audit of antenatal referrals to the anaesthetist

1. Audit of Antenatal Referrals to the Anaesthetist Dr E A Chubb SpR Anaesthetics Dr G E W Roberts Consultant Anaesthetist October 2008

3. OAA /AAGBI Guidelines for Obstetric Anaesthetic Services (2005) Section 4 : Services and Standards � Guidelines should be available to obstetricians and midwives on conditions requiring antenatal referral to the anaesthetist. A system should be in place to ensure that such women are seen and assessed by a senior anaesthetist within a suitable time frame, preferably in early pregnancy�

4. OAA /AAGBI Guidelines for Obstetric Anaesthetic Services (2005) Section 9 : List of recommended protocols 1) Conditions requiring antenatal referral to the anaesthetist

5. NWW Trust guideline for Antenatal Referrals to the Anaesthetist � March 2007 Difficult airway CVS disease RS disease Musculoskeletal CNS disease Haematological Endocrine Renal disease Hepatic disease Immune Transplant patients Obstetric problems Previous anaesthetic problems Medical conditions of note

6. Method Retrospective review of case notes Cross reference to Trust guidelines Does the patient have co-morbidity requiring anaesthetic referral?

7. Method Retrospective review of case notes Cross reference to Trust guidelines Does the patient have co-morbidity requiring anaesthetic referral? Was patient referred antenatally?

8. Method Retrospective review of case notes Cross reference to Trust guidelines Does the patient have co-morbidity requiring anaesthetic referral? Was patient referred antenatally? Was anaesthetic intervention needed?

9. Method Retrospective review of case notes Cross reference to Trust guidelines Does the patient have co-morbidity requiring anaesthetic referral? Was patient referred antenatally? Was anaesthetic intervention needed? Any anaesthetic complications?

10. Results

11. Cases requiring referral Jehovah�s Witness Poorly controlled epilepsy Antiphospholipid Syndrome Spina Bifida

12. Cases antenatally referred Jehovah�s Witness Poorly controlled epilepsy Antiphospholipid Syndrome Spina Bifida

13. Cases requiring anaesthetic intervention Jehovah�s Witness Poorly controlled epilepsy Antiphospholipid Syndrome Spina Bifida

14. Results 1 anaesthetic intervention (epidural) No adverse incidents/outcomes

15. Jehovah�s Witness Issues of blood transfusion Advance Directives ? Cell salvage ? Blood �fractions� e.g albumin ? Epidural blood patch Clinicians right to refuse elective treatment

16. Poorly controlled Epilepsy 24 yr old primip Brittle control since diagnosis Daily absences , Tonic-clonic seizures at least once a month Medications : Epilim Chrono 1000mg bd Ethosuxamide 750mg bd Under review at the Walton Hospital (last in 12/2006)

17. Poorly controlled Epilepsy Increased risk of : Pre-eclampsia Antepartum haemorrhage IUGR Caesarean section Seizures triggered by pain,anxiety,excitement Increased frequency in 45% Lowered seizure threshold (EFL)

18. Antiphospholipid Syndrome Thrombosis Increased risk of miscarriage pre-eclampsia placental abruption IUGR Mother - stroke , MI , valvular lesions (AR) Treatment involves aspirin , heparin

19. Spina Bifida NTD ~ 1 in 1000 Spina bifida cystica vs. Spina bifida occulta

20. Spina Bifida NTD ~ 1 in 1000 Spina bifida cystica vs. Spina bifida occulta Spina bifida occulta <20% incidence � failure of fusion of 1 arch no external lesion cord normal

21. Spina Bifida NTD ~ 1 in 1000 Spina bifida cystica vs. Spina bifida occulta Spina bifida occulta <20% incidence � failure of fusion of 1 arch no external lesion cord normal Problem: SBO vs. occult spinal dysraphism

22. Spina Bifida Issues: Increase in problematic blocks Dural puncture Direct trauma to low lying cord If patient has : neurological abnormalities cutaneous manifestation ? tethered > 1 lamina involved cord

24. Under the Radar Gitelman�s syndrome Primary renal tubular hypokalaemic metabolic acidosis K2+ Mg2+ Ca2+ Generalised weakness and muscle cramps

26. The Maths slide 4 out of 144 = 3% needing referral 25% referred 2000 deliveries / year = 60 cases Based on this audit = 45 cases of special interest not referred a year

27. Is This A Problem? Small numbers No action in the one referred Epidural sited in one case once referred in labour No critical incidents �First do no harm�

28. Reasons for lack of referral New guideline Clear lines of referral? Do Obstetricians know it exists? ANC Community clinics

29. Action on this Audit Review guideline Raise awareness of its existence copies to respective clinics Feedback from Obstetric colleagues High (anaesthetic) risk folder on LW Re-audit in 6 � 12 months Audit of cases actually referred

30. Cases Referred Aortic / pulmonary valve replacement Morbid obesity + asthma Extreme needle phobia Hemiglossectomy Exercise � induced anaphylaxis

31. And One That Wasn�t 01:40 � 2cm dilated , request for epidural

32. And One That Wasn�t 01:40 � 2cm dilated , request for epidural Tetralogy of Fallot � corrected aged 8 seen in ANC Cardiology opinion

33. Cardiology Opinion �As I mentioned in my previous letter, I don�t expect too much of a problem during delivery. She will obviously require antibiotic prophylaxis and also need high flow O2 during delivery�

34. Echocardiogram Normal LV + function Normal Aortic / Mitral valves Dilated RV Moderate PR / TR ? Pulmonary hypertension ( Echo 2004 � PAP of 35mmHg)

35. Summary Antenatal consultation achieves many goals Anaesthetic involvement in high risk cases desirable ( OAA / AAGBI) ( CEMD / CEMACH )

36. Summary Antenatal consultation achieves many goals Anaesthetic involvement in high risk cases desirable ( OAA / AAGBI) ( CEMD / CEMACH ) THANKYOU FOR YOUR ATTENTION

37. References Why Mothers Die 1997 � 1999 : CEMD 2001 Saving Mothers Lives 2003 � 2005 : CEMACH 2007 Guidelines for Obstetric Anaesthetic Services (revised edition):OAA/AAGBI 2005 Obstetric Anaesthesia and Uncommon Disorders :Gambling et al, 2008 Spina Bifida, tethered cord and regional anaesthesia : Ali , Anaesthesia 2005 Anaesthetic management of parturients with antiphospholipid syndrome; a review of 27 cases : CJ Ralph, IJOA October 1999 C-281 Guideline for Antenatal Referrals to the Anaesthetist: NWW NHS Trust 2007