Obstetrical team of the « Mother-Child » College Members: L.Decatte J.M. Foidart C. Hubinont C. Kirkpatrick D. Leleux M. Temmerman F. Van Assche J. Van Wiemeersch We are just starting!

Rationale for a proposal: «The way that perinatal services are organised and delivered have a substantial impact on important clinical outcomes such as mortality or disability rates. Preterm infants who are cared for in the largest intensive care units, where staff can develop and maintain their skills have better outcomes than infants cared for in smaller, less busy units.» BMJ (2004); 329 :

Rationale for a proposal (2): «Infants who are admitted when neonatal intensive care units are getting busier have a significantly greater risk of dying.» BMJ (2004); 329 :

Risk of death for infants in neonatal units according to occupancy of unit on admission BMJ (2004); 329 :

In Belgium, the criteria used for intra-uterine transfer to MICs and for maternal retransfer to peripheral maternity are not standardised. The delineation of national guidelines aims at optimizing the antenatal care and the foeto- maternal prognosis at a justifiable cost. The cost/benefit ratios (about clinical and financial efficacy) of the MICs were not assessed.

1. Registration and evaluation of maternal morbidity and pregnancy outcome in women with a high risk pregnancy and/or intra-uterine transfer in a Maternal Intensive Care (MIC) Unit 2. Accurate global perinatal epidemiology PROPOSALS

1. Pregnancy maternal and perinatal outcomes 2. Criteria for intra-uterine transfer 3. Criteria for retransfer to peripheral maternities Reasons (1): Since the creation of the MICs and NICs in August 1996, no evaluation has been achieved in Belgium of their impact on:

4. Maternal morbidity and mortality associated with high risk pregnancies cared for in Belgian MICs 5. The costs involved in such strategies Reasons (2): Since the creation of the MICs and NICs in August 1996, no evaluation has been achieved in Belgium on their impact on:

Therefore, the obstetrical branch of the « mother-child » college suggests to evaluate: 1. The clinical activity of the MICs 2. The impact on maternal pregnancy outcome (morbidity and mortality), of intra-uterine transfer in a MIC

Therefore, the obstetrical branch of the « mother-child » College suggests: 3. To evaluate, in collaboration with the team of neonatology of this College, the impact of maternal treatment in a MIC upon perinatal morbidity and mortality 4. To correlate the perinatal outcomes with the type of maternal pathology and treatment

Therefore, the obstetrical branch of the « mother-child » College suggests to evaluate: 5. The cost/benefit ratio of maternal intra-uterine transfer. We will document the cost of therapeutic intervention versus beneficial impact on maternal and perinatal outcome

Criteria for Evaluation (1) Maternal indications for maternal transfer - Uncomplicated preterm labour - Coexisting diseases - Perinatal emergency transfer - Spontaneous rupture of membranes - Antepartal haemorrhage - Infection risk (chorioamnionitis, pyelonephritis,…)

Criteria for Evaluation (2) Maternal indications for maternal transfer - Diabetes - Hypertensive diseases of pregnancy (Preeclampsia, HELLP syndrome, eclampsia…) - Cholestasis

- Drug usage - Other medical (hyperthyroidism, epilepsy, pulmonary dysfunction, deep venous thrombophlebitis or pulmonary embolism, other cardiovascular complications,...) - Other obstetric (twin-to-twin transfusion syndrome, intra-uterine growth retardation, cholestasis of pregnancy,…) Criteria for Evaluation (3) Maternal indications for maternal transfer

- Antenatal steroids - Tocolytics (beta-mimetics, calcium channel blockers, Atosiban, others) - Antibiotics - Others Treatment before, during and after intra-uterine transfer

- Type of stay (duration) - Retransfer to a peripheral hospital - Duration of stay in the MIC before retransfer to a peripheral hospital - Delivery during stay - Medical assistance during stay Stay

- Cervical length (cervical echography ?) - Cervical dilatation - Cervical consistency - Type of presentation (cephalic, breech,others) Pelvic inspection before intra-uterine transfer

- Gestational age at transfer - Gestational age at delivery Gestational age

- Single - Twins - Triplets - Quadruplets - Parity - Gestation - Maternal age Pregnancy

- Vaginal – spontaneous - Vaginal – instrumental (forceps or vacuum) - Caesarean section planned - Caesarean section after onset of labour - Indications: maternal, fetal Mode of delivery

- Less than one hour or one hour - One hour to less than 2 days (time necessary for steroids efficacy) - 2 days up to one week - Over one week Time to delivery interval

- Intensive care unit admission (requiring ventilation, CPAP or over 60% oxygen, CVP lines, intra-arterial line, invasive blood pressure monitoring, anti-hypertensive infusion, renal replacement therapy,…) - Others Postpartum complications

- Postpartum haemorrhage requiring transfusion - Hypertension requiring treatment - High dependency care (frequent BP monitoring, pulse oximetry, oxygen, special midwife input) Postpartum complications

- Stillborn - Neonatal death - Admission to neonatal intensive care unit - Apgar score - Neonatologist criteria (to be implemented in collaboration with the neonatologist team of this College) Perinatal outcome

Epidemiology - Establishment of accurate perinatal and obstetrical epidemilogy with on line registration of classical obstetrical and perinatal criteria allowing adequate evaluation - Contacts taken with and approval by the VVOG, GGOLFB and SPE

Conclusions The obstetrical team of the Mother-Child College is just starting its activities in close coordination with the Neonatologist team It has a strong commitment The delineation of an optimal therapeutic strategy must be based on scientific hard epidemiological data to be collected,…at a certain price. This requires appropriate funding