Woman died due to tear during surgery for ectopic pregnancy

Surgery to save the life of a pregnant woman was underway only minutes when unexpected bleeding was discovered, an inquest into the 34-year-old woman’s death has heard.

Malak Thawley, a teacher, was rushed to the National Maternity Hospital in Dublin following a seven week scan that revealed an ectopic pregnancy.

Doctors at Holles Street found a live pregnancy in the right fallopian tube and together with Mrs Thawley and her husband Alan Thawley agreed the best course of action was surgery, due to the danger of rupture.

Ms Thawley, from Dallas, USA died due to a tear in the abdominal aorta during the course of surgery for an ectopic pregnancy on May 8th, 2016.

An inquest into her death on Wednesday at Dublin Coroner's Court heard of a number of issues that arose as doctors tried to save the woman's life. Vascular clamps were not available at Holles Street and were sent there from the Blackrock Clinic with a garda escort. Staff members, the inquest heard, also crossed the road to get bags of ice from a pub during an emergency effort to save Mrs Thawley's life.

Theatre nurse Auri Travisora met Mrs Thawley and her husband when they arrived at the hospital ahead of the procedure scheduled for 4pm. "I welcomed the couple, we ran through the checklist together. I asked her if she was in pain and she said 'no.' She said she was from Dallas and this was her first pregnancy."

She added: “The couple embraced and then her husband left the theatre with a midwife”.

Mrs Thawley lay down and the nurse covered her with blankets and connected a cardiac monitor. “She was very anxious, she held my hand tightly and asked me to pray for her,” Ms Travisora said.

Dr David Crosby was working as a second year specialist registrar in obstetrics and gynaecology at Holles Street and was on a 12 hour shift from 8am to 8pm on that date. He met and discussed the surgery with the couple and they agreed that a laparoscopic surgery for the removal of a right-sided ectopic pregnancy was the best option.

Prior to May 8th, he had performed 92 laparoscopic procedures as primary operator, five of which were performed independently.

“This was the first maternal death I have been involved in,” Dr Crosby said.

The operation began at 4.38pm.

Answering questions about the procedure, Dr Crosby said that making the initial incision, he was conscious of the bowel, blood vessels and the abdominal aorta. He used a veress (spring-loaded) needle to make an incision through the abdominal wall and then inserted a surgical instrument known as a primary trocar. The trocar is 11m in diameter and activates a camera once it has passed through the abdominal wall, the inquest heard.

“The trocar contains the port with the laparoscope to visualise the abdominal cavity,” Dr Crosby said.

His vision through the camera was obscured however and he removed it, wiped it with a swab and reinserted it. It was still obscured. On the third try using a blunt instrument the doctor was able to see 200mls of blood in the abdominal cavity.

“I thought at this stage it was a ruptured ectopic pregnancy,” Dr Crosby said.

"I asked the scrub nurse to telephone Dr Declan Keane (consultant obstetrician and gynaecologist on call) and ask him to attend theatre immediately for a laparotomy for suspected ruptured ectopic pregnancy or a vascular injury," Dr Crosby said.

The abdominal aorta injury was identified at 5.35pm with the arrival of Dr Mary Barry, a consultant vascular surgeon from St Vincent's Hospital. The inquest heard that vascular clamps were not available at Holles Street and were sent there from the Blackrock Clinic with a garda escort.

Nurse Jenny Saltori prepared instruments for the laparotomy, a process she said took two minutes. However, under questioning, she said there were other tasks for her to do and she had more to do because there was not enough staff present.

Asked if this slowed the process, Ms Saltori replied ‘Yes.’

The inquest continues.