Very large country (8 th ) 6.5 M/y in 2011 36 States > 50% rural > 70% poor Gov’t health...

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Career development in Fetal Medicine Lut Geerts Tygerberg Fetal Medicine Unit

Transcript of Very large country (8 th ) 6.5 M/y in 2011 36 States > 50% rural > 70% poor Gov’t health...

Career development in Fetal Medicine

Lut GeertsTygerberg Fetal Medicine Unit

Nigerian context

Very large country (8th)

6.5 M/y in 2011

Nigerian context

36 States > 50% rural > 70% poor Gov’t health spending

Nigerian context

Very high maternal mortality rate

5.8% CS rate53% Skilled birth attendant66% ANC (58% regular)

Significance of congenital anomalies

10%

FA significance - Nigeria

FA significance - Nigeria

Birth Trauma

GE LBW DM Congenital anomalies

Road traffic accidents

CAD CA

24

101.5

23.6

55.4

7.5

21.5

121.6

93.4

Causes of deaths (all ages)

Death rate /100.000

FA - Significance of PND

More important: folate, iodine intake, rubella vaccination, reducing consanguinity, effective family planning

FA Prevalence - Nigeria

14th highest: 73.5/1000 LB> 450.000/y!

Fetal Medicine - Nigeria

Not only mortality Long term morbidity

Not only fetal anomalies! Twins FGR Fetal disease (anaemia, infection)…

Dr Zipporah Kpamor

Career development in Fetal MedicineA personal journey….

South Africa 1990

No obstetric US service outside the metro

Haphazard routine US service in metro Limited to academic centres Provided by medical practitioners Little connection to obstetric priorities

The scene at the time

RCTs (Sweden, Norway, Finland, UK, USA) no benefit on overall outcome

The scene at the time

Immediate effect - STOP routine scanning- Staff reduction

High risk for fetal anomaly: 20 w FA scan (AMA, teratogens, FH,..)

Low risk women: Selective scanning policy(specific indications only)

Concern – are the RCT data applicable to us? Less restrictive “selective” indications Lower risk populations

The challenge

Finding the place of US in the local setting

RCT: 500 Routine, 500 Selective (low risk)› 100% scanned vs 25% scanned› Dating algorithm for uncertain LMP› Management algorithm for suspected

postdates

First RCT – Results (1996)

No reduction in antenatal visits or admissions or further selective scans

Less undiagnosed twins (+ earlier) Less postdates (9 vs 38), Less PD IOL (1 vs

14)

RCT – Results (1996)

No improvement in adverse outcomes› TPRW OR 0.68 (0.26-1.71)› PNM (9 vs 13) OR 0.70 (0.19-2.47)

More LBW (102 vs 68) OR1.61 (1.13-2.30)

Inconvenient for patients (travel) EXPENSIVE!! (₤ 69 pp vs ₤ 54 for all

care)

The next step - Research

Design a cost–efficient service Maximising benefit Cheap:

› Sonography students (Training started 1994)› Portable machine › Basic scan only› In the community› FREE

Cost-analysis (salary, equipment, consumables, transport…)

The next step – Cohort study

1998, two comparable MOUs N=3009 (718 baseline) – 1 scanning day per week

1 MOU: Routine (basic) US (up to 24w)

1 MOU: Selective US (same indications as before)

Cheap (< 2$ per MOU patient)› No reduced AN visits› No reduced PNM, adverse outcomes› Less undiagnosed twins (earlier)

Cohort study - Results

› Less referrals for “fetal evaluation” (15.9% vs 29.6%, p<0.000)

› More “term” deliveries: RR 0.84 (0.77-0.91)

(79.9 vs 72.5%) - same for spt labours- Less suspected PTL (12.0 vs 16.7%)- Less suspected PD (8.1 vs 10.2%)

› Keeps more women in MOU!› Completely funded by sale of pictures

Cohort study - Dating

Inaccuracy of “certain LMP”› 28.4% > 3w LMP (29.8% FH)

Dating (2013)

10

20

30

40

50

60

70

80

90

100

≤ 3 days

≤ 7 days

≤ 10 days

≤ 14 daysLMP FH Clinical US

0

2

4

6

8

10

12

14

US <20w 20-24w 24-30w >30w

Absolute error

SD

Pret

erm

Post

term LG

A0

5

10

15

20

25 Not scannedScanned

Dating – Outcomes

Scanned < 24w

Not scanned <24w

02468

10121416

SGA

From Research to Service

Expanded to cover all MOUs Formal post for chief sonographer

› Approx. 5000 scans per year (Anatomy)› Authority to refer directly to level III› Education - Feedback to nursing staff

Roaming sonographer in 2 rural regions › Visit frequency dependent on clinic load› Previously un-serviced area› Drastic increase in referrals to level III

Lessons learnt

10% need referral from MOU Increasing level III referrals

Lessons learnt

Routine work is not for subspecialists Service open to abuse! 2012 – Provincial Policy -

Implementation Drive towards cost reduction Adapt to changing scene – Research

Need to adapt

Urban migration – need for rationalisation

Epidemic of obesity(FH dating)

HIV epidemic(Invasive procedures)

< 25 ≥ 30 ≥ 35 ≥ 400

20

40

60

80

% > 3 weeks overestimation according to BMI

29%

15%

67%

50%

Cost reduction

AMA (37+) vs scan-based risk (1: 200) (retrospective 2003-2005, 136 aneuploidies)

› Sensitivity: - T21 44% 93%- All aneuploidies 44% 94%

› Yield (all abnl) 1:43 1:13

Reduce AMA-procedures by 66% Doubled number of prenatal diagnoses No increase in invasive testing

Career development in Fetal Medicine

The hard part….

…Creating the basis

Widespread (but contained) access to high quality screening› Within the community› Cheap

Maximise on general obstetric benefits Fetal Medicine as a bonus

Fetal Medicine 2013

Total obstetric US 8722 Level III 5302

› Fetal anomaly visits 1982› Severe FGR 949› Iso-immunization 138› Complicated twins 711› Genetic screening HR 1460

Diagnostic procedures 325 (1/10+)

Career development in Fetal Medicine

The easier part….

Fetal Medicine Training

Three legs› Theoretical knowledge› Practical skills› EXPOSURE to PATHOLOGY

1. Theory

Curriculum: RCOG, CMSA.. ADAPTED

1. Theory

Practice guidelines e.g. ISUOG, RCOG, AIUM…

1. Theory

Standard text books (some free, online)› www.openultrasound.com› www.fetalmedicine.com

Journal clubs Targeted literature search

› PubMed› UpToDate› OMIM› Cochrane library..

1. Theory

Congresses, Scientific meetings

1. Theory

Online visual material

1. Theory

Online lectures, webcasts, slides

1. Theory

Online courses

2. Practical Training

You must put in the hours! Practice guidelines Stepwise targets

› Basic› Fetal anatomy survey T2› Soft markers T2› Doppler› Cervix› T1 survey› T1 NT + other markers

2. Practical Training

Keep images for review Assessment and Structured feedback

› ? Telemedicine› ? Simulation models› Online accreditation

e.g. FMF: quality review and ongoing certification

3. Exposure to Pathology

Screening service to create the need Support from laboratory services Academic input from other disciplines

(genetics, cardio, neuro,..) – local context

Need for ongoing audit and feedback› Genetics, Autopsy, Follow up

3. Exposure to Pathology

Visit to international centres› Observer› Fellowship› Formal subspecialty training

Personal Career development

in Fetal Medicine

Development of RELEVANT Fetal Medicine services

Need for ongoing research on priorities in local setting

Future … greatest impact

Thank you…