The process….
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Transcript of The process….
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Improving quality and safety in maternity services: Can we improve the prevention, detection and management of congenital abnormalities?
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The process….• We identified the perinatal deaths in 2010 that were the result
of congenital cardiovascular, central nervous system or chromosomal abnormalities.
• We collected the lead maternity carer (LMC), general practitioner (GP) and hospital notes for each of the women.
• Using an audit tool we went through the notes and collected information on the care the women received.
• We reviewed sets of images for ultrasounds the women had between 10 weeks and the abnormality being detected.
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The findings….
• There were 137 perinatal deaths included in the audit.
– 73 were classified as chromosomal abnormalities (53%).
– 35 were classified as central nervous system (26%).
– 29 were classified as cardiovascular system abnormalities (21%).
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Findings: early pregnancy
• First contact with a health professional occurred within 10 weeks in 74% of cases and within 14 weeks in 85% of cases.
• Only 66% of women booked before 14 weeks.
• Folic acid supplements were recorded as taken by 7% of women prior to pregnancy and by 54% of women during the antenatal period.
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Findings: delay in the pregnancy pathway
•Median number of days between 1st trimester screening and referral = 2 days.
•Median number of days between 2nd trimester screening and referral = 9 days.
•Median number of days between anatomy scan and referral = 0 days.
•Median number of days between referral and appointment with an obstetrician = 1 day.
•Median number of days between referral and appointment with maternal fetal medicine = 6 days.
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Findings: Ultrasound• 82 women were included in the ultrasound audit, we
requested 131 sets of ultrasound images.
• 25 scans for 17 women were not available as the images had not been retained by the ultrasound provider.
• There were 5 cases where the expert reviewer was able to identify the abnormality earlier.
• There was also a case of anencephaly that would likely have been detectable earlier (at a 12 week scan) but the images had not been kept by the ultrasound provider.
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Summary....
• 6 sets of LMC notes had not been retained by the LMC.
• 20 potentially avoidable neural tube defect abnormalities where the mother had not taken pre-conceptual folate.
• Ninety seven women (75%) were offered screening.
• 15 women declined screening.
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Summary
• There were 5 abnormalities that could have been detected earlier based on the ultrasound images.
• 4 babies were discharged from hospital before the abnormality was detected.
• There was a longer than expected interval to review by MFM specialist.
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Recommendations……
– Pre-conceptual counselling for all women.
– Raise awareness around pre-conceptual folate.
– Promote booking <10 weeks.
– GPs and LMCs need to be proficient in offering first trimester screening and interpreting results.
– GPs need to facilitate expeditious booking with an LMC.
– LMCs should offer screening to all women who have not already had screening.
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Recommendations…… – Review potential for screening for more congenital
abnormalities.
– All LMCs should document pre-conceptual and antenatal folate use.
– LMCs must retain a copy of the woman’s notes.
– Radiology services should retain a copy of ultrasound images and audit their images.
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Recommendations……
– Provision of real time images to MFM services for review.
– The National MFM network should audit the time from referral to review in their service to ensure that the majority of women are seen within the recommended week.
– Enhance the current birth defects register to include congenital abnormalities where a perinatal death occurred.