Andrea Prudente was never in danger of dying and there was a "possibility" that the foetus she was carrying could live, the head of obstetrics and gynecology at Mater Dei told a court on Friday. 

Details about the medical condition of the expectant mother who experienced symptoms of miscarriage during her trip to Malta last June, emerged in court when medical specialists who were both directly and indirectly involved in the case, were summoned to the witness stand.

They were testifying in constitutional proceedings before the First Hall, Civil Court where the US woman is claiming that her fundamental rights were breached when doctors in Malta refused to terminate her pregnancy at 16 weeks. 

She was eventually medically evacuated to Spain, where her pregnancy was terminated. The case has since sparked proposed changes to Malta's strict anti-abortion law.

Developments in the field over the past two decades or so meant that today there was a 79.2% survival rate of the unborn baby when the mother’s waters ruptured before 20 weeks pregnancy, said Yves Muscat Baron, consultant head of the obstetrics and gynecology department at Mater Dei Hospital. 

In this case, Prudente had a urinary tract infection prior to the rupture and was administered antibiotics. 

'You know what to do'

Muscat Baron explained how the patient’s consultant, Alberto Vella, had first spoken to him about the case after he received a call from doctor Isabel Stabile who said that the woman was “in danger.”

“You know what to do,” she had told Vella, who went to the head of department. 

“He came to me rather worried,” recalled Muscat Baron who, in turn, summoned a case conference with two senior consultants as was the normal practice when faced with any such complicated case. 

They unanimously decided that the case was to continue to be handled as they had always done for years. 

“We never had any misadventures.”

Therefore, upon admission to Mater Dei on June 16, Prudente was closely monitored. 

Antibiotics were administered intravenously, her pulse, temperature and blood pressure were checked regularly and so was her blood. 

Inflammatory markers and white blood cell count as per test results showed that all were well within normal parameters.

Given that she was on antibiotics, the white blood cell count, indicative of infection, was dropping. 

Bleeding for two weeks

The patient’s admission report indicated that she had been bleeding for two weeks. 

At 15 weeks and four days, her waters broke and upon admission on June 16, there was no fluid. 

Unfortunately, to make matters worse, she tested positive for COVID-19, went on Muscat Baron, later explaining how more recent medical studies appear to show that the virus may also impact a pregnancy. 

In Prudente’s case, medical parameters were monitored on a daily basis. Such monitoring was usually done on alternate days and therefore in this case, doctors had gone “an extra mile” to make sure that the situation was “super safe.”

Ruptured membranes could also seal and heal and amniotic fluid could form again, taking between ten to fourteen days to do so. 

The baby could survive in that interim period, said the witness, adding that the unborn child needed only two centimetres of fluid.

The chances of survival would be minimal if it were to have no fluid for three or four months. 

Bereavement midwife

Asked about the role of the ‘bereavement midwife’ who was called in to assist Prudente and her partner, Muscat Baron explained that this pre-natal help was introduced a few years ago and it was normal procedure to preempt support in case of a pregnancy that presented some difficulty. 

Asked whether this procedure was regulated by a protocol, the specialist replied, “I believe there is but as a practice, we bring in a bereavement midwife. We involve her before. We don’t let the baby die and then bring her in.”

Indeed, this was a support facility offered to patients who were on midwives’ checklist. 

Some 20% of expectant women had mental health issues due to the pregnancy, pointed out Muscat Baron. 

In this case, since Prudente had traveled from the US, she was not booked on that checklist but she was still provided with the assistance of the midwife. 

Asked why a bereavement midwife was called in in this case, the doctor replied, “when there is a possibility - that 20% of non-survival rate - of the baby dying, there is a service whereby the patient gets psychological support beforehand, rather than meet a stranger should [death] materialize.” 

In this case, “there was the possibility that the baby could live,” testified the witness. 

He explained that non-viable means that if the baby is born at that stage, it would not survive.

Prudente had visited the Gozo hospital on June 12, a day after traveling from the US where she had undergone an ultrasound because she was “spotting.” 

When four days later she was admitted to Mater Dei, another ultrasound showed that there was no amniotic fluid, but the witness could not tell when the patient’s waters broke. 

State Advocate lawyer Fiorella Fenech Vella pointed out that Prudente had not been discharged from Mater Dei, as mentioned by her lawyer, Lara Dimitrijevic, but had “wanted to leave.”

Asked by Madam Justice Miriam Hayman about any decision on terminating the pregnancy, Muscat Baron replied, “we never took that decision….At no point was there a choice. At no point was the patient in danger of dying.”

The doctor wrapped off his testimony with reference to a similar case that happened at the same time as Prudente’s case.

Another patient experienced a rupture of membranes at 13 weeks.

She too was administered antibiotics and managed to carry her baby for another three months before she gave birth. 

The baby needed surgery to the intestines, but the mother now had a “live, healthy baby.” 

'A chance, not a big one'

Prudente’s consultant also testified on Friday. Alberto Vella had advised her admission to Mater Dei after an initial examination.

Hospital checks showed that the patient had suffered prolapsed uterus and the umbilical cord was “loose” but a foetal heartbeat was still registered. 

Following rest, the cord moved upwards and the cervix was completely closed.

“In such conditions, you never know what is going to happen,” said Vella, explaining that survival was possible but there were also cases where the body “removes” the baby.

He too said that Prudente “was never in danger of dying".  He said that she was suffering from anxiety.

Normal management procedure is to try to take the pregnancy forward by some months, while the patient is monitored constantly.

“When the mother is in danger, the foetus is removed immediately,” he said.

In Prudente’s case, given that she was on holiday in Malta, she would have been hospitalized to ensure such monitoring. 

And “all was not ominous,” added the doctor, explaining that the amniotic fluid could form again after rupturing of membranes. 

Asked whether Prudente was at risk, the witness replied, “it was completely minimized. She was in hospital, so if any risks arose, they would be dealt with.”

The couple were “very pleasant people” who did not “argue” when the consultant explained “from day one, that management had to be respected.”

Then why did she discharge herself, the witness was asked.

“Because she had an air ambulance. She wanted to terminate rather than wait,” said Vella.

“We have no legal right to terminate a pregnancy. There was a foetal heartbeat and her parameters were normal.”

Asked to explain what such a patient would go through until her baby either died or she miscarried, the doctor explained that that was why a midwife was called in to provide support. 

“She had an internal conflict,” replied Prudente’s consultant, explaining how the patient, who was not young and in a country away from home, had found herself in such a situation after her waters broke. 

There was also the issue of expenses.

If the baby survived, it would have probably needed specialized and very expensive care. 

“If she remained in hospital there was a chance, not a big one, that the baby would have survived.”

Two senior consultants, Mark Formosa and Albert Scerri, testified briefly explaining that after being consulted by the head of department, they confirmed that Prudente’s case was being handled according to professional practices. 

Prudente’s medical records from the Gozo General Hospital were also exhibited in evidence on Friday. 

She had been discharged after undergoing blood tests and an ultrasound, doctor Michael Refalo testified. 

The bereavement midwife called in to support Prudente and her partner, recalled having met the couple during two sessions. 

“They were very concerned,” said Sandra Castillo.

Psychological issue

Whilst assessing the patient to gauge her level of anxiety and address her concerns, the midwife was told that Prudente suffered from anxiety. 

“What I do recall is that they were very concerned that she might have a relapse of her psychological issue….She did not wish to continue to wait.”

Asked by the court whether the patient had discussed the issue of termination, the midwife said that “she wanted to terminate. I told her that it could not be done in Malta. Her husband was present. I spoke to both. He was concerned about her.

“Their concern was her psychological relapse until they waited for the baby to die or infection to set in so that the pregnancy could be terminated.”

The case continues in February. 

Lawyer Lara Dimitrijevic represented Prudente. Lawyers Fiorella Fenech Vella and Rachel Aquilina are representing the respondents.