Consultant-led Maternity Units Research Articles

Severe, uncontrolled epilepsy in pregnancy: A population-based case-control study

Background Epilepsy affects one percent of the UK population and is the most common serious neurological condition experienced during pregnancy. We compared the characteristics, clinical management, and pregnancy outcomes in women with severe, uncontrolled epilepsy to those of women with well controlled disease. Methods We conducted a population-based case-control study in all UK consultant-led maternity units. Cases of severe uncontrolled epilepsy during pregnancy were identified prospectively and reported via the UK Obstetric Surveillance System (UKOSS). Severe epilepsy was defined a-priori as ≥1 of the following: admission to hospital during pregnancy to manage seizures; prescribed ≥3 antiepileptic medications; or died from epilepsy. Controls comprised women with epilepsy not meeting the case definition, identified within the same centres as cases. Pre-pregnancy epilepsy control and pregnancy outcomes were compared between groups using multivariable logistic regression. Results We identified 94 cases between 1 October 2015 and 31 March 2017 and compared these with 186 controls. Cases were significantly more likely to be admitted to manage seizures in the year preceding pregnancy (42/94 cases vs 10/186 controls, adjusted odds ratio [aOR]=7.38 [95% CI 2.70-20.2]), and to report their most recent seizure within 3 months of pregnancy (51/94 cases vs 18/186 controls, aOR=5.86 [95% CI 2.30-15.0]). Cases were significantly more likely to deliver before 37 weeks (20/94 cases vs 8/186 controls, aOR=7.61 [95% CI 2.87-20.2]). Conclusions Women admitted for seizure management in the year before pregnancy are at higher risk of severe epilepsy during pregnancy and of preterm birth. These women should be prioritised for discussion about pregnancy and contraception. When pregnant, they should be reviewed as early as possible by specialists in the management of epilepsy during pregnancy. Delivering messages about the importance of pregnancy planning and contraception to all women with epilepsy should be viewed as the responsibility of all clinicians involved their care.

Re-exploration following caesarean birth: a prospective national case-control study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system.

Re-exploration following caesarean birth and the associated maternal morbidity has not been investigated in the UK. Our aims were to determine the national incidence and identify the associated risk factors. We conducted a prospective observational case-control study across 194 UK consultant-led maternity units in women whose caesarean birth was complicated by a re-exploration. Independent factors for re-exploration were analysed using multivariable multi-level mixed effects logistic regression. Over the study period (1 June 2021 and 31 May 2022) 238,423 caesarean births were recorded across the UK of which 187 women underwent re-exploration, giving an incidence of one re-exploration per 1282 caesarean births (95%CI 1:1099-1:1471). Haemorrhage (124/187, 66.3%) and sepsis (31/187, 16.6%) were the most common findings at re-exploration. Median (IQR [range]) time interval to re-exploration following the caesarean birth was 1 (0-4 [0-28]) day. Mechanical ventilation was required in 34 (18.6%) women, cardiac arrest was reported in 5 (2.7%) and 3 (1.6%) women died. Independent preceding factors associated with a re-exploration included: receipt of blood transfusion (adjusted OR (95%CI) 8.25 (2.66-25.61)); use of a general anaesthetic (adjusted OR (95%CI) 3.33 (1.61-6.88)); pre-eclampsia (adjusted OR (95%CI) 3.27 (1.55-6.91)); black ethnicity (adjusted OR (95%CI) 3.14 (1.39-7.11)); postpartum haemorrhage (adjusted OR (95%CI) 2.82 (1.81-4.37)); use of anticoagulants or antiplatelet drugs pre-caesarean birth (adjusted OR (95%CI) 2.26 (1.35-3.81)); and emergency caesarean birth (adjusted OR (95%CI) 1.89 (1.01-3.57)). Re-exploration following caesarean birth in the UK is uncommon but is associated with significant maternal morbidity and mortality. These study findings will help guide informed consent and encourage appropriate surveillance of high-risk women postpartum.

The UK Breast Cancer in Pregnancy (UKBCiP) Study. Incidence, diagnosis, management and short-term outcomes of breast cancer first diagnosed during pregnancy in the United Kingdom: A population-based descriptive study.

The incidence of breast cancer first arising during pregnancy has been estimated in several countries to be 2.4-7.8/100,000 births, but has not been established in the United Kingdom (UK). We aimed to estimate the incidence of breast cancer diagnosed during pregnancy in the UK and to describe its management and short-term outcomes for mothers and babies. This population-based descriptive study used the UK Obstetric Surveillance System (UKOSS). Cases were prospectively identified through monthly UKOSS mailings to all UK consultant-led maternity units. All cases of breast cancer diagnosed first during pregnancy, between October 1, 2015, and September 30, 2017, were eligible, with 84 confirmed cases analyzed. Women with breast cancer diagnosed before pregnancy or with a recurrence were excluded. The primary outcomes were the incidence of breast cancer first diagnosed during pregnancy, maternal mortality, severe maternal morbidity, perinatal mortality, and severe neonatal morbidity. The incidence was 5.4/100,000 maternities (95% CI 4.37, 6.70). Nine women (11%) had undergone in vitro fertilization (IVF), compared with an estimated 2.6% IVF pregnancies in the UK at that time. During pregnancy, 30 women (36%) underwent surgery and 37 women (44%) received chemotherapy. Three women had major maternal morbidity during pregnancy. Two women died and two perinatal deaths occurred. The incidence of breast cancer arising in pregnancy in the UK is similar to that reported in other countries. The higher proportion of IVF pregnancies among women diagnosed with breast cancer during pregnancy needs further investigation, as it may not be entirely explained by relatively advanced maternal age. With caveats, the management followed that outside pregnancy, but there was considerable variation in practice. Although short-term outcomes were generally good for mothers and babies, a larger prospective study is required. It is often possible to avoid exposing the baby to iatrogenic prematurity.

Management and outcomes of women with low fibrinogen concentration during pregnancy or immediately postpartum: A UK national population-based cohort study.

Pregnant women with a fibrinogen level <2 g/L represent a high-risk group that is associated with severe postpartum hemorrhage and other complications. Women who would qualify for fibrinogen therapy are not yet identified. A population-based cross-sectional study was conducted using the UK Obstetric Surveillance System between November 2017 and October 2018 in any UK hospital with a consultant-led maternity unit. Any woman pregnant or immediately postpartum with a fibrinogen <2 g/L was included. Our aims were to determine the incidence of fibrinogen <2 g/L in pregnancy, and to describe its causes, management and outcomes. Over the study period 124 women with fibrinogen <2 g/L were identified (1.7 per 10 000 maternities; 95% confidence interval 1.4-2.0 per 10 000 maternities). Less than 5% of cases of low fibrinogen were due to preexisting inherited dysfibrinogenemia or hypofibrinogenemia. Sixty percent of cases were due to postpartum hemorrhage caused by placental abruption, atony, or trauma. Amniotic fluid embolism and placental causes other than abruption (previa, accreta, retention) were associated with the highest estimated blood loss (median 4400 mL) and lowest levels of fibrinogen. Mortality was high with two maternal deaths due to massive postpartum hemorrhage, 27 stillbirths, and two neonatal deaths. Fibrinogen <2 g/L often, but not exclusively, affected women with postpartum hemorrhage due to placental abruption, atony, or trauma. Other more rare and catastrophic obstetrical events such as amniotic fluid embolism and placenta accreta also led to low levels of fibrinogen. Maternal and perinatal mortality was extremely high in our cohort.

WILL (When to Induce Labour to Limit risk in pregnancy hypertension): a multicentre randomised controlled trial — adaptations to deliver a timing-of-birth trial during the COVID-19 international pandemic

BackgroundAs a pragmatic randomised timing-of-birth trial, WILL adapted its trial procedures in response to the COVID-19 pandemic. These are reviewed here to inform post-pandemic trial methodology.MethodsThe trial (internal pilot) paused in March 2020, re-opened in July 2020, and is currently recruiting in 37 UK NHS consultant-led maternity units. We evaluated pandemic adaptations made to WILL processes and surveyed sites for their views of these changes (20 sites, videoconference).ResultsDespite 88% of sites favouring an electronic investigator site file (ISF), information technology requirements and clinical trial unit (CTU) operating procedures mandated the ongoing use of paper ISFs; site start-up delays resulted from restricted access to the CTU. Site initiation visits (SIVs) were conducted remotely; 50% of sites preferred remote SIVs and 44% felt that it was trial-dependent, while few preferred SIVs in-person as standard procedure. The Central team felt remote SIVs provided scheduling and attendance flexibility (for sites and trial staff), the option of recording discussions for missing or future staff, improved efficiency by having multiple sites attend, and time and cost savings; the negative impact on rapport-building and interaction was partially mitigated over time with more familiarity with technology and new ways-of-working. Two methods of remote consent were developed and used by 30/37 sites and for 54/156 recruits. Most (86%) sites using remote consenting felt it improved recruitment. For remote data monitoring (5 sites), advantages were primarily for the monitor (e.g. flexibility, no time constraints, reduced cost), and disadvantages primarily for the sites (e.g. document and access preparation, attendance at a follow-up meeting), but 81% of sites desired having the option of remote monitoring post-pandemic.ConclusionsCOVID adaptations to WILL trial processes improved the flexibility of trial delivery, for Central and site staff, and participants. Flexibility to use these strategies should be retained post-pandemic.Trial registrationISRCTN77258279. Registered on 05 December 2018.

Pregnancy outcomes following different types of bariatric surgery: A national cohort study

ObjectiveTo assess the impact of type of bariatric surgery on pregnancy outcomes. Study designThis is a national prospective observational study using the UK Obstetric Surveillance System (UKOSS). Data collection was undertaken in 200 consultant-led NHS maternity units between November 2011 and October 2012 (gastric banding), and April 2014 and March 2016 (gastric bypass and sleeve gastrectomy). Participants were pregnant women following gastric banding (n = 127), gastric bypass (n = 134) and sleeve gastrectomy (n = 29).Maternal and perinatal outcomes were compared using generalised linear and linear mixed models. Maternal outcomes included gestational weight gain, pre-eclampsia, gestational diabetes, anaemia, surgical complications. Perinatal outcomes included birthweight, small/large for gestational age (SGA/LGA), preterm birth, stillbirth. ResultsMaternal: Women pregnant after gastric banding and sleeve gastrectomy had a lower risk of anaemia compared with gastric bypass (banding (16 %) vs bypass (39 %): p = 0.002, sleeve (21 %) vs bypass: p = 0.04). Gestational diabetes risk was lower after gastric banding compared with gastric bypass (7 % vs 16 %, p = 0.03) despite women with banding having significantly greater weight at booking as well as gestational weight gain. Women pregnant after gastric banding and sleeve gastrectomy had a lower risk of surgical complications than after gastric bypass (banding (0.9 %) vs bypass (11.4 %): p = 0.03, sleeve (0.0 %) vs bypass: p = 0.06).Perinatal: Infants born to mothers after gastric banding had a higher birthweight than those born to mothers after gastric bypass (mean difference = 260 g (125–395), p < 0.001). Infants were more likely to be LGA if their mothers had gastric banding compared with gastric bypass or sleeve gastrectomy (banding (21 %) vs bypass (5 %): p = 0.006; banding vs sleeve (3 %): p = 0.03). Risk of preterm birth was higher in women with gastric banding compared with gastric bypass (13 % vs 8 %, p = 0.04). ConclusionsWomen planning bariatric surgery should be counselled regarding the differing impacts of different types of procedure on any future pregnancy. Pre-existing gastric bypass is associated with higher rates of potentially serious surgical complications during pregnancy.

The outcome of pregnancy in women with cystic fibrosis: a UK population-based descriptive study.

To estimate the incidence of cystic fibrosis in pregnancy and to explore obstetric and neonatal outcomes. A population-based descriptive study using the methodology of the UK Obstetric Surveillance System (UKOSS). All consultant-led maternity units in the UK. All pregnant women with a diagnosis of cystic fibrosis who booked for antenatal care in a UK obstetric unit between March 2015 and February 2017. Prospective case collection identified using UKOSS monthly notification. Incidence, maternal morbidity, maternal mortality, gestation at delivery, neonatal mortality, neonatal morbidity. We report 71 pregnancies over a 2-year period. There was one early miscarriage, four terminations and three sets of twins, resulting in the live birth of 69 infants. There were no maternal deaths. One infant died following spontaneous preterm birth at 29weeks' gestation. The mean gestation at delivery was 36.2 completed weeks. The mean birthweight centile for gestational age was the 61st centile. We report a positive correlation between both maternal lung function (FEV1 ) and mean gestation at delivery, and between FEV1 and mean birthweight centile for gestational age. Pregnancy outcomes are generally good in women with cystic fibrosis. Successful pregnancy is possible even in those women with FEV1 <60% predicted, although such women have higher chance of preterm delivery and a smaller baby. Pregnant women with cystic fibrosis who have poorer lung function at the beginning of pregnancy have a higher risk of having a premature or smaller baby.

An evaluation of the potential to improve perinatal outcomes by improving antenatal detection of small for gestational age babies in Scotland: a retrospective population cohort study

Background: Small for gestational age (SGA) babies are at high risk of perinatal mortality. We aimed to determine the potential to reduce perinatal mortality by improving antenatal detection of SGA babies in Scotland. Methods: We conducted a retrospective population study of all singleton SGA babies born in the 15 Consultant-led maternity units in Scotland in a 3-month period (1st Dec 2014 to 28th Feb 2015 inclusive). Demographic and pregnancy outcome data were extracted from Scottish birth records for all pregnancies; case note review was performed for all SGA cases [defined as birthweight less than the 10th centile for their gestational age at delivery as defined by the appropriate sex-specific UK-WHO Child Growth Standards]. Results: The SGA rate in Scotland was 5.5% (673/12218; 95% confidence interval [CI] 5.1, 5.9) and 27.6% (186/673; 95% CI 24.3, 31.2) of SGA cases were identified prior to delivery. SGA was associated with 18.2% (12/66; 95% CI [10.1%, 30.0%) of all perinatal deaths. The majority (10/12, 83.3%) of SGA babies who died had been identified as SGA in the antenatal period. There was no difference in perinatal mortality whether SGA was detected or not (5.4% [10/186; 95% CI 2.8, 10.0] in the SGA detected group vs 0.4% [2/487 [95% CI 0.3, 2.2] in the non-detected group after adjusting for risk factors for SGA, gestation at delivery and birthweight centile (Adjusted odds ratio [AOR] 0.85 [95% CI 0.5, 1.5], p=0.556). Conclusions: Despite only around a quarter of SGA babies being identified antenatally, the potential to reduce perinatal mortality in the Scottish population by improving SGA detection is limited. Only a minority of perinatal deaths occurred in SGA babies; and in the majority of these SGA was detected antenatally.

Design errors in vital sign charts used in consultant-led maternity units in the United Kingdom

BackgroundPaper-based charts remain the principal means of documenting the vital signs of hospitalised pregnant and postnatal women. However, poor chart design may contribute to both incorrect charting of data and clinical responses. We decided to identify design faults that might have an adverse clinical impact. MethodsOne hundred and twenty obstetric early warning charts and escalation protocols from consultant-led maternity units in the United Kingdom and the Channel Islands were analysed using an objective and systematic approach. We identified design errors that might impede their successful use (e.g. generate confusion regarding vital sign documentation, hamper the recognition of maternal deterioration, cause a failure of the early warning system or of any clinical response). ResultsWe found 30% (n=36/120) of charts contained at least one design error with the potential to confuse staff, render the charts difficult to use or compromise patient safety. Amongst the most common areas were inadequate patient identification, poor use of colour, illogical weighting, poor alignment and labelling of axes, and the opportunity for staff to ‘game’ the escalation. ConclusionsWe recommend the urgent development of an evidence-based, standardised obstetric observation chart, which integrates ‘human factors’ and user experience. It should have a clear layout and style, appropriate colour scheme, correct language and labelling, and the ability for vital signs to be documented accurately and quickly. It should incorporate a suitable early warning score to guide clinical management.

Study protocol: quantitative fibronectin to help decision-making in women with symptoms of preterm labour (QUIDS) part 2, UK Prospective Cohort Study

IntroductionThe aim of the QUIDS study is to develop a decision support tool for the management of women with symptoms and signs of preterm labour, based on a validated prognostic...

Paving the way for improved management of severe immune thrombocytopenia purpura in pregnancy.

Those of us who take care of women with blood disorders have few data on which to base our management of thrombocytopenia in pregnancy, particularly immune thrombocytopenia purpura (ITP). We extrapolate from the management of ITP in non-pregnant individuals and try to raise platelet counts in an attempt to meet the bleeding challenges of childbirth. Thirty years ago we believed that ITP conferred fetal risks similar to those conferred by alloimmune thrombocytopenia. Experience and small series have taught us otherwise, but fetal let alone maternal risks have not been well quantified. Care et al. have provided us with data from the largest series of ITP patients in pregnancy to date. Using the UK Obstetric Surveillance System (UKOSS), which has been developed to study rare disorders in pregnancy, the investigators identified pregnant women with severe ITP from 1 June 2013 through to 31 January 2015. Rather than researching the diagnosis, the investigators adopted a practical definition of severe ITP, which included: (1) thrombocytopenia with a nadir platelet count of <50 × 109 l−1 after obstetric and hereditary causes had been excluded; or (2) thrombocytopenia that was treated. All 202 UK hospitals with consultant-led maternity units were queried monthly. The investigators reported on the incidence of severe ITP in pregnancy, current management, and the maternal and fetal outcomes of pregnancy. They estimated that the incidence of severe ITP in pregnancy is 1 in 10 000 pregnancies. They found that outcomes for neonates were better than expected, with no cases of intracranial haemorrhage or death. They found that there were no cases of epidural, caesarean section wound, or perineal haematoma following delivery. They also found that severe ITP in pregnancy carries a high risk of severe postpartum haemorrhage. Although this was an observational as opposed to a randomised study, the treated and untreated groups were comparable, with no difference in the lowest platelet count prior to pregnancy. Treatment [with steroids, intravenous immunoglobulin (IVIG), or both] appeared to make no difference in either maternal or fetal outcomes. These findings are surprising. Perhaps we should not be surprised that fetal outcomes were good because, in theory, maternal autoantibodies should not significantly impact fetal platelets. More surprising, however, is that the rate of postpartum haemorrhage was five times higher than estimates from the literature, and that treatment of severe ITP in pregnancy, which is targeted at raising platelet counts to achieve a ‘safe’ threshold in pregnancy or to achieve a target platelet count for delivery, appears to be ineffective in protecting women with severe ITP from postpartum haemorrhage. By providing us with evidence for this rare disorder, the investigators have paved the way for improving the management of severe ITP in pregnancy. They have shown us that existing treatments, which may improve platelet counts, may not improve platelet function, and do not appear to reduce the high risk of postpartum haemorrhage. Randomised trials in rare disorders are often not feasible, but it is time to consider alternative treatments and alternative study designs to capture the results of such treatments. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Vital Signs and Other Observations Used to Detect Deterioration in Pregnant Women

Abstract Background Obstetric early warning systems are recommended for monitoring hospitalised pregnant and postnatal women. We decided to compare: (i) vital sign values used to define physiological normality; (ii) symptoms and signs used to escalate care; (iii) type of chart used; and (iv) presence of explicit instructions for escalating care. Methods One-hundred-and-twenty obstetric early warning charts and escalation protocols were obtained from consultant-led maternity units in the UK and Channel Islands. These data were extracted: values used to determine normality for each maternal vital sign; chart colour-coding; instructions following early warning system triggering; other criteria used as triggers. Results There was considerable variation in the charts, warning systems and escalation protocols. Of 120 charts, 89.2% used colour; 69.2% used colour-coded escalation systems. Forty-one (34.2%) systems required the calculation of weighted scores. Seventy-five discrete combinations of ‘normal' vital sign ranges were found, the most common being: heart rate=50–99beats/min; respiratory rate=11–20breaths/min; blood pressure, systolic=100–149mmHg, diastolic ≤89mmHg; SpO 2 =95–100%; temperature=36.0–37.9°C; and Alert-Voice-Pain-Unresponsive assessment=Alert. Most charts (90.8%) provided instructions about who to contact following triggering, but only 41.7% gave instructions about subsequent observation frequency. Conclusion The wide range of ‘normal' vital sign values in different systems suggests a lack of equity in the processes for detecting deterioration and escalating care in hospitalised pregnant and postnatal women. Agreement regarding ‘normal' vital sign ranges is urgently required and would assist the development of a standardised obstetric early warning system and chart.

Vital signs and other observations used to detect deterioration in pregnant women: an analysis of vital sign charts in consultant-led UK maternity units

BackgroundObstetric early warning systems are recommended for monitoring hospitalised pregnant and postnatal women. We decided to compare: (i) vital sign values used to define physiological normality; (ii) symptoms and signs used to escalate care; (iii) type of chart used; and (iv) presence of explicit instructions for escalating care. MethodsOne-hundred-and-twenty obstetric early warning charts and escalation protocols were obtained from consultant-led maternity units in the UK and Channel Islands. These data were extracted: values used to determine normality for each maternal vital sign; chart colour-coding; instructions following early warning system triggering; other criteria used as triggers. ResultsThere was considerable variation in the charts, warning systems and escalation protocols. Of 120 charts, 89.2% used colour; 69.2% used colour-coded escalation systems. Forty-one (34.2%) systems required the calculation of weighted scores. Seventy-five discrete combinations of ‘normal’ vital sign ranges were found, the most common being: heart rate=50–99beats/min; respiratory rate=11–20breaths/min; blood pressure, systolic=100–149mmHg, diastolic ≤89mmHg; SpO2=95–100%; temperature=36.0–37.9°C; and Alert-Voice-Pain-Unresponsive assessment=Alert. Most charts (90.8%) provided instructions about who to contact following triggering, but only 41.7% gave instructions about subsequent observation frequency. ConclusionThe wide range of ‘normal’ vital sign values in different systems suggests a lack of equity in the processes for detecting deterioration and escalating care in hospitalised pregnant and postnatal women. Agreement regarding ‘normal’ vital sign ranges is urgently required and would assist the development of a standardised obstetric early warning system and chart.

Pregnancy outcomes in women with mechanical prosthetic heart valves: a prospective descriptive population based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system.

To describe the incidence of mechanical prosthetic heart valves (MPHV) in pregnancy in the UK; rates of maternal and fetal complications in this group of women, and whether these vary with the anticoagulation used during pregnancy. Prospective descriptive population-based study. All consultant-led maternity units in the UK. All women with an MPHV who were pregnant between 1 February 2013 and 31 January 2015. Collection and analysis of anonymous data relating to pregnancy management and outcome, using the UKOSS notification and data collection system. Maternal death, serious maternal morbidity, poor fetal outcome. Data were obtained for 58 women giving an estimated incidence of 3.7 (95% CI 2.7-4.7) per 100 000 maternities. There were five maternal deaths (9%); a further 24 (41%) suffered serious maternal morbidity. There was a poor fetal outcome from 26 (47%) pregnancies. Only 16 (28%) women had a good maternal and good fetal outcome. Low-molecular-weight heparin (LMWH) was used throughout pregnancy by 71% of women. Of these, 83% required rapid dose escalation in the first trimester. Monitoring regimens lacked consistency. This study has estimated the incidence of MPHV in pregnant women in the UK. It includes the largest cohort managed with LMWH throughout pregnancy reported to date. It demonstrates a high rate of maternal death, and serious maternal and fetal morbidity. Women with MPHVs, and their clinicians need to appreciate the significant maternal and fetal risks involved in pregnancy. Care should be concentrated in specialist centres. High rates of poor maternal and fetal outcomes in pregnant women with mechanical prosthetic heart valves.

Placental Growth Factor (PlGF) in Women with Suspected Pre-Eclampsia Prior to 35 Weeks' Gestation: A Budget Impact Analysis.

ObjectiveTo model the resource implications of placental growth factor (PlGF) testing in women with suspected pre-eclampsia prior to 35 weeks’ gestation as part of a management algorithm, compared with current practice.MethodsData on resource use from 132 women with suspected pre-eclampsia prior to 35 weeks’ gestation, enrolled in a prospective observational cohort study evaluating PlGF measurement within antenatal assessment units within two UK consultant-led maternity units was extracted by case note review. A decision analytic model was developed using these data to establish the budget impact of managing women with suspected pre-eclampsia for two weeks from the date of PlGF testing, using a clinical management algorithm and reference cost tariffs. The main outcome measures of resource use (numbers of outpatient appointments, ultrasound investigations and hospital admissions) were correlated to final diagnosis and used to calculate comparative management regimes.ResultsThe mean cost saving associated with the PlGF test (in the PlGF plus management arm) was £35,087 (95% CI -£33,181 to -£36,992) per 1,000 women. This equated to a saving of £582 (95% CI -552 to -£613) per woman tested. In 94% of iterations, PlGF testing was associated with cost saving compared to current practice.ConclusionsThis analysis suggests PlGF used as part of a clinical management algorithm in women presenting with suspected pre-eclampsia prior to 35 weeks’ gestation could provide cost savings by reducing unnecessary resource use. Introduction of PlGF testing could be used to direct appropriate resource allocation and overall would be cost saving.

The epidemiology and outcomes of women with postpartum haemorrhage requiring massive transfusion with eight or more units of red cells: a national cross-sectional study.

To ascertain the incidence of massive transfusion (MT) in obstetrics in the UK, and describe its management and clinical outcomes. A population-based cross-sectional study conducted through the UK Obstetric Surveillance System (UKOSS). All UK hospitals with consultant-led maternity units. Any pregnant woman at ≥20 weeks of gestation receiving ≥8 units of red blood cells within 24 hours of giving birth, from July 2012 to June 2013. Prospective case identification through the monthly mailing of UKOSS. We identified 181 women who had undergone MT, making the estimated incidence of MT associated with postpartum haemorrhage (PPH) 23 per 100 000 maternities (95% confidence interval 19-26) per year. The median estimated blood loss was 6 l (interquartile range 4.5-8.0 l). The majority of women presented outside working hours (63%), 40% had had previous caesarean sections and 3% had normal vaginal births without risk factors. The main cause for MT was uterine atony (40%) and the main mode of birth was caesarean section (69%). Of the 181 women, 15 received >20 units of red blood cells. In total, 45% of women underwent hysterectomy, and among all causes of PPH, placenta accreta had the highest hysterectomy rate. Two women died, 82% were admitted to intensive care/high-dependency units, and 28% developed major morbidities. Massive transfusion due to PPH is associated with high rates of morbidity and hysterectomy. Clinical and research efforts should focus on approaches to recognise and optimise timely resuscitation and management of these severe cases. Massive transfusion due to postpartum haemorrhage is associated with high rates of morbidity and hysterectomy.

Pregnancy Outcomes in Patients with Myeloproliferative Neoplasms in the United Kingdom

IntroductionPhiladelphia negative myeloproliferative neoplasms (MPNs) are associated with an increased incidence of haemorrhagic and thromboembolic complications as well as progression to myelofibrosis and acute myeloid leukaemia. MPNs have a peak incidence in 6th and 7th decade of life. However, they can occur in younger age groups and women of child bearing age.Pregnant women with MPN are at an increased risk of maternal thrombosis and haemorrhage and also of impaired uterine blood flow, placental dysfunction, fetal growth restriction, pre-term delivery and fetal loss. There are no prospective studies of pregnancy outcome in the literature.MethodA national prospective cohort was established to describe the maternal and fetal outcomes of pregnancy in women with MPN in the United Kingdom (UK). Data were collected using the UK Obstetric Surveillance System (UKOSS) between January 2010 and December 2012 (UKOSS methodology described by Knight et al, 2005). UK hospitals with a consultant led maternity unit identified pregnant woman with a MPN and provided detailed data on antenatal, maternal and fetal outcomes. Pregnancy outcome data were compared with that reported by the UK Office of National Statistics (ONS) in 2011.Results58 women were identified: 47 with Essential Thrombocythaemia (81%), 5 with Polycythaemia Vera (8.6%), 5 with Myelofibrosis (8.6%) and 1 with JAK2 positive MPN unspecified (1.7%). The incidence of MPN in pregnancy was 6.4/100,000 maternities.The median age was 33 years (range 16-42), compared to average national age during 2011 of 29.7 years. There were 58 live births (56 singleton, 2 twin), one miscarriage and one stillbirth (at 37 weeks) with a miscarriage rate of 1.8% and the perinatal mortality rate of 17/1000 live and stillbirths. The national rates reported by ONS in 2011 were 6.4 miscarriages/100 pregnancies and of 5.2 stillbirths/1000 live and stillbirths. The incidence of pre-eclampsia was 8.8% (n=5/57), compared to 3.4% as reported by Ananth et al 2013. The majority 78.9% (n = 45/57) of women laboured; 42.1% (n = 24/57) underwent induction and spontaneous vaginal delivery occurred in 39% (n = 22/57) of women. Caesarean section (CS) was performed in 42.1% (n = 24/57). Most of the caesareans were performed pre-labour, with an elective CS rate of 24.6% (n = 14/57), and emergency CS rate of 17.5% (n = 10/57). The UK average CS rate in 2011 was 24.8%.Most (86%; 49/57) women delivered at term (>37 weeks). The incidence of preterm (< 37 weeks) and very preterm (<32 weeks) birth was 7.0% (n = 4/59) and 3.5% (n =2/59) respectively; ONS 2011 UK averages were 10.7% and 5.3% respectively. The median birth weight was 3150g (range 720 - 4700g); 13.6% (n = 8/59) of neonates had a low birth weight (<2500g) and 5.1% (n=3) had a very low birth weight (<1500g). 5% of births in 2011 were documented to be below 2500g according to ONS.There was considerable variation amongst clinicians in the management of MPNs. Only 50% (n = 29/58) of women were in receipt of aspirin therapy prior to the index pregnancy. This increased during pregnancy with over 88% (n = 51/58) prescribed aspirin; 38% (n = 22/58) were on both aspirin and low molecular weight heparin. Cytoreductive therapy was used in 43% (n=25/58) of the women prior to index pregnancy (including hydroxyurea (HU), anagrelide (ANA) and interferon). During the index pregnancy, 7 women continued cytoreductive therapy, switching to interferon when prior HU or ANA were used. One woman with ET was initiated on interferon.ConclusionThis first prospective analysis of maternal and fetal outcomes in women showed an incidence of MPN in pregnancy of 6.4/100,000 maternities which is consistent with previous reports. The increased occurrence of pre-eclampsia and fetal growth restriction might explain the higher rates of induction and caesarean section. The majority (87%) of babies were delivered at term.Although this was a small sample, it was reassuring there were no maternal deaths or admissions to intensive care, and only one perinatal death, as previous retrospective data has reported worse outcomes. The clinician variability in the approach to the management of women with MPNs in pregnancy suggests further improvements may be possible. DisclosuresHarrison:Shire: Speakers Bureau; Novartis: Honoraria, Research Funding, Speakers Bureau; Sanofi: Honoraria, Speakers Bureau; Gilead: Honoraria; CTI Biopharma: Consultancy, Honoraria, Speakers Bureau.

Selected maternal morbidities in women with a prior caesarean delivery planning vaginal birth or elective repeat caesarean section: a retrospective cohort analysis using data from the UK Obstetric Surveillance System

ObjectiveTo conduct a secondary analysis of data from the UK Obstetric Surveillance System (UKOSS) to estimate the rates of specific maternal risks associated with planned vaginal birth after caesarean (VBAC)...

Incident reviews in UK maternity units: a systematic appraisal of the quality of local guidelines.

BackgroundMaternity care is recognised as a particularly high-risk speciality that is subject to investigation and inquiry, and improvements in risk management have been recommended. However, the quality of guidelines for local reviews of maternity incidents is unknown. The aim of the study is to appraise the quality of local guidance on conducting reviews of severe maternity incidents in the National Health Service.MethodsGuidelines for incident reviews were requested from all 211 consultant-led maternity units in the UK during 2012. The Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) was used to evaluate the quality of guidelines. The methods used for reviewing an incident, the people involved in the review and the methods for disseminating the outcomes of the reviews were also examined.ResultsGuidelines covering 148 (70%) of all NHS maternity units in the UK were received for evaluation. Most guidelines (55%) received were of good or high quality. The median score on ‘scope and purpose’ (86%), concerned with the aims and target population of the guideline, was higher than for other domains. Median scores were: ‘stakeholder involvement’ (representation of users’ views) 56%, ‘rigour of development’ (process used to develop guideline) 34%, ‘clarity of presentation’ 78%, ‘applicability’ (organisational and cost implications of applying guideline) 56% and ‘editorial independence’ 0%. Most guidelines (81%) recommended a range of health professionals review serious maternity incidents using root cause analysis. Findings were most often disseminated at meetings, in reports and in newsletters. Many guidelines (69%) stated lessons learnt from incidents would be audited.ConclusionsOverall, local guidance for the review of maternity incidents was mostly of good or high quality. Stakeholder participation in guideline development could be widened, and editorial independence more clearly stated. It was unclear in over a quarter of guidelines whether changes in practice in response to review recommendations were audited or monitored; such auditing should be mandatory. Further research is required to examine the translation of guidance into practice by evaluating the quality of local reviews of maternity incidents.

Conditions triggering local incident reviews in UK hospital maternity units: A national survey.

ObjectivesIn countries, such as the UK, where maternal deaths are rare, reviews of other severe complications of pregnancy and the puerperium can provide an additional perspective to help learn lessons to improve future care. The objective of this survey was to identify the types of incidents which triggered local reviews in the UK, in order to inform national safety reporting guidance.DesignA national descriptive survey.SettingUK.ParticipantsConsultant-led maternity units.Main outcome measureSeventy-one per cent of maternity units provided an incident review trigger list. The conditions included were classified by two assessors. Incidents that were listed by at least 5% of maternity units were reported and compared with incidents recommended for review by the Royal College of Obstetricians and Gynaecologists (RCOG).ResultsThe conditions covered were highly variable, although those recommended by the RCOG were most highly represented. The most commonly listed conditions that had not been recommended for review by the RCOG included inadequate staffing levels (70%), cardiac arrest (69%) and maternal sepsis (64%).ConclusionsSubstantial variation exists in the types of incident listed for review by maternity units in the UK. Importantly, some units are not reviewing cases of severe infective complications even though this is a current major concern. Future guidance concerning local serious incident review processes should include how the list of conditions triggering a review should be managed in the light of changing clinical and safety priorities.