advances in evidence-based antenatal care david ellwood professor of obstetrics & gynaecology...
Post on 23-Dec-2015
215 Views
Preview:
TRANSCRIPT
Advances in evidence-based antenatal care
David EllwoodProfessor of Obstetrics & Gynaecology
Primary Care Network, UQCCR, 28th August 2013
Numbers of births
Primary Care Network, UQCCR, 28th August 2013
Maternal age in 2010 Median age of all mothers was 30 yrs 3.9% of mothers were <20 23.0% of mothers were over 35 4.1% were over 40 Significant increase in the proportion of
mothers >35 over last 20 years
Primary Care Network, UQCCR, 28th August 2013
Changes in first-time mothers
Primary Care Network, UQCCR, 28th August 2013
Primary Care Network, UQCCR, 28th August 2013
‘The most significant reproductive threat of modern times has to be the overweight & obesity epidemic’
Overweight & obesity Major risk factor which impacts on all types of
adverse outcome in pregnancy & birth No national data previously reported Only 5 jurisdictions were able to provide data on
BMI at booking for the 2010 collection» 49.9% had a booking BMI of >25» 22.4% were >30 (obese)» Approximately 4% have BMI >40 (ACT data)» 3 per 1000 have BMI >50 (AMOSS)
Primary Care Network, UQCCR, 28th August 2013
Smoking in pregnancy Data quality is variable but has
been improving over time All states & territories submitted
data in 2010 Overall rate was 13.5% (cf. 16.2%
in 2007)» Rates vary from 11.2% (NSW &
ACT) to 25.5% (TAS)» 36.7% of teenage mothers
admitted smoking in pregnancy (cf. 39% in 2007)
Primary Care Network, UQCCR, 28th August 2013
Key points about ANC Antenatal care is an intervention that is used for over
300,000 women each year in Australia There are a number of important elements
» screening for maternal and fetal health» education and access to information» emotional and psychological support
Antenatal care is delivered in many different settings and by as variety of health care professionals
It is expensive, and until recently, there were no national guidelines which are evidence-based
Primary Care Network, UQCCR, 28th August 2013
Cost estimates for ANC? 300,000 women per year in Australia 10 visits each ($50-70 each) Antenatal investigations ($200-300) Ultrasounds x 2 ($140-500) These estimates vary from $250M to 450M per
annum across Australia
Primary Care Network, UQCCR, 28th August 2013
Evidence-based Antenatal Care
Clinical Practice Guidelines
Antenatal care – module 1
Published in 2012 (Co-Chairs: Professors Caroline Homer & Jeremy Oats)
Primary Care Network, UQCCR, 28th August 2013
Grades of EvidenceGrade A: Body of evidence can be trusted to guide practice
Grade B: Body of evidence can be trusted to guide practice in most situations
Grade C: Body of evidence provides some support for recommendations but care should be taken in its application
Grade D: Body of evidence is weak and recommendation must be applied with caution
CBR: Recommendation formulated in the absence of quality evidence
PP: Area is beyond the scope of the systematic literature review and advice was developed by the EAC and/or the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care
Primary Care Network, UQCCR, 28th August 2013
Evidence-based antenatal investigations
First trimester (Maternal Health Screening)» Ultrasound (8 to 14 weeks) for those who are uncertain of
their conception date (B)» Asymptomatic bacteruria testing early in pregnancy (A)» Vitamin D screening to those with risk factors (CBR)» Give information about testing for chromosome abnormalities
Primary Care Network, UQCCR, 28th August 2013
Antenatal Investigations (2) Recommended infection screens
HIV testing at first antenatal visit (B) Hepatitis B testing (A) Hepatitis C only for those with identifiable risk factors (C) Syphilis testing at first antenatal visit (B) Rubella immunity (B) Chlamydia for women under 25 (C)
Primary Care Network, UQCCR, 28th August 2013
Nutritional supplements in pregnancy Folic Acid (500 micrograms per day) from 12 weeks
before until 12 weeks after conception (A) No benefit in taking Vitamins A, C or E supplements
and may cause harm (B) Iodine supplementation (150 micrograms per day) for
all pregnant women (CBR) No routine iron supplementation (B)
Primary Care Network, UQCCR, 28th August 2013
Two recent and controversial aspects Screening and/or testing for chromosomal
abnormalities Screening for gestational diabetes
(Both of these are significantly age-related….)
Primary Care Network, UQCCR, 28th August 2013
Screening for Chromosomal Abnormalities Combined 1st trimester screening (nuchal
translucency & PAPP-A/HCG) has been a successful program for 10-15 years
It is safe, effective, and acceptable to most women Advantages
» relatively inexpensive ($100-150)» high detection rate (93 to 95%)
Disadvantages» high screen positive rate (5%)» diagnostic test is invasive» hard to understand (adjusted risk)
Primary Care Network, UQCCR, 28th August 2013
Non-invasive fetal testing Fetal DNA from the maternal circulation can now be
used to diagnose fetal aneuploidy (although current approach is to confirm with CVS or amniocentesis)
Detection rates for T21, T18 and 13, and sex chromosome aneuploidy are > 99%
But is this an improvement on the current approach? How should it be judged?
» effectiveness» cost» acceptability
Primary Care Network, UQCCR, 28th August 2013
Options for screening/diagnosis of T21
1. Continue with current approach of NT/SS followed by CVS or amniocentesis
2. NT/SS followed by NIFT for those who are screen positive
3. NT/SS for low risk women and NIFT for high risk
(a) > 35 years (23%)
(b) > 40 years (4%)
4. NIFT for all women who want it
(and can afford to pay for it…)
Primary Care Network, UQCCR, 28th August 2013
Cost comparisons for different DS approaches
Primary Care Network, UQCCR, 28th August 2013
Model 1 Model 2 Model 3.A Model 3.B Model 4
No. of DS detected in 100,000 women (220)
205 203 214 214 218
Procedure-related losses 34 2 27 33 3
Low Cost
Total cost ($) 13,780,250 14,121,486 26,822,321 16,174,482 70,144,326
Cost per person ($) 139 141 268 162 701
Cost per DS detected ($) 67,221 69,564 125,338 75,582 321,763
High Cost
Total cost ($) 48,250,000 47,439,200 67,291,100 51,795,030 136,461,100
Cost per person ($) 482 478 673 518 1,364
Cost per DS detected ($) 235,826 235,537 314,458 242,033 625,968
Which way to choose? Using NIPT alone will maximise the diagnoses of DS, reduce the
overall procedure-related loss rate, but is extremely expensive Using NIPT as a ‘second screen’ reduces the numbers of
CVS/amniocenteses performed (and therefore the procedure –related losses) but does add time to the process
The most cost-effective approach is using NIPT only for those who are very high risk and are likely to need invasive testing regardless of the screening result
If NIPT could be accepted as the diagnostic test as well this would eliminate the need for CVS or amniocentesis
If the cost of NIPT reduced to about $150 per patient it would be cost-comparable, with the highest detection rate and virtually no procedure-related losses
Primary Care Network, UQCCR, 28th August 2013
Screening for Gestational Diabetes Current approach is 50g glucose load for all women,
with 75g GTT for screen +ve women (>7.8mmol/L) Recent recommendations from ADIPS are;
» 75g GTT for all & early testing (as soon as possible after conception) for high risk women
» No need for 3 day CH20 dietary loading
» Change criteria for diagnosis of GDM; Fasting BSL reduced to 5.0mmo;/L Add a 1 hour criterion (>10.0mmol/L) Increase the 2 hour cut-off to 8.5mmol/L
Primary Care Network, UQCCR, 28th August 2013
Problems with these changes This will lead to an increase in the number of cases of
GDM diagnosed, and therefore increased numbers who need to be managed by a multi-disciplinary team
Compliance is a problem with the current approach so it is likely that this will reduce further
Unknown fetal effects of treating more women with insulin from earlier in pregnancy
There has been no rigorous cost-benefit analysis to support this change
Primary Care Network, UQCCR, 28th August 2013
CONCLUSIONS Antenatal care now has a rigorous, evidence-based
guideline Unfortunately, much of the evidence for some of the
recommendations is quite poor Antenatal care is very expensive, and it is important
that cost-benefit analyses are done to inform best practice
Primary Care Network, UQCCR, 28th August 2013
top related