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Maternity Network:Purpose, plans, projects
Mr Lawrence Impey FRCOGConsultant in Obstetrics and Fetal Medicine, OUH
Clinical Lead for Fetal Medicine, OUH
Clinical Lead for AHSN Maternity Network
Why does maternity matter?
Maternity is:
2 ‘patients’ undergoing a normal life event
1 is never seen before they stop becoming our ‘patient’
Capacity to affect long term health of both, and subsequent generations.
Improve health of the nation= start with maternity
Maternity CareAntenatal care, advice, screening
Fetal Medicine: the sick or potentially sick fetus. Identification of this fetus is as important as its treatment
Maternal Medicine: the sick or potentially sick mother either predating, or as a result of pregnancy
Delivery: the most dangerous hours of 2 lives, but overall a small contributor to adverse outcomes
Postnatal care: the time that gets forgotten
Pregnancy is a normal life event. The importance of keeping ‘normal’ pregnancy normal
What is not going right?
Stillbirth
Preterm labour
Data: not knowing how we are doing
Poor communication
Caesarean section rates
Massive obstetric haemorrhage
Sepsis
Breastfeeding rates
Mental health issues
Midwifery staffing
Consultant presence on DS….
Maternity Network Aims: early
Improve clinical care and consistency across network
Improve data/ outcome collection across network
Start addressing ‘urgent clinical issues’: preterm birth, stillbirth across the network
To enable introduction of innovation and large scale research
Different from SCN?
Clinically ledDefine our own targetsBroad aimsResearch involvementPotential commercial involvementStarting with an ODN
The achievable
Fetal Medicine
Approx 13 tertiary referral centres in England
Varying degrees of skills and capacity in other units
Not ‘fatal’ medicine and abnormalities/ rarities, but best used to prevent preterm delivery, stillbirth, over intervention
Rationale for Fetal Medicine in a Maternity Network
Variable practice, policies and probably outcomes for fetal medicine and outcomes partly dependent on fetal medicine (eg stillbirth and preterm labour) across network
Limited data on what is happening/ outcomes; ‘ivory tower syndrome’
National data on fetal medicine almost useless
Specialised commissioning CRGs attempting to lead tertiary level practice and rationalise where/who provides service
Limited centralised maternity outcome data in England meaning audit and comparisons difficult, and research data collection hindered
Doctors in training ‘rotate’ through the Trusts
Fetal medicine expertise has the capacity to address some of the big issues
Oxford Maternity Network Plan
1. ‘CARE AND CONSISTENCY’: Develop agreed fetal medicine protocols and referral pathways across network area.
– Using best evidence and national/RCOG guidelines– Common best practice incl. referral according to individual Trust’s facilities
and needs
2. ‘DATA SHARING’: Help supply and link fetal medicine and ultrasound systems across network.
– Communication re individual patients– Outcomes/ audit of practice and complications– Develop large dataset
3. Initiate linking all maternity outcome systems: a national issue4. Immediate action on urgent clinical problems in network5. With universities and commercial organisations, develop an infrastructure for innovation and network wide research
1. Progress at 6 months: Data ‘sharing’:
Agreement from Trusts’ IT, IG, key players
Partnership with commercial ultrasound reporting systems
Adapted and costed
Introduction Dec 2014
Live patient update immediate
Partnership with Oxford University re local data collection
Complete fetal medicine data collection mid 2015
2. Progress at 6 months: ‘Care and consistency’
Individual Trusts’ guidelines collectedNetwork guidelines on key areas developedDelivered and discussed at Sept 2014 meetingUndergoing adaptation appropriate for each unit
Small for gestational age: early and lateRhesus diseaseComplex multiple pregnancyFetal abnormalitiesThreatened miscarriage/ preterm labour from 16 weeks
A Network Guideline:
Management of singleton preterm IUGR Version 1: 17/09/2014
EFW or AC <10th centile with UA RI/PI>95th c
Check diagnosis: Check for anomaly and CMV. Consider uterines/ karyotype/MCA.
>24w and >500g <24w or <500g
See 1-2 weeks
Monitor mother
UA RI/PI >95th c
Repeat UA 2-3/ week
Monitor mother
AEDF (significant growth now unlikely)
In-patient care and steroids (may get temporary improvement) Monitor mother
If:
>500g and <26w >500g and <29w >500g and >29w >500g and <32w
If active Rx requested:
<27 >27
WPH, RBH MKH
all transfer Transfer Level 3 consider transfer no transfer usually
UA: no action UA: no Rx (alone) UA: del if rev UA: del if rev
CTG: don’t do CTG: del <3.0 CTG: del<3-4.0 CTG: del<4.0
DV: del if rev DV: del if >95th c/ DV: don’t do DV: don’t do
absent a wave
3-5: Progress at 6 months
3. Linked maternity outcome data
4. Urgent clinical problems
5. Innovation and research….
Some cross- network Projects
Audit of why extreme preterm babies born outside L3 NNUAudit of practices to screen for/ identify IUGR (risk of stillbirth)Maternal experiences of termination of pregnancy for fetal abnormality
Universal availability of screening results that can be used to screen for stillbirthUniversal fibronectin usage in threatened preterm labourUniversal prenatal diagnosis of placenta accreta (AIP)Automated image quality analysis for anomaly scanningDevelopment of robotic remote ultrasound scanningEarly diagnosis of pre eclampsiaPPIEE: for quality and for researchRationalisation of preterm labour servicesScreening for preterm labour
Summary
Formalise an ODN for fetal medicine, playing to strengths of individual TrustsCommon guidelines based on best practice: ‘TV Maternity service’ instead of maternity services that ignore eachotherDevelop network-wide data collection for commissioning, quality analysis…Infrastructure for research and innovationGather information on contributors to ‘urgent issues’Start addressing these ‘urgent issues’ across the network with: 1. innovation for evidence based practice and 2. with research for where evidence is lacking
Urgent: Preterm delivery
The largest cause of disability in childhood
The commonest cause of neonatal unit admission
The commonest cause of neonatal death
The most ignored problem in maternity care
Preterm birth in the right place
Under the best circumstances neuroprotection (steroids, Mg)
Prevention of recurrence
Screening?
Preterm delivery
Death
0
10
20
30
40
50
60
70
23 25 27 29 31GA (wks)
80
%
Handicap
0
10
20
30
40
50
60
70
23 25 27 29 31GA (wks)
%
Urgent: Preterm deliveryAudit to determine why extreme preterm babies are born outside Level 3 NNUs (25-50% increase in mortality)
EPIcure 2:
Of 2460 babies born between 22 and 26 weeks in England in 2006, only 56% were delivered in a L3 unit.
If they were they did significantly better:
Risk of death: aOR 0.73 (95% CI 0.59 to 0.90)
Survival without morbidity aOR 1.27 (0.93 to 1.74)).Marlow et al 2014
PTL audit preliminary results
67 ‘cases’ 1/4/12-31/3/14 retrospective notes review31 women: (10 missing notes, 13 MKH)
23-28 (multiple) weeks7 multiple pregnanciesSevere IUGR/ pre eclampsia 2< 500g 2
Prev PTL 10 32%Fibronectin assay 0 0%Steroids 21 68%Magnesium 3 10%had been admitted prev with threatened PTL 10 32%had been IP >4hours before del 20 65%5 had ‘rescue’ cerclage 5 16%IOL/ cs 5 16%IUT attempted: 5 16%IUT declined by Oxford/ other 5/5 100%Of no IUT attempt: in labour 15/26 58%
too unwell 3/26 12%PN transfer 26 84% (1 of others died)
Change of policy: IUT requests no longer directed to NNU, but to OUH obstetric consultant
Cervical length (mm)
%
0
10
20
30
40
50
60
70
80
90
100
Risk
Heath et al 1998
Outcome
Vaginal progesterone
(n (%)) Placebo (n (%))Relative risk
(95% CI) P
Primary outcome
Preterm birth < 33 weeks
21/235 (8.9) 36/223 (16.1) 0.55 (0.33–0.92) 0.020
Secondary outcomes
Preterm birth < 28 weeks
12/235 (5.1) 23/223 (10.3) 0.50 (0.25–0.97) 0.036
Preterm birth < 35 weeks
34/235 (14.5) 52/223 (23.3) 0.62 (0.42–0.92) 0.016
Preterm birth < 37 weeks
71/235 (30.2) 76/223 (34.1) 0.89 (0.68–1.16) 0.376
Respiratory distress syndrome
7/235 (3.0) 17/223 (7.6) 0.39 (0.17–0.92) 0.026
Bronchopulmonary dysplasia
4/235 (1.7) 5/223 (2.2) 0.76 (0.21–2.79) 0.678
Proven sepsis 7/235 (3.0) 6/223 (2.7) 1.11 (0.38–3.24) 0.853
Necrotizing enterocolitis
5/235 (2.1) 4/223 (1.8) 1.19 (0.32–4.36) 0.797
Intraventricular hemorrhage, Grade III/IV
0/235 (0.0) 1/223 (0.5) 0.32 (0.01–7.73)*
0.305
Periventricular leukomalacia
0/235 (0.0) 0/223 (0.0) Not estimable NA
Perinatal death 8/235 (3.4) 11/223 (4.9) 0.69 (0.28–1.68) 0.413
Fetal death 5/235 (2.1) 6/223 (2.7) 0.79 (0.25–2.57) 0.700
Neonatal death 3/235 (1.3) 5/223 (2.2) 0.57 (0.14–2.35) 0.43
Screening and prevention of spontaneous preterm labour
Screening possiblePrevention possiblePreterm labour avoidable
Innovation/ evidence is adopted slowly
Magnesium sulphate for neuroprotection: good evidence that CP and ‘CP or death’ is reduced, <32 weeks
1980s first data
1995: case control study
2002: first RCT
2009: meta analysis
2014: when did your Trust start giving it?
Universal preterm labour screening
Infrastructure for data collection
Funding for extra 10 min scan at existing anomaly scan
Guidelines for management
Guidelines for referral for extreme situations
TVS cervix at 20 weeks
Cervix <25mm: prescribe progesterone
Cervix <15mm: repeat 2 weeks
Cervix <10mm: refer to fetal medicine
?recruit to RCT
Some of the contributors to the Maternity Clinical Network
• Thames Valley & Wessex Neonatal Operational Delivery Network• Maternity and Children's Strategic Clinical Network• University of Oxford• University of West London• Oxford Brookes University• Life Science Businesses – such as Intelligent Ultrasound, HealthNetConnections,
Roche• Oxford Deanery /Health Education Thames Valley• Milton Keynes Hospital NHS Foundation Trust• Frimley Park NHS Foundation Trust (Wexham Park)• Buckinghamshire Healthcare NHS Trust• Oxford University Hospitals NHS Trust• Royal Berkshire NHS Trust• Great Western Hospitals NHS Foundation Trust
• Katherine Edwards!
Thank you
Why are we going to succeed?
Aiming for important things, already prioritised
Cooperation of multiple units/ agencies=power
Clinicians involved
Academic support and aims
Energy
What do we want from you?
Midwife/ obstetrician/ public health/ commissioner participation in network direction
Support for and development of existing projects
Involvement/ideas for priorities, innovation, enablement
Academic/ Industry collaboration1. Oxford University
Information/ biobank enlarging across the network
Infrastructure developed already increasing wide scale research participation
2. Intelligent Ultrasound
automated audit of USS quality trialling in local Trust
3. Viewpoint and Astraia
Development of networked information systems
4. Roche
developed multiple biomarkers incl. use in pregnancy. Eg prediction of pre eclampsia
Potential network-wide commercially funded innovation and translational research
SB and growth restrictionEvidence that ‘placental behaviour’ often manifest as growth aberrations contribute to ante and intrapartum stillbirth, preterm delivery and handicap.
Ultrasound can help:
Currently use ‘risk factors’ and clinical methods eg SFH measurement
(GROW packages help identify those in need of one)
Problems are:
Most pregnancy problems occur in ‘low risk’ women: problem not seen
Too many women are labelled ‘high risk’: other problems created:
increased medicalisation, intervention, expense, morbidity etc
Need to know who is truly high risk: a good screening test
Better targeting of surveillance and medicalisation= problems found
Better identification of majority who are truly low risk= less medicalisation
Development of a screening test for growth restriction
Previous pregnancy outcome
Pre-existing health issues
Low risk (70%) High risk (30%)
SFH
Ultrasound
Fetal medicine assessment/Delivery
Previous pregnancy outcome
Pre-existing health issues
PAPP-A
Uterine artery Doppler
Placental volume
PIGF etc
Low risk (95%) High risk (5%)
SFH
Ultrasound
Fetal medicine assessment/Delivery
Urgent: StillbirthIssues surrounding placental failure: the main contributor to stillbirthPreterm: preterm risks versus placental failure risksAt term: which small baby has placental failure?
Immediate actions:Developed guideline for management of early placental failureDeveloping network protocol following OUH model for (local) management of the small baby to follow best practice whilst minimising intervention