Audit of the multiple pregnancy antenatal pathway at a London teaching hospital
Introduction
The prevalence of multiple pregnancies has been increasing in the last 20 years(1,2). Complications such as post-partum haemorrhage, preterm birth, growth restriction, stillbirth, and neonatal death are higher compared to singleton pregnancies(1,2). Due to this, increased monitoring and contact with healthcare professionals are needed(3). The aim of this audit is to review current practice and adherence to local and NICE standards for the antenatal and intrapartum care of women with multiple pregnancies.
Methods
Demographic data, pregnancy related factors, adherence to local antenatal pathways for multiple pregnancies and outcome data were collected from women with both dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twin pregnancies. Data was accessed through electronic patient records and hand-held antenatal maternity notes and descriptive analysis of the data were undertaken.
Auditable Standards
•A total of 60 multiple pregnancies were reviewed, with 49 DCDA pregnancies and 11 MCDA pregnancies.
•Dating scans: 93.9% (N=46) of DCDA and 90.9% (N=10) MCDA pregnancies had a dating scan at 11+2 – 14+1 gestation, with 98% chronicity determined for DCDA and 100% for MCDA.
•Chromosomal abnormality screening: Of those who haveaccepted screening (83.7 %, 81.8% MCDA), only 4.0% had additional risks.
•Anemia management: 87.8% (N=43) of DCDA pregnancies had haemoglobin (Hb) concentrations checked at booking and at 20-24 weeks, with 18.6% and 9.3% of these respectively being anemic. 54.5% (N=6) and 72.7% (N=8) of MCDA pregnancies had Hb checked at booking and 20-24 weeks respectively, with 33.3% and 37.5% of these being anemic.
•Pre-eclampsia prophylaxis: 79.6%(N=39) of DCDA pregnancies met the criteria for Aspirin. Of these 94.9%(N=37) were documented to be taking Aspirin while 46.2% (N=18) were prescribed online. 61.1% (N=11) were prescribed at 12-16 weeks and 38.9% (N=7) at >16 weeks gestation.
•45.5% (N=5) of MCDA pregnancies met the criteria for aspirin. Of these, 100%were documented to be taking Aspirin, with 40% (n=2) prescribed online. 50% were prescribed at 12-16 weeks and 50% prescribed >16 weeks.
Pregnancy Outcomes
•93.9% (N=46) and 90.9% (N=10) of DCDA and MCDA pregnancies resulted in livebirths.
•Gestation at birth: 41% (N=19) DCDA and 30% (N=3) and MCDA pregnancies delivered at term, respectively.
•Neonatal outcomes: APGAR scores at term indicated healthy newborns with majority needing ward-based care only (74% DCDA, 33% MCDA).
Summary of Main Recommendations
•Twin pregnancies are at a higher risk of anaemia as found in this audit. Routine anaemia screening and management should be improved.
•To meet the required NICE standards, a specialist multidisciplinary team is needed.
•Consider patient leaflet for patient groups for aspirin use.
•Further work includes collecting patient and staff (MW) feedback on the antenatal pathway.
Refereneces:
3.Ratha C, Kaul A. An Analysis of Pregnancy Outcome in Dichorionic and Monochorionic Twins Given Special Antenatal and Intranatal Care: A Four-Year Survey. J Obstet Gynaecol India. 2014 Aug;64(4):255–9.
