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