Audit of emergency obstetric referrals from a secondary level hospital in Haryana, North India

Referral Audit of Critically Ill Obstetric Patients: A Five-year Review from a Tertiary Care Health Facility in India

Background

In resource-limited facilities, the greatest number of unfavorable maternal-fetal outcomes at referral hospitals is chronicled from emergency obstetric referrals of critically ill patients from lower health facilities. An efficient obstetric referral system is thus necessitated for improving maternal health. Referral practices have not been optimized effectively till date, owing to paucity of a detailed profile of referred women and indigenous barriers encountered during implementation process.

Materials and methods

This five-year retrospective audit was conducted in the Department of Obstetrics and Gynecology, VMMC and Safdarjung Hospital, New Delhi from September 2018 to 2023, in which records of all critically ill obstetric women referred were reviewed. The primary outcomes included were proportion and pattern of patients being referred, while secondary outcomes included demographic variables, referring hospital, reason and number of steps in referral, duration of hospital stay and fetomaternal outcome. The data were recorded on a predesigned case proforma and analyzed using the SPSSv23 version of software, after application of appropriate statistical tests.

Results

The referral rate to obstetric intensive care unit (ICU) ranged from 39 to 47% in last 5 years; hypertensive disorder of pregnancy (31%) being the foremost cause of the referrals. Around 2/3rd women were transferred without escort (70%) or prior communication (90.6%) and referral slips were incomplete in half the admissions.

Conclusion

Ensuring emergency obstetric care (EmOC) at various levels by up-gradation of health infrastructure would go a long way in improving fetomaternal health outcomes. There is need of standardized referral slips tailor-made to each state and contextualized protocols for early recognition of complications and effective communication between referral centers.

How to cite this article

Marwah S, Suri J, Shikha T, Sharma P, Bharti R, Mann M, et al. Referral Audit of Critically Ill Obstetric Patients: A Five-year Review from a Tertiary Care Health Facility in India. Indian J Crit Care Med 2024;28(8):734-740.

Course and outcomes of pregnancy in women treated for acromegaly: Discerning a contemporary cohort

OBJECTIVE

To analyze pregnancy course and outcomes in women treated for acromegaly and compare outcomes based on disease activity at the time of conception.

DESIGN

Retrospective study.

PATIENTS

Women with acromegaly diagnosed prior to or during pregnancy from 2010 to 2019, representing cases (14 pregnancies in 12 cases), were later stratified based on active (n = 5) or controlled disease (n = 9) at time of conception. Female acromegalic patients over the same period constituted the 'acromegaly cohort' (AC) (n = 75).

RESULTS

All cases had macroadenomas with nadir GH of 15.06 ng/ml (IQR 9-30), IGF-I index of 3.04 (1.96-3.82), for which they had undergone pituitary surgery; except two patients diagnosed during pregnancy, who received pharmacotherapy followed by surgery 4 months postpartum. Adjuvant pharmacotherapy was required in 71.4% patients and radiotherapy in 35.7%. Pregnancy occurred at a median of 2 (0.8-5.1) years after surgery and 21.4% required assisted reproduction. All had term delivery with normal APGAR except one case with gestational hypertension, who delivered a preterm baby. None had congenital malformations. Despite higher baseline IGF-I, GH and tumor volume in those with pre-conceptional active acromegaly, materno-fetal outcomes were not different from those with controlled disease (p > 0.05). Similar or greater proportion of cases had normal GH and no residual tumor postpartum, even in those with pre-conceptional active acromegaly.

CONCLUSION

The current study showed conducive outcomes of gestation in women treated for acromegaly and no higher rates of pregnancy parameters or complications than non-acromegaly pregnancies in the same population. Active acromegaly does not seem to have an adverse bearing on outcomes.

Improving quality of care for pregnancy, perinatal and newborn care at district and sub-district public health facilities in three districts of Haryana, India: An Implementation study

Introduction

Improving quality of care (QoC) for childbirth and sick newborns is critical for maternal and neonatal mortality reduction. Information on the process and impact of quality improvement at district and sub-district hospitals in India is limited. This implementation research was prioritized by the Haryana State (India) to improve the QoC for maternal and newborn care at the busy hospitals in districts.

Methods

This study at nine district and sub-district referral hospitals in three districts (Faridabad, Rewari and Jhajjar) during April 2017-March 2019 adopted pre-post, quasi-experimental study design and plan-do-study-act quality improvement method. During the six quarterly plan-do-study-act cycles, the facility and district quality improvement teams led the gap identification, solution planning and implementation with external facilitation. The external facilitators monitored and collected data on indicators related to maternal and newborn service availability, patient satisfaction, case record quality, provider’s knowledge and skills during the cycles. These indicators were compared between baseline (pre-intervention) and endline (post-intervention) cycles for documenting impact.

Results

The interventions closed 50% of gaps identified, increased the number of deliveries (1562 to 1631 monthly), improved care of pregnant women in labour with hypertension (1.2% to 3.9%, p<0.01) and essential newborn care services at birth (achieved ≥90% at most facilities). Antenatal identification of high-risk pregnancies increased from 4.1% to 8.8% (p<0.01). Hand hygiene practices improved from 35.7% to 58.7% (p<0.01). The case record completeness improved from 66% to 87% (p<0.01). The time spent in antenatal clinics declined by 19–42 minutes (p<0.01). The pooled patient satisfaction scores improved from 82.5% to 95.5% (p<0.01). Key challenges included manpower shortage, staff transfers, leadership change and limited orientation for QoC.

Conclusion

This multipronged quality improvement strategy improved the maternal and newborn services, case documentation and patient satisfaction at district and sub-district hospitals. The processes and lessons learned shall be useful for replicating and scaling up.

What necessitates obstetric transfers? Experience from a secondary care hospital in India

Background:

India attributes to about 15% of the maternal mortality globally. Many a time poor maternal and neonatal outcomes occur unanticipated during intrapartum and postpartum period. An efficient referral system identifies the indications necessitating prompt referrals besides ensuring patient friendliness and continuity of care.

Methodology:

The descriptive, retrospective study was done in a secondary care hospital of a teaching institution in South India, run by primary care physicians, obstetricians and pediatricians. It describes the referrals from labour room in a year, identifying the referral rate, indications, maternal and neonatal outcomes.

Results:

The referral rate was found to be 3 per cent. The most common indication for the referrals was hypertensive disorders of pregnancy (54.5 percent). Among the women referred, there were no maternal deaths and majority had uncomplicated postpartum period. Eleven women developed postpartum hemorrhage. Neonatal outcome reflected a good trend as 83 per cent had an uneventful hospital stay. There were eight early neonatal deaths.

Conclusion:

The hospital could reduce the referral load to its tertiary care due to adequate training of primary care post graduates in basic obstetrics and anaesthesia skills, establishing standardized referral protocol and monitoring with regular clinical audits. Patient experience could be improved with inter referral unit communication and linking the health information system.