asked the judge.
“I don’t know, because she went to Spain to have an abortion. She was responding well to antibiotics… The patient had never been in danger of death.”
Dimitrijevic asked whether there any other dangers were faced by the patient. “The risk of sepsis (infection spreading to the blood) is 1% in cases of ruptured membranes. Over the past 20 years, the mortality rate was 0.1% and has probably reduced because we now administer intravenous antibiotics immediately,” Muscat Baron said.
While antibiotic use in pregnant women had been avoided in the past out of superbug fears, Muscat Baron said this superbug had never materialised. “In my experience, I encountered four similar cases in which the baby survived, both in the UK and here. One patient had ruptured membranes at 13 weeks. She took antibiotics and treatment… the baby lived, after life-saving surgery was performed.”
Consultant Albert Vella
The next witness, Mr Alberto Vella, said upon seeing the scans presented in court that it was clear that Prudente’s cervix was very closed and “that the problem had resolved itself”, with an ultrasound confirming that the foetal heartbeat was there, despite the lack of fluid after the sac had been perforated, which provided a potential entry point for future infections.
“(In non-viable pregnancies), many times the body itself removes the baby,” he said
“When you have conditions like these, you don’t know what is going to happen and often the patient miscarries on her own… If there is an infection which is dangerous to the mother the body disposes of the foetus.”
If the foetus is not viable it is removed by inducing labour to save the mother from septicaemia, Vella said. “We always work in the hope that a pregnancy could take longer [than normal] and still be viable,” adding that it was not unusual to have ruptured membranes that repair themselves and refill with amniotic fluid.
Vella recalled that Prudente was anxious, telling her he could not administer a pessary or other medication if there was a heartbeat. “That would be illegal. Besides, these were not necessary at that point in time.”
“But was she at a potential risk?” Dimitrijevic pressed on.
“It was minimal. She was in hospital, if anything happened it would be treated there. It wouldn’t snowball.”
The judge asked at what point there was a disagreement with the management of the pregnancy. “There was none... I had told them that I would take action if things started to go bad… They were very nice people,” he repeated. “The patient had been told that the doctors had no legal right to terminate a viable pregnancy.”
Vella however said there was “a chance – not a great one – that the baby could live”, when asked by State Advocate Fiorella Fenech Vella.
“I believe she had a conflict,” Vella said. “She’s not young, her waters broke… these things happen at a shocking cost if done privately. Then there is the risk of a premature baby which requires incubation treatment at a special unit, at a huge running cost.”