A specialised clinic for the antenatal care of high-risk patients was established in Cork in January 2004. It is led

by 2 specialists in materno-fetal medicine and provides care for patients from a large catchment area. Small clinic

numbers, specialised midwives, ready access to medical experts and fetal assessment facilities, facilitate an

efficient use of resources. We report on the experience and outcomes of this clinic after the first year in operation.

A database was set up to store relevant information on patients who attended the clinic in 2004. 143 patients

attended. Risk categories included maternal medical disease (62%); multiple pregnancy (11%); previous poor obstetric

history (10%); fetal anomaly (8%). Average gestation; 35.9 weeks, average birth weight; 2598g. Caesarean section rate;

41%. Perinatal mortality rate 67 per 1000 (uncorrected); and 20% neonates required NICU care. This approach to

highrisk obstetric care resulted in favourable outcomes. The management strategy applied in Cork may be a suitable

prototype for comparable areas throughout Ireland

Allen, C.

Greene, Richard A.

Higgins, John R.

Cork Open Research Archive

Title Audit of antenatal clinic for high-risk obstetric patients; activity andoutcomesAuthor(s) Allen, C.; Greene, Richard A.; Higgins, John R.Publication date 2007-10Original citation Allen C, Greene RA, Higgins JR. (2007) 'Audit of Antenatal Clinic forHigh-Risk Obstetric Patients; Activity and Outcomes'. Irish MedicalJournal, 100(9) :591-593.Type of publication Article (peer-reviewed)Link to publisher'sversionhttp://www.imj.ie//ViewArticleDetails.aspx?ArticleID=2633Access to the full text of the published version may require asubscription.Rights © Copyright 2007 Irish Medical JournalItem downloadedfromhttp://hdl.handle.net/10468/486Downloaded on 2017-02-12T08:23:29ZAudit of Antenatal Clinic for High-Risk Obstetric Patients; Activityand OutcomesIr Med J. 2007 Oct;100(9):591-3C Allen, R Greene, J HigginsUnified Maternity Services, CorkAbstractA specialised clinic for the antenatal care of high-risk patients was established in Cork in January 2004. It is ledby 2 specialists in materno-fetal medicine and provides care for patients from a large catchment area. Small clinicnumbers, specialised midwives, ready access to medical experts and fetal assessment facilities, facilitate anefficient use of resources. We report on the experience and outcomes of this clinic after the first year in operation.A database was set up to store relevant information on patients who attended the clinic in 2004. 143 patientsattended. Risk categories included maternal medical disease (62%); multiple pregnancy (11%); previous poor obstetrichistory (10%); fetal anomaly (8%). Average gestation; 35.9 weeks, average birth weight; 2598g. Caesarean section rate;41%. Perinatal mortality rate 67 per 1000 (uncorrected); and 20% neonates required NICU care. This approach tohighrisk obstetric care resulted in favourable outcomes. The management strategy applied in Cork may be a suitableprototype for comparable areas throughout Ireland.IntroductionA pregnancy is defined as âhigh riskâ when the likelihood of an adverse outcome to the woman and/or her baby isgreater than that outcome in the general pregnant population1. The majority of pregnancies do not fall in this categoryand antenatal care can be adequately provided for âlow riskâ women by local arrangements between GP/midwife/obstetrician (although there is no consensus as to what constitutes the ideal model). The commonest way in which riskin pregnancy is identified is general risk recognition by the care-provider2. A minority of the general pregnantpopulation is deemed high-risk so, in areas without a large maternity unit, these patients will attend routineantenatal clinics. Special requirements for the care of these pregnancies is not often easily accessed in the busyroutine setting, with consequent possible delays with results and inconvenience for the patient.A specialised clinic for the antenatal care of high-risk patients was established in January 2004 at the ErinvilleHospital, Cork. This clinic is reserved for high-risk pregnancies and provides increased antenatal care requirementsin a âone-stopâ fashion. Clinics take place between an outpatient department and fetal assessment unit. Twoconsultant specialists in materno-fetal medicine lead the clinic thus ensuring the presence of a second opinion fordifficult cases. Two Specialist Registrars, one Senior House Officer, one specialised midwife, one ultrasonographer,and clerical staff also attend the clinic. No other outpatient clinics, which could potentially draw away resources,occur during the high-risk clinic, and ultrasound facilities are also protected during this time. The number ofpatients per clinic is small giving more time per patient in a non-pressurised environment for doctors. A consultantHaematologist attends the high-risk clinic every second week while joint care with other physicians requires somepatients to attend other sites. Support services of Neonatology, social work and chaplaincy attend as required. Casesare discussed weekly at a multidisciplinary meeting after the clinic. Referring doctors are kept informed ofmanagement with summaries sent after all first visits, and subsequently as required. We report on the experience andoutcomes of this clinic after the first year in operation.MethodsMedical and IT personnel set up a customised database. This was used to collect relevant information on all patientswho attended the high-risk clinic from January 1st to December 31st 2004. Data regarding patient demographics, sourcesof referral, clinical information, risk factors, antenatal management, delivery data and perinatal outcomes werecollected.ResultsOne hundred and forty three women attended the high-risk clinic from January 1st to December 31st 2004. The majority(53%) of patients were referred from another clinic (obstetric or medical)and 46% of patients were referred directlyby their GP. The rate of patient referrals increased as the year progressed. Most women referred were resident in Corkcity, but the catchment area included the counties of Cork, Kerry, Limerick and Waterford. The average number ofpatients per clinic was 15 and clinic sessions lasted three hours per week. The average number of clinic visits perpatient was 12. The average number of ultrasounds performed per patient was eight.The average maternal age was 30.3 years (range 18-44) compared to the national average maternal age of 30.2 years3. 39%of women were nulliparous, 61% were multiparous. More than half of the women (65%) did not take folic acid in thepericonceptual period. 20% of women were cigarette-smokers with about one third smoking more than 20 cigarettes perday. The majority (93%) did not drink alcohol since becoming pregnant but of those who did, nearly w were taking morethan 10 units per week. No patients were documented to be using illicit drugs. The study population represented allsocio-economic backgrounds and included immigrants as well as Irish women.Table 1 Reasons for Referral to High-Risk Obstetric ClinicHigh-Risk Category n (%)Maternal medical condition 89 (62.2)Muti-fetal gestation 15 (10.5)Previous obstetric history 14 (9.8)Fetal condition 11 (7.6)Advanced maternal age 5 (3.5)Prepregnancy counselling 4 (2.8)Post-natal issue 2 (1.4)Placenta praevia 2 (1.4)Cervical lesion 1 (0.7)The reasons for referral to the high-risk clinic are shown in Table1. In 86% cases involving a maternal medicalcondition, care was provided jointly by obstetrician and physician. Haematologic conditions, especially coagulationdisorders comprised the majority of maternal medical conditions (Table 2) and low molecular weight heparin therapy wasused in 17/21 patients with coagulopathies. Serial intravenous immunoglobulin (IVIG) treatment was used for onepatient in whom the fetus was at risk of fetal alloimmune thrombocytopenia (FAITP). Of the multiple pregnancies, 11were monochorionic diamniotic (MCDA) twinpregnancies, three were dichorionic diamniotic (DCDA) twin pregnancies, andone was a monochorionic triamniotic triplet pregnancy. Three pregnancies were affected by twin-twin transfusionsyndrome (TTTS).Table 2 Categories of Maternal Medical Conditions ReferredCondition nHaematologic 25Endocrine 15Audit of Antenatal Clinic for High-Risk Obstetric Patients; Activity and Outcomes 1Neurologic 9Hypertension 8Autoimmune disorder 7Viral exposure 5History of recurrent pregnancy loss 5Cardiac anomaly 3Complex surgical history 2Respiratory 1Psychiatric 1Fetal Outcomes142 women attended the clinic; 15 women had a multi-fetal pregnancy giving a potential of 158 fetuses. Fivepregnancies ended in miscarriage, one had an ectopic pregnancy and 26 attended elsewhere for delivery. Four attendedfor pre-pregnancy counselling only. Thus, in total there were 122 viable fetuses and data were available for 119 ofthese.There were 111 live-births. Of the singleton pregnancies 45% had a spontaneous vaginal delivery, 37% were delivered byCaesarean Section, 10% required instrumental delivery, 2% had a vaginal breech delivery and 6% delivered in anotherunit. Of the multi-fetal pregnancies 50% had a spontaneous vaginal delivery, and 50% were delivered by CaesareanSection.Table 3 Perinatal Outcomes Compared with General Obstetric PopulationHigh-Risk Obstetric Group General Obstetric PopulationSingleton Multi-fetal Singleton Multi-fetalPregnancies Pregnancies Pregnancies PregnanciesAverage gestation (weeks) 38.7 33.1 39.5 35.9Average birth weight (g) 3256 1939 3504 2490PMR uncorrected (per 1000 livebirths) 44 130 7.9 8.4Total uncorrected PMR 67 25.1The average gestations at delivery and birth weights are shown in Table 3. 20% (23/111) of neonates required NICUadmission. Perinatal deaths occurred in 8/119 of infants in this high-risk group and are shown in Table 4.Table 4 Perinatal Deaths in the High-Risk Obstetric GroupGestation Associated FeaturesSingleton stillbirth 32 weeks Placental abruption (maternal factor V Leiden homozygote)Singleton stillbirth 24 weeks Maternal thrombocytopeniaSingleton stillbirth 25 weeks Cystic hygromaSingleton intrauterine death 25 weeks Trisomy 13Intrauterine death of one twin 34 weeks Twin-twin transfusion syndromeIntrauterine death of one triplet 28 weeks Twin-twin transfusion syndromeNeonatal death twin I 27 weeks Twin-twin transfusion syndromeNeonatal death twin II 27 weeks Twin-twin transfusion syndromeDiscussionThe outcomes for this high-risk group in terms of birth weight and gestation at delivery compare favourably tonational figures. However, the perinatal mortality rate (PMR) is significantly higher than the national average. It isdifficult to compare the PMR with high-risk groups in other units due to the absence of a control group. Largermaternity units in this country often sub-divide clinics for the risk categories which are amalgamated in the Corkgroup. Similarly it is difficult to compare the Caesarean section rates without a similarly heterogeneous high-riskgroup for comparison.The first year of this dedicated high-risk clinic saw maternal medical conditions as the major reason for referral.This highlights the importance of direct communication channels between obstetricians and hospital physicians; webelieve this is achieved in a dedicated high-risk obstetric clinic. The clinic is a ready route of referral forphysicians and GPs whose patients become pregnant or are contemplating pregnancy. Similarly, obstetricians caring forthe high-risk group will benefit from this increased liaison. It is possible that risk categories proportions willalter in the future as we see a trend towards older maternal age, increased caesarean section rates, increased bodymass index, increased immigrant populations, more assisted reproduction, improved survival rates following cancer andchildhood diseases.These bring new challenges to the optimal care of the pregnant patient and the fetus that may be best addressed indedicated clinics.The majority of women in the high-risk group were not taking preconceptual folic acid. The study group did not differsignificantly from the general pregnant population in terms of demographics and this is a disappointing findingespecially in view of recent public health campaigns to highlight the importance of folate supplementation in theprevention of neural tube defects. This finding may lend support to the campaign for folic acid supplementation offood. Approximately one fifth of pregnant women in this group continued to smoke in pregnancy despite counsellingregarding the additional harmful effects to the fetus. A smoking cessation programme with support of counsellors mayimprove this but remains unproven at present. The results of such programmes in other units should become available inthe near future.GPs and other doctors quickly became aware of this service following its introduction with a general increase in newreferrals throughout the first year in operation. This trend is likely to continue in parallel with projectedpopulation growth in Ireland and an increasing birth rate placing increased demands on maternity services. Thecatchment area covered a large geographical area but the pregnant women in the study group showed a willingness totravel long distances for specialised care. This is an important observation in view of possible centralisation ofmedical services, including maternity, in the future.In general, the experience from this clinic after its first year in operation has been positive for patients anddoctors. With financial restraints on national medical budgets we feel that the concerted approach provides increasedresources for healthcare delivery in a cost-effective manner. We believe it provides an appropriate managementstrategy for high-risk obstetric patients from a large catchment area and may serve as a model for care of suchpatients in other similar geographical areas. ReferencesJames DK. Risk at booking visit. Pregnancy and Risk, Chichester: John Wiley. 1988;45-80.1. Chard T. Obstetric risk scores. Fetal Medicine Review 3; 1-10.2. Report on perinatal statistics for 2001. HIPE & NPRS unit, ESRI. April 2005. Department of Health and Children.3. Comments: Correspondence:´ J´ Higgins Cork´ University´ Maternity´ Hospital,´ Wilton,´ Cork Email:´ <ahref=mailto:higginsj@ucc.ie>higginsj@ucc.ie</a>Audit of Antenatal Clinic for High-Risk Obstetric Patients; Activity and Outcomes 2

Audit of antenatal clinic for high-risk obstetric patients; activity and outcomes

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