The process….

1. Improving quality and safety in maternity services: Can we improve the prevention, detection and management of congenital abnormalities?

2. The process…. • We identified the perinatal deaths in 2010 that were the result of congenital cardiovascular, central nervous system or chromosomal abnormalities. • We collected the lead maternity carer (LMC), general practitioner (GP) and hospital notes for each of the women. • Using an audit tool we went through the notes and collected information on the care the women received. • We reviewed sets of images for ultrasounds the women had between 10 weeks and the abnormality being detected.

3. The findings…. • There were 137 perinatal deaths included in the audit. • 73 were classified as chromosomal abnormalities (53%). • 35 were classified as central nervous system (26%). • 29 were classified as cardiovascular system abnormalities (21%).

4. Findings: early pregnancy • First contact with a health professional occurred within 10 weeks in 74% of cases and within 14 weeks in 85% of cases. • Only 66% of women booked before 14 weeks. • Folic acid supplements were recorded as taken by 7% of women prior to pregnancy and by 54% of women during the antenatal period.

6. Findings: delay in the pregnancy pathway • Median number of days between 1st trimester screening and referral = 2 days. • Median number of days between 2nd trimester screening and referral = 9 days. • Median number of days between anatomy scan and referral = 0 days. • Median number of days between referral and appointment with an obstetrician = 1 day. • Median number of days between referral and appointment with maternal fetal medicine = 6 days.

7. Findings: Ultrasound • 82 women were included in the ultrasound audit, we requested 131 sets of ultrasound images. • 25 scans for 17 women were not available as the images had not been retained by the ultrasound provider. • There were 5 cases where the expert reviewer was able to identify the abnormality earlier. • There was also a case of anencephaly that would likely have been detectable earlier (at a 12 week scan) but the images had not been kept by the ultrasound provider.

8. Summary.... 6 sets of LMC notes had not been retained by the LMC. 20 potentially avoidable neural tube defect abnormalities where the mother had not taken pre-conceptual folate. Ninety seven women (75%) were offered screening. 15 women declined screening.

9. Summary • There were 5 abnormalities that could have been detected earlier based on the ultrasound images. • 4 babies were discharged from hospital before the abnormality was detected. • There was a longer than expected interval to review by MFM specialist.

10. Recommendations…… • Pre-conceptual counselling for all women. • Raise awareness around pre-conceptual folate. • Promote booking <10 weeks. • GPs and LMCs need to be proficient in offering first trimester screening and interpreting results. • GPs need to facilitate expeditious booking with an LMC. • LMCs should offer screening to all women who have not already had screening.

11. Recommendations…… • Review potential for screening for more congenital abnormalities. • All LMCs should document pre-conceptual and antenatal folate use. • LMCs must retain a copy of the woman’s notes. • Radiology services should retain a copy of ultrasound images and audit their images.

12. Recommendations…… • Provision of real time images to MFM services for review. • The National MFM network should audit the time from referral to review in their service to ensure that the majority of women are seen within the recommended week. • Enhance the current birth defects register to include congenital abnormalities where a perinatal death occurred.