The prediction, diagnosis and management of complications in monochorionic twin pregnancies

Monochorionic twin pregnancies are high-risk and closely monitored antenatally. A systematic review revealed no existing predictive factors for twin-twin transfusion syndrome (TTTS), growth restriction, or intrauterine fetal death (IUFD). The Optimal Management of Monochorionic Twins (OMMIT) study found that first trimester inter-twin nuchal translucency discordance, crown-rump length discordance, β-hCG, PAPP-A, AFP, PlGF and sFlt-1 do not predict adverse outcome. A difference was seen in novel second trimester biomarkers: in the recipient twin amniotic fluid metabolites pre- and post-fetoscopic laser ablation; and a relationship with recipient twin cardiac function was demonstrated. Discovery work on miRNA in second trimester maternal serum of TTTS pregnancies found no difference compared to uncomplicated monochorionic twin pregnancies. A systematic review provided a more personalised risk prediction for the surviving co-twin in single IUFD, including that that the rate of abnormal brain imaging is 20% and the IUFDs occurring at 14-28 weeks are at higher risk. A preliminary study of parent-fetal antenatal and postnatal attachment and depression in TTTS pregnancies found maternal attachment increased postnatally and depressive symptoms decreased, whereas paternal scores did not change. This thesis has reported exciting findings which have clinical implications, and advance knowledge of complicated monochorionic twin pregnancies

P14.02 An electronic behaviour diary: Monitoring the effects of advanced obstetric surgical skills training

Objective: Training should lead to improvements in the quality of clinical care delivery. It is essential to follow up participants after a training intervention to monitor changes in behaviour associated with adoption of lessons learned into clinical practice. We introduced an electronic diary to facilitate monitoring whilst minimising effort for participants. Method: An electronic diary was created using a freely available on-line platform. Following a training intervention on advanced obstetric surgical skills, obstetric residents from Kenya were invited to pilot completing the diary after their labour ward shifts. Entries were anonymised. Participants were asked to enumerate the times they utilised specific skills, or to state why they had been unable to do so, using tick box options. Reflections on skills used were entered using free comments. Results: All participants reported changed behaviours, for example, improved surgical knot-tying, safer needle handling, separate closure of uterine incision angles and techniques for delivery of the impacted fetal head. 6 reported conducting vaginal breech birth and 6 performed vacuum-assisted birth. All reported improvements in use of the safe surgical checklist, obtaining consent and respectful maternity care. 7 had participated in newborn resuscitation. Reflections suggested participants experienced improved levels of confidence and satisfaction when implementing new skills. Conclusion: This pilot study has demonstrated the feasibility of monitoring clinical behaviour change following training using an electronic platform. Monitoring the effect of training is essential to prove that training results in improvements to clinical practice. We plan to roll out this intervention following future training interventions

P04.41 Exploring reasons for and outcomes of second stage caesarean section and assisted vaginal birth in selected hospitals in Kenya

Objective: Obstetric vacuum devices for assisted vaginal birth (AVB) can avoid the need for unnecessary second-stage caesarean sections (SSCS), associated with increased morbidity and mortality. Despite emergency obstetric training since 2019, AVB was rarely performed. This study sought to better understand missed opportunities and reasons for non-performance of AVB in Kenya. Method: A mixed-methods design incorporated a review of randomly selected SSCS and AVB case notes, and key informant interviews with healthcare providers, from 8 purposively selected, high-volume hospitals in Kenya. The reviews were carried out by four experienced obstetricians (3 Kenyan, 1 British). The interviews were semi-structured and conducted online and analysed using a thematic approach. Results: Six AVB and 66 SSCS cases were reviewed. Nine percent of SSCS could have been AVB, and 58% reviewers were unable to determine appropriateness due to poor record keeping. Perinatal mortality was 9%, and 11% of infants and 9% of mothers experienced complications following SSCS. Twenty interviews, with obstetricians, midwives and medical officers, explored themes of previous experience, confidence, and adequacy of training relating to AVB. Reasons for non-performance included lack of equipment and staff. Conclusion: Increases in appropriate use of AVB could save the lives of infants and mothers and reduce ongoing morbidity. In order to achieve this, the varied reasons for non-performance of AVB need to be systematically addressed at local, regional and national levels

P14.01 An example of too much too soon? A review of caesarean sections performed in the first stage of labour in Kenya

Objective: Caesarean Section (CS) has potential short and long-term complications and is associated with excess maternal death. Decisions to perform (CS) are frequently made by inexperienced and unsupported non-specialist doctors, sometimes resulting in inappropriate decision-making and surgery. Our study assesses decision-making for CS in the first stage of labour in Kenya. Method: A panel of one UK and six Kenyan expert obstetricians reviewed clinical data extracted from 87 case-notes, that were randomly selected from a series obtained from seven referral hospitals in five Kenyan counties over six months in 2020. Following a preliminary review of the data and email discussion, an online panel was convened to discuss outstanding cases where consensus was yet to be reached. Agreement was reached by the panel in all but 5 cases. Results: In 41.3% cases, CS was considered appropriate, including 8% where CS was performed too late. The decision to delivery interval exceeded 2 h in 58.6% cases, including 16 cases of non-reassuring fetal status. In 10.3% it was considered that due to delay, further reassessment should have occurred. In 9.1% the CS was done too soon. There was insufficient information available to make a full assessment in 21.8% of cases. In 11.5% the CS was inappropriate. Conclusion: This review demonstrates that unnecessary caesarean sections are being performed, while some with appropriate indications are subject to delays. There is need for improved support for decision-making, coupled with improved record-keeping, improved quality of fetal monitoring during labour and more timely surgery when necessary

Statistical methods for prognostic factor and risk prediction research

Prognosis research is an important part of medical research as it seeks to understand, predict, and improve future outcomes in people with a given disease or health condition. This thesis focuses on the application and development of statistical methods for prognosis research, with a particular focus on the identification of prognostic factors and the performance of risk prediction models. The first part of the thesis considers the use of a single study for prognostic factor and prediction model research. Prognostic factors of adverse outcome in monochorionic diamniotic twin pregnancies are investigated and difference in nuchal translucency and crown-rump length were found to have prognostic value. The instability of developing a prediction model in small sample sizes is also illustrated. Then, a review of published prediction models is conducted which reveals potential concerns that measurement error may affect the predictors included in many models, and a lack of clarity about the timing of predictor measurements and the intended moment of using the proposed models. Recommendations for improved reporting are provided. A real example is then used to illustrate how displacing the collection of a time-varying predictor from the intended moment of model use leads to substantial differences in the predictor-outcome association, and the subsequent performance of the prediction model. The second part of the thesis focuses on the synthesis of IPD from multiple studies. An IPD meta-analysis is used to validate existing stillbirth prediction models and demonstrates that the models should not be recommended for clinical practice due to poor predictive performance and insufficient clinical utility. Finally, a novel analytic method is developed to calculate the power of an IPD meta-analysis to examine prognostic factor effects with binary outcomes, based on published study aggregate data, to help researchers decide on the benefit of the IPD approach in advance of collecting IPD

Annual SHOT Report 2020

SHOT is affiliated to the Royal College of Pathologists. This report is produced by SHOT working with MHRAKey SHOT messages • Ensuring transfusion teams are well resourced: Clinical and laboratory teams can function optimally only if adequately staffed and well resourced. Healthcare leaders and management must ensure that staff have access to the correct information technology (IT) equipment and financial resources for safe and effective functioning • Addressing knowledge gaps, cognitive biases, and holistic training: Transfusion training with a thorough and relevant knowledge base in transfusion to all clinical and laboratory staff along with training in patient safety principles, understanding human factors and quality improvement approaches are essential. It is important that staff understand how cognitive biases contribute to poor decision making so that they can be mitigated appropriately • Patient safety culture: Fostering a strong and effective safety culture that is ‘just and learning’ is vital to ensure reduction in transfusion incidents and errors, thus directly improving patient safety • Standard operating procedures (SOP): SOP need to be simple, clear, easy to follow and explain the rationale for each step. This will then ensure staff are engaged and more likely to be compliant and follow the SOP • Learning from near misses: Reporting and investigating near misses helps identify and control risks before actual harm results, thus providing valuable opportunities to improve transfusion safety • Learning from the pandemic: The learning from the pandemic experiences should be captured in every organisation, by everyone in healthcare and used to improve patient safet