The major goal of obstetric care is to ensure the birth of a healthy baby with minimal risk to the mother. Therefore determining which interventions are most likely to improve patient safety is an important global health issue. The Oxford English Dictionary defines risk as: 'hazard, chance of bad consequences, loss.'www.ogf.co.zaam201

Soma-Pillay, Priya

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Obstetrics & Gynaecology Forum • May 2013 1“Every minute, somewhere in the world a woman diesin pregnancy or child birth.”1IntroductionThe major goal of obstetric care is to ensure the birth of ahealthy baby with minimal risk to the mother. Thereforedetermining which interventions are most likely to improvepatient safety is an important global health issue. TheOxford English Dictionary defines risk as: ‘hazard, chanceof bad consequences, loss.’ Risk assessment is the process where:• Hazards are identified• The risk associated with that hazard is analysed• Appropriate ways to eliminate or control the hazard aredetermined.2Obstetric risk assessment involves the identification ofproblem areas associated with the mother, fetus andorganisation of service.Maternal risk assessmentPre-conceptualMaternal risk assessment should begin pre-conceptually.Optimising maternal health prior to conception isimportant for improving pregnancy outcome. The evidenceis especially strong for medical conditions such asdiabetes.3 Hyperglycemia is the most important cause ofadverse fetal risk in pregnancy. Normalising blood glucoselevels before and in early pregnancy can reduce the risk ofmiscarriage and congenital malformations to that of non-diabetic women.4Women who are known epileptics should be counselledabout the risks of increased seizure frequency inpregnancy and the potential effects of seizures andanticonvulsant medication on pregnancy outcome. Thesewomen should be placed on anticonvulsant mono-therapywith the lowest effective dose to prevent seizures andconsidered for alteration or withdrawal of theanticonvulsant treatment prior to conception. Folic acidsupplementation should be initiated at least 1 month priorto conception.All women should have their body mass index (BMI)calculated at the pre-conceptual visit. Women with BMIs>26kg/m2 should be counselled about risk to their ownhealth and the further effect on pregnancy. These womenshould be offered behavioural strategies to reduce calorieintake and increase physical activity.The pre-conceptual visit also allows the mother to bescreened for toxins such as alcohol, cigarettes andrecreational drugs. Tobacco use in pregnancy has beenassociated with adverse outcomes such as miscarriage,prematurity and low-birth weight while a spectrum ofbirth defects ranging from subtle growth restriction to thefetal alcohol syndrome is associated with alcohol use inpregnancy. Evidence – based guidelines have beendeveloped for the identification and intervention for withwomen who engage in excessive drinking and/orsmoking.5 A systematic review of 12 studies has foundgood evidence for the effectiveness of behaviouralinterventions in reducing alcohol consumption at 6 and12 months.6This is also the ideal opportunity for any medicationto be stopped (e.g. valproate and isoretinin) or changedto one that is safer for the fetus (heparin for warfarin).PrenatalThe prenatal visit should take place before 10 weeks ofgestation. A complete history and examination will revealthe patient’s risk profile and allow for preventativemeasures to be instituted.Women with a prior history of pre-eclampsia have a7% risk of developing pre-eclampsia in the presentpregnancy.7 This risk is further increased if the patienthas pre-existing hypertension, renal disease orantiphospholipid syndrome. In low-risk patients, firsttrimester screening using maternal factors, uterine arterydoppler, blood pressure and pregnancy - associatedplasma protein - A (PAPP-A) is useful to predictpreeclampsia.7 First trimester metabolomic detection forpredicting early and late onset preeclampsia has recentlybeen described.8 A model consisting of maternaldemographics and multiple metabolites showed a 76.7%sensitivity and 100% specificity for pre-eclampsiadetection. Once a patient at risk of developing pre-eclampsia is identified, prophylactic measures to reducethis risk may be prescribed. Low-dose aspirin willreduce ones risk by 15% while in women with a lowbaseline calcium intake: the risk reduction may be up to80%.Risk factors for thromboembolism should also bedetermined at this visit. Several authoritative bodies haveprescribed guidelines for thromboprophylaxis and anindividual risk assessment should be done early inpregnancy for women with a history of previousthromboembolism. Obstetric emergenciesThree important causes of maternal mortality globallyare embolism, haemorrhage and pregnancy-relatedhypertension. Quick identification of these and otheremergencies and a rapid coordinated response areimportant for ensuring favourable outcomes.GUEST EDITORIAL O&G Forum 2013;23:1-6Risk assessment in obstetricsCorrespondenceDr Priya Soma-Pillayemail: Priya.somapillay@up.ac.zaObstetrics & Gynaecology Forum • May 2013 2Postpartum haemorrhageRisk factors for postpartum haemorrhage includemultiparty, uterine distension from multiple gestations,polyhydramnios, macrosomia and prolonged labour. Use ofactive management of the third stage of labour has beenshown to significantly reduce the risk of postpartumhaemorrhage (RR 0.38, 95%CI 0.32-0.46).9 Managementshould be aggressive and involves delivery of the placenta,establishing intravenous access, identifying the cause ofbleeding, uterotonic agents, transfusion, uterine packing,haemostatic sutures (B - Lynch), vessel ligation andhysterectomy.Pre-eclampsia and eclampsiaEmergencies associated with hypertension in pregnancyaccount for 12% of maternal deaths worldwide.10 This ismainly due to eclampsia and unexplained coma. Predictingwhich patient is at risk of eclampsia is difficult: butadequate blood pressure control and delivery if the bloodpressure is not controlled will reduce the risk of intra-cranial bleeds. Magnesium sulphate will reduce the risk ofeclamptic fits by more than half.11 Management of aneclamptic fit includes establishing an airway andoxygenation and administration of magnesium sulphate.EmbolismPulmonary embolism is a leading cause of death in thedeveloped world. In pregnancy, prevention of deathrequires a high index of suspicion followed by a timely andaccurate diagnostic approach. The American ThoracicSociety recommends imaging evaluation for patients withthe following clinical symptoms: shortness of breath,pleuritic chest pain, hypoxemia, tachycardia, hemoptysis,syncope cough and unexplained hypotension.12Fetal risk assessmentFetal medicine is a subspeciality in obstetrics that focuseson high-risk pregnancies and the role includes ultrasoundfor fetal assessment and diagnosis of anomalies, invasiveprenatal diagnosis and management of pregnanciescomplicated by maternal medical disorders, multiplepregnancies and the antenatal management of extremeprematurity. First trimester screeningFetal aneuploidies are a major cause of perinatal mortalityand childhood morbidity.13 First trimester screeningidentifies pregnancies at risk thus enabling patients toreceive counselling and appropriate diagnostic testing.Screening using nuchal translucency thicknessmeasurement, maternal serum beta-HCG and PAPP-A aswell as additional markers such as fetal nasal bonemeasurement, ductus venosus doppler and tricuspidregurgitation detects 95% of foetuses with trisomy 21 witha 2.5% false positive rate.14 Trisomy 13 and 18 are alsoassociated with an increased nuchal thickness and a lowbeta-HCG and PAPP-A values. Nuchal translucency mayalso be used to screen for fetal aneuploidy in twinpregnancies while in monochorionic twin pregnancies adiscordant nuchal measurement may predict thedevelopment of early twin-to-twin transfusion syndrome. Second trimester fetal anomaly scanA detailed fetal scan done between 20-23 weeks ofgestation serves as a screening tool for fetal structuralmalformations. In an Australian cohort involving 12 169patients, the sensitivity of detection rate was 72.8% forpatients allocated to routine ultrasound screening.13Preventing preterm birthRecent evidence has shown that both cervical cerclage andvaginal micronized progesterone reduces the risk ofpreterm birth in a specific group of women at very highrisk, that would be defined by all 3 of the following:• A current singleton pregnancy• A history of spontaneous preterm birth in a priorpregnancy• A cervical length of <25mm in the current pregnancy.Untreated these patients have a 15-20% risk of pretermbirth before 28 weeks, 25-30% risk before 32 weeks and a50-60% risk before 37 weeks.15Trials comparing cerclage with no cerclage, showed thatcerclage resulted in significant reductions in the following16:• Recurrent preterm birth before 35 weeks, relative risk(RR) 0.70• Perinatal mortality, RR 0.65• Composite neonatal morbidity, RR 0.60.The use of vaginal progesterone in patients with the same3 risk factors resulted in reductions in17:• Recurrent preterm birth before 33 weeks, RR 0.54• Composite neonatal morbidity and mortality, RR 0.41Fetal anemiaThe most important causes of fetal anemia includealloimmune antibodies, fetal infection including parvovirusB19 and feto - maternal haemorrhage. The middle cerebralartery (MCA) peak systolic flow measurement is ascreening tool to detect fetal anemia. The MCA peaksystolic velocity has a sensitivity of 88%, specificity of 82%and accuracy of 85% (95% CI 79-90%) for the detection offetal anemia.18 This non-invasive method is used for bothdetection and monitoring of fetal anemia.Intra-uterine growth restriction (IUGR)Intra-uterine growth restriction is associated with increasedperinatal mortality. Timely diagnosis and appropriatemonitoring is used to opitimise the timing of delivery.Doppler measurement of the fetal umbilical artery, ductusvenosus waveform and middle cerebral artery waveformsare used to determine placental function and fetal well-being. A Cochrane review of the use of umbilical arterydoppler compared with no doppler ultrasound in 18 trialswith 10 000 high risk patients showed a 29% decrease inperinatal mortality, with a risk ratio of 0.71 (95% CI 0.53-0.98).19An absent or reverse ductus venosus a-waveform is astrong predictor of fetal acidaemia and perinatal death.20 Ameta-analysis of 18 studies reported that abnormal ductusvenosus waveform on doppler ultrasound predictedadverse perinatal outcome with a pooled positiveGUEST EDITORIAL O&G Forum 2013;23:1-6Obstetrics & Gynaecology Forum • May 2013 4likelihood ratio of 3.15 (95% CI 2.19 – 4.54) and negativelikelihood ratio of 0.49 (95% CI 0.40-0.59).20 An absent orreversed a-wave in the ductus venosus for more than 7days predicts stillbirth, irrespective of gestational age.21Organisation of servicePatient safety is also dependent on the rate of preventableadverse events. Death from medical errors presents asignificant burden to the health-care system. The 2008-2010 Saving Mothers Report found that 23.2% of maternaldeaths were preventable.22 Gluck reports 5 categories ofsolutions to reduce “error” in the healthcare system.23These are:1. Provide leadership2. Respect human limitations3. Develop effective team function4. Create a learning environment5. Anticipate the unexpected.Provide leadershipPatient safety should begin in the boardroom of ourhospitals. Leaders have the responsibility of providingnecessary resources within their sphere so that providershave the training and tools to deliver effective and safecare.Respect human limitsWork processes should be standardised as this increasesefficiencies, reduces reliance on memory and reduces therisk of error.24 Standard protocols should be developed todeal with common scenarios –for example, posthysterectomy or postpartum instructions - and these canstill be flexible to allow for individual variations.The effect of sleep deprivation on human performanceis well known. The level of impairment associated with 24hour sleep deprivation results in the same cognitiveimpairment as being legally drunk.25 The AmericanAccreditation Council for Graduate Medical Education haslimited resident work hours to improve patient safety.26 Thishas resulted in a reduction of all types of serious medicalerrors, but most especially diagnostic errors.27Develop effective team functionCommunication problems are an important cause ofpreventable adverse outcomes in medicine.Miscommunication can occur at 2 levels: between health-care providers and between health-care provider and thepatient. Transfer of information from one health-careprovider to another is prone to error. This process is oftenunstructured, incomplete and sometimes interrupts otheractivities. Several techniques have been developed toimprove communication. One such technique is SBAR:situation, back-ground, assessment and recommendation.Verbal communications between providers should beacknowledged and repeated.Create a learning environmentSimulators are fast becoming a popular form of training inthe medical field. Simulators have the advantage of trainingfor uncommon and unpredictable events in a controlledenvironment without endangering patients. Although thereis growing enthusiasm for this type of learning, the long-term efficacy still needs to be validated.28Anticipate the unexpectedMedical systems need safety nets so that when problemsarise they may be recognised and treated before thepatient is harmed. Up to 70% of patients experiencesignificant respiratory compromise up to 8 hours prior tocardiopulmonary arrest.29 Healthcare workers should betrained to respond appropriately to certain triggers such asdeterioration of vital signs, mental status or altered bloodgas. Once a problem is recognised, protocols should befollowed so that a diagnosis is made and treatment can beimplemented timeously.ConclusionObstetric risk assessment should not be a singleevaluation; instead this is a series of assessments andinterventions throughout pregnancy and the postpartumperiod. These assessments are also applied by differentpractitioners in the healthcare system. The ultimate aim isfor the individual components to collectively result in a safeand successful pregnancy outcome. Dr Priya Soma-PillayFetomaternal Medicine Subspecialist, Department ofObstetrics and Gynaecology, University of Pretoria, Pretoria,South AfricaReferences1. Freedman L, Wirth M, Waldman R et al. Background Paper of theTask Force on Child Health and Maternal Health. MillenniumProject UN Development Group, 2003.2. Canadian Centre for Occupational Health and Safety.http://www.ccohns.ca/oshanswers/hsprograms/risk-assessment.html.3. Kitzmiller JL, Gavin LA, Gin GD et al. Preconception care ofdiabetes. Glycemic control prevents congenital anomalies. JAMA1991; 265:731.4. Dicker D, Feldberg D, Samuel N et al. Spontaneous abortion inpatients with insulin-dependent diabetes mellitus: the effect ofpreconceptual diabetic control. Am J ObstetGynecol 1988;158:1161.5. Floyd RL, Jack BW, Ceflo R et al. The clinical content ofpreconception care:alcohol, tobacco and illicit drug exposures.AJOG 2008; 199: 5333-5339.6. Whitlock EP, Polen MR, Green CD et al. Behavioural counsellinginterventions in primary care to reduce risk/harmful alcohol useby adults: a summary of the evidence for the US PreventativeServices Task Force. Ann Int Med 2004; 140: 557-568.7. Scazzochio E, Figueras F Crispi F et al. Performance of firsttrimester screening of preeclampsia in a routine care low-risksetting. Am J ObstetGynecol 2013; 203.8. Bahado-Singh RO, Akolekar R, Mandal R et al. First trimestermetabolomics detection of late onset preeclampsia. Am JObstetGynecol 2013; 208:58.9. Prendiville WJ, Elbourne D, McDonald S. Active versus expectantmanagement in the third stage of labour. Cochrane DatabaseSyst Rev 2000. CD000007.10. Guise JM. Anticipating and responding to obstetric emergencies.Best Practice & Research Clinical Obstetrics and GyneacologyGUEST EDITORIAL O&G Forum 2013;23:1-6Obstetrics & Gynaecology Forum • May 2013 62007; 21:625-638.11. Duley L, Gulmezoglu AM, Henderson-Smart DJ. Magnesiumsulphate and other anticonvulsants for women with pre-eclampsia.Cochrane Database Syst Rev 2003. CD000025.12. Leung AN, Bull TM, Jaeschke R. Special Report: ATS/STR ClinicalPractice Guideline: Pulmonary Embolism in Pregnancy. Radiology2012; 262: 635-646.13. Tan WS, Guaran R, Challis D. Advances in maternal fetal medicinepractice. Journal of Paediatrics and Child Health 2012; 48: 955-962.14. Nicolaides K. Screening for fetal aneuploidies at 11 to 13 weeks.PrenatDiagn 2011;31: 7-15.15. Conde-Agudelo A, Romero R, Nicolaides K et al. Vaginalprogesterone vs cervical cerclage for the prevention of pretermbirth in women with a sonographic short cervix, previous pretermbirth, and singleton gestation: a systematic review and indirectcomparison metaanalysis. Am J ObstetGynecol 2013;208: 42.16. Berghella V, Rafael TJ, Szychowski JM. Cerclage for short cervix onultrasonography in women with singleton gestation and previouspreterm birth. A meta-analysis. ObstetGynecol 2011; 117: 663-71.17. Romero R, Nicolaides K, Conde-AgudeloA et al. Vaginalprogesterone in women with an asymptomatic sonographic shortcervix in the midtrimester decreases preterm delivery andneonatal morbidity: a systematic review and metaanalysis ofindividual patient data. Am J ObstetGynecol 2012: 206;124.18. Oepkes D, Seaward PG, Vandenbussche F et al. Diamond StudyGroup. Doppler ultrasonography versus amniocenthesis to predictfetalanemia. N Engl. J Med. 2006; 355: 156-164.19. Alfirevic Z, Stampalija T Gyte GM. Fetal and umbilical Dopplerultrasound in high risk pregnancies. Cochrane Database Syst Rev2010;1 :CD007529.20. Baschat A, Gembruch U, Weiner C. Qualitative venosus Dopplerwaveform analysis improves prediction of critical perinataloutcomes in premature growth restricted foetuses. UltrasoundObstet. Gynecol. 2003; 22:240-5.21. Turan OM, Turan S, Berg C et al. Duration of persistent abnormalductusvenosus flow and its impact on perinatal outcome in fetalgrowth restriction. Ultrasound Obstet Gynecol. 2011; 38: 295-302.22. Department of Health 2012. Saving Mothers 2008-2010: Fifth reporton the confidential Enquiries into maternal Deaths in South Africa.Pretoria: Department of Health.23. Gluck P. Patient safety in women’s health care: a framework forprogress. Best Practice & Research Clinical Obstetrics andGynaecology 2007; 21: 525-536.24. Bohmer RM. Medicine’s service challenge: blending custom andstandard care. Health Care Manage Rev 2005; 30: 322-330.25. Dawson D, Reid K. Fatigue, alcohol and performance impairment.Nature 1997; 388: 235.26. Friedman WA. Resident duty hours in American neurosurgery.Neurosurgery 2004; 54: 925-931.27. Landrigan CP, Rothschild JM, Cronin JW et al. Effect of reducinginterns’ work hours on serious medical errors in intensive careunits. New Engl J Med 2004; 351: 1838-1848.28. Bradely P. The history of simulation in medical education andpossible future directions. Med Edu 2006; 40: 254-262.29. Schein RM, Hazaday N, Pena M et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990; 98: 1388-1392.GUEST EDITORIAL O&G Forum 2013;23:1-6Open access to O&G Forum websitewww.ogf.co.zaUser ID - inhouse / Password - 2011O&G FORUM

Risk assessment in obstetrics

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Risk assessment in obstetrics

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