Antenatal screening for hepatitis C: Universal or risk factor based?

BACKGROUND

There is no clear consensus on whether antenatal screening for hepatitis C (HCV) should be universal, or based on an assessment of risk factors.

AIM

To report the HCV status and risk factors for HCV amongst women delivering at a tertiary metropolitan hospital in order to better understand the implications of changing from universal to risk factor based HCV screening.

MATERIALS AND METHODS

An audit of practice was performed at Mater Mothers' Hospitals (Brisbane) using routinely collected data from 2007 to 2013 (n = 57,659). The demographic and clinical characteristics of HCV-positive women (n = 281) were compared with those with a negative result (n = 57,378), and compared for the presence or absence of risk factors for HCV.

RESULTS

From a cohort of 57,659 women, 281 (0.5%) women were HCV positive. HCV-positive women were more likely to have received blood products (10.0 vs 3.1%; P < 0.001), have a history of illicit drug use (72.2 vs 9.8%; P < 0.001), and have at least one risk factor for HCV infection (92 vs 17%; P < 0.001). Of the HCV-positive women, only seven of the 281 (2.5%) had no identifiable risk factor, whilst most (83%) HCV-negative women did not have any documented risk factor for HCV infection.

CONCLUSION

Most women testing positive for HCV antibodies have identifiable risk factors; however, a small number will not be detected if a risk factor based screening approach is adopted. The benefits of universal screening must be weighed against the potential cost savings of a risk factor based screening program.

Maternity Care Plans: A retrospective review of a process aiming to support women who decline standard care

BACKGROUND

All competent adults have the right to refuse medical treatment. When pregnant women do so, ethical and medico-legal concerns arise and women may face difficulties accessing care. Policies guiding the provision of maternity care in these circumstances are rare and unstudied. One tertiary hospital in Australia has a process for clinicians to plan non-standard maternity care via a Maternity Care Plan (MCP).

AIM

To review processes and outcomes associated with MCPs from the first three and a half years of the policy's implementation.

METHODS

Retrospective cohort study comprising chart audit, review of demographic data and clinical outcomes, and content analysis of MCPs.

FINDINGS

MCPs (n=52) were most commonly created when women declined recommended caesareans, preferring vaginal birth after two caesareans (VBAC2, n=23; 44.2%) or vaginal breech birth (n=7, 13.5%) or when women declined continuous intrapartum monitoring for vaginal birth after one caesarean (n=8, 15.4%). Intrapartum care deviated from MCPs in 50% of cases, due to new or worsening clinical indications or changed maternal preferences. Clinical outcomes were reassuring. Most VBAC2 or VBAC>2 (69%) and vaginal breech births (96.3%) were attempted without MCPs, but women with MCPs appeared more likely to birth vaginally (VBAC2 success rate 66.7% with MCP, 17.5% without; vaginal breech birth success rate, 50% with MCP, 32.5% without).

CONCLUSIONS

MCPs enabled clinicians to provide care outside of hospital policies but were utilised for a narrow range of situations, with significant variation in their application. Further research is needed to understand the experiences of women and clinicians.

Comparing fetal scalp lactate and umbilical cord arterial blood gas values

BACKGROUND

Fetal scalp lactate has been shown to be as effective as scalp pH in predicting fetal outcomes. However, there is limited clinical evidence to demonstrate a strong correlation with fetal acidaemia at birth.

AIMS

To compare the diagnostic accuracy of fetal scalp lactate and umbilical cord arterial blood gas values sampling, as it is used in clinical practice.

METHODS

A retrospective cohort study was performed on 661 term (≥37 weeks) births where a fetal scalp lactate sample was taken during labour. Cases were excluded where either the lactate was taken greater than 1 h prior to delivery, incomplete cord gas analyses were available, or a sentinel hypoxic event occurred prior to delivery. The final data set included 229 microvolume scalp lactate measurements which were compared with neonatal paired cord blood gas values taken at delivery.

RESULTS

A fetal scalp lactate measurement of ≥4.8 mmol/L had a positive predictive value (PPV) of 1% and a negative predictive value (NPV) of 100% in predicting umbilical artery pH ≤7.00, and a PPV of 5% and a NPV of 98% in predicting umbilical artery pH ≤7.10. The sensitivity and specificity for these values were 100%, 23% and 90%, 23%, respectively.

CONCLUSIONS

Fetal scalp lactate microsampling has a strong negative predictive value for fetal acidaemia at birth.

Why group & save? Blood transfusion at low-risk elective caesarean section

Women undergoing elective caesarean section (CS) routinely have a group and save ordered as part of their preoperative assessment, whereas women with expected vaginal birth do not. Our aim was therefore to determine the rate of blood transfusion at elective CS compared with vaginal birth in a large Australian maternity hospital. A retrospective cohort study was performed using routinely collected de-identified data of 35 477 women, over 4 years, who delivered at the Mater Mothers' Hospital, Brisbane, Australia. After excluding women with established risk factors for transfusion, the likelihood of blood transfusion following elective CS was significantly lower compared to vaginal birth (aOR 0.47 (0.29, 0.77)).