Pregnancy Screening Pathway Dr Surindra Maharaj Consultant Obstetrician NHS Lanarkshire 16 June...
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Transcript of Pregnancy Screening Pathway Dr Surindra Maharaj Consultant Obstetrician NHS Lanarkshire 16 June...
Pregnancy Screening Pathway
Dr Surindra Maharaj
Consultant Obstetrician
NHS Lanarkshire
16 June 2009
Antenatal Screening for Sickle Cell & Thalassaemia Pathway
• Screening for Clinically Significant SCD– Hb S; Hb SC; HbS/β-thal; Hb SD;
Hb SO; Hb S/HPFH
• Screening for Other Haemoglobinopathies– Β-thal major/intermedia; Hb H;
Hb E/β thal; Hb SE
Other
• Clinically benign Haemoglobinopathies– HB C/β thal; Hb D/β thal; Hb DD; Hb CC;
Hb CE; Hb DE; Hb EE– Several other variants will also be detected
• There are >1,000 types/ Hb variants or mutations– Can be inherited in various combinations
• Correct counselling is extremely important
Why are we Screening Now?
• CEL 31– The introduction of haemoglobinopathy
screening both during pregnancy and for newborn babies
– NHS Boards will be responsible for implementing the changes in maternity and child health services required to deliver these improvements no later than 31 March 2011
Who to screen?
• Universal Screening vs
• Selected Screening
• For Antenatal purposes, Scotland is considered as having a low prevalence for SCD (<1.5 /10,00 births with SCD)
• A targeted screening programme, based on the Family Origin Questionnaire is proposed
•Trigger Recognition
•Conveying this Informationto laboratory
•SWMHR Redesign
•Use of IT/PMS to aidthese concerns
• Rule/Logic based DataEntry
• Easy Lab access to information
Means a change in how ethnicity data is
collected and coded
When to screen
• Antenatally
• Before pregnancy– Pre-pregnancy counselling clinics– Assisted conception clinics
• If screened before pregnancy, the results must be recorded and accessible for any subsequent pregnancy
Antenatal Pathway
Pregnancy ConfirmedCheck previous testing
FBC Previous result available
MCHFamily Origin Questionnaire
Determine inclusion/exclusion criteria
UnaffectedMother
Carrier
Affected Mother
INCLUDEDEXCLUDED
Record in SWHMR
Included
Information GivenMaternal Test
Offered
Unaffected Mother
Record in SWHMRMaternal Low Risk
Letter
Carrier MotherContact her to
offer Paternal testing
Affected Mother
Urgent apptConsultant/Team CareOffer Paternal testing
Aim to perform screening by 8-10
weeksDeclines
Record in SWHMR
Accepts Consented
TEAM: Obstetrician, Haematologist, Hb Counsellor, Midwife, Paediatrician
Patient InformationLeaflet
http://sct.screening.nhs.uk/
Paternal Testing
Mother declinesFather declines or unavailable
Offer Counselling visit with Team Specialist to discuss risk
Declines
Record in notesInform Obstetric teamInform Paediatric team
Accepts
Paternal test takenFamily Origin recorded
Consent for result release
note: the father himself may have previous results available
Unaffected Father
Record in SWHMRResult to father/GP
Carrier FatherContact them to
offer further Counselling
Affected FatherUrgent apptCounselling
Inform GP/Paeds
Paternal Test Accepted
Consultant Haematologist
Counselling and Risk Discussion
Declines
Record in NotesObs/PaedNotification
Accepts
Offer Prenatal DiagnosisIf appropriate
Record in NotesObs/PaedNotification
Declines
Accepts
Prenatal DiagnosisClinical Genetics
Aim to achieve thisby 12+6 Weeks
Results of Prenatal Diagnosis
Results of Prenatal Diagnosis
Unaffected Fetus
Record in SWHMRResult to parents/GP
Carrier Fetus
Affected Fetus
Counselling VisitOptions discussed
Termination
Termination Arranged
Neonatal Screen
Paediatric notification
Continuing
Record Screening Status on Birth
Notification
Potential problem areas?
• We need earlier information dissemination and earlier booking– The majority of women book between 11-14– Major workforce implications
• The issue of late bookers
• We need for rapid testing, rapid reporting and rapid patient feedback– Small diagnostic and therapeutic window
Potential problem areas?• We need timely partner testing
• We need timely reporting of PND– Glasgow and Oxford
• Increased workload for midwives
• Earlier bookings may mean more patients– Seeing women who would have miscarried
had booking been later
• KCND issues
• Interpretation services
The Challenge for Antenatal Services
• Staff Training and Awareness– Midwives– Obstetricians– Paediatricians– Haematologists
• Identifying a Specialist Care Team• Assess the need/role for a Specialist
Haemoglobinopathy Counsellor• The role of the screening coordinators
http://sct.screening.nhs.uk/
The Challenge for Antenatal Services
• Reorganisation of antenatal services– Earlier booking required– Community awareness programmes– First contact
• Pharmacies/Chemists• Midwives: Can the First Visit be abolished?• Telephone assessments• Royal Mail/IT/PMS/Remote Case Note Generation• GPs and GP receptionists• Information campaign
The Challenge for Antenatal Services
• Reorganisation of antenatal services– Local laboratories and transport
• Fast turnover and reporting is the goal• Report standardisation• Quality control and certification• Obtaining previous screening results
– Central laboratories and communication• Glasgow • Oxford
– Laboratory IT Links essential
The Challenge for Antenatal Services
• Reorganisation of antenatal services– Who receives and gives the results to patients– The roles of:
• Midwife• Hb Screening coordinator/practitioner• “Counsellor”
– Timely referral to all of these HCPs– Expansion of clinical services
• Clinics-antenatal and neonatal• PND/Genetics/Clerical support