Improving quality and safety in maternity services: Can we improve the prevention, detection and management of congenital abnormalities?

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.

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%).

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.

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.

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.

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.

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.

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.

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.

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.