Soins maternels intensifs (Maternal Intensive Care) en Belgique - KCE

More documents

Recommendations

Info

16 Maternal Intensive Care in Belgium KCE Reports 94 The concepts referring to certain aspects of obstetrical intermediate care and intensive are used mixed, depending on the country-specific health care organisation. For example in some countries mechanical ventilation is a part of obstetrical high dependency care and in others it is only located within the intensive care unit. This report focuses on the ‘intermediate care’ concept, but the variety of meanings and the limited amount of intermediate care research, obliged to also study several forms of intensive care. Hence, an outline of the broad scope of levels of care for maternal morbidity was not found. As an answer to all the etymologic confusion, we will try to give a clear picture of all the concepts within the ‘peripartum continuum’. A. Peripartum Continuum As an answer to all the etymologic confusion, a clear picture of the concepts within the ‘peripartum continuum’ is given. Intensive observation of obstetrical patients (MIC) can be required by different situations and pathologies. These form a continuum of severity ranging from low-risk physiologic pregnancy 5 > morbidity 6 > severe morbidity 7 > near miss 8 > death 9 . The extremes of this continuum are reasonably easy to demarcate, but identifying the concepts in-between is less obvious. Clear thresholds at which a woman can be categorised as having a severe morbidity or as a near miss are difficult to define. The reason why a woman progresses from one category to another is even harder to demarcate 3 . The last 15 years several reports from centres all over the world described the characteristics and treatment of critically ill pregnant or puerperal women. Studies report significant variations in patient populations, definitions of major morbidity, ICU (Intensive Care Unit) admission criteria, utilisation rates, treatment and outcomes, hospital settings, nursing policies, and management protocols 5 . It is then not straightforward to compare the Belgian MIC-situation to the international obstetrical high-risk population and management. Most of the published international literature about pregnancy complications and (severe) maternal morbidity deals with intensive care for peripartal women. Systems of care applicable to the general (non-obstetrical) critical care have been extrapolated to pregnant patients 9, 10 . Models or detailed guidelines from any specialty organisation describing the plan of care of critically ill obstetric patients do not exist 5 . It results clearly from our systematic literature search that reliable evidence based definitions and guidelines for obstetrical intensive/intermediate care are lacking. B. Standard Care Van Zelm et al (1995) describe standard care as care that is no medium or intensive care and can be delivered by nurses/midwives with a basis nursing/midwifery degree. A midwife is trained and capable to care for women with a normal, physiological and lowrisk pregnancy and childbirth 10 . 5 Low-risk is understood as a pregnancy without any risk before and after pregnancy (Lodewyckx et al, 2004). 6 Morbidity: A diseased condition or state, the incidence of a disease or of all diseases in a population (University of Newcastle, 1997). 7 Severe acute maternal morbidity: “a very ill pregnant or recently delivered woman who would have died had it not been that luck en good care was on here side” (Say, L., Pattison, R.C. & Gülmezoglu, M.A., 2004) 8 Near miss: “acute organ system dysfunction which if not treated appropriately could result in death (Wagaarachchi, P.T. & Fernando, L., 2001) Near miss: “… a narrow category of morbidity encompassing potentially life-threatening episodes” (Geller et al., 2002) 10 A normal childbirth is according to the WHO (2003): “…spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition".
KCE Reports 94 Maternal Intensive Care in Belgium 17 Low-risk is understood as a pregnancy without any risk before and after pregnancy (see table). Collaboration with a specialist obstetrician is required when any of the risk factors is found 11 . The absence of the underneath risk factors during the perinatal period demarcate a woman as low-risk. In other words the risk factors in the underneath table give a limited indication of factors that require more than standard care. Table 1: List of risk factors that require additional care, not limitative (translation of list in KCE report 6A) General risk factors Age under 16 or above 40 years, BMI under 18 or above 35, suboptimal socio-economic conditions, risk-behaviour: smoking, alcohol and drug use, use of medication, risks at work, other risk factors of personal, family or genetic nature Clinical examination and history • Medical: cardio-vascular disorders, hypertension, thrombosis, lung embolism, kidney disorders, metabolic disorders, thromboembolic disorders, neurologic disorders, lung disorders, haematologic disorders, auto-immune disorders, malign disorders, serious infections, psychiatric disorders and any other pre-existing disorder that is relevant during pregnancy • Gynaecologic: disorders of the uterus anatomy, operations, deviant cytology, disorders of the pelvis, abnormalities of the pelvic diaphragm , IUD, history of mutilation/circumcision • Obstetric: complicated obstetric history, rhesus/iso immunisation, blood group antagonism, repeated miscarriage, cervix insufficiency, cerclage, pre-eclampsia, HELLP (Haemolysis Elevated Liver enzymes-Low Platelet count syndrome), prenatal blood loss, preterm birth, problematic growth of the foetus, Caesarean section, big multiparae, serious perinatal morbidity, difficult delivery, postpartum psychosis or –depression Risks current pregnancy • General: late entry prenatal care, psychiatric disorder, adoptive child • Medical: hyperemesis gravidarum, gestational diabetes, gestational hypertension, thrombo-embotic disorder, coagulation disorder, malign disorders, infectious disorders • Obstetric: amniocentesis, chorion villi sampling, multiple pregnancy, intra-uterine death, threatening preterm birth, cervix insufficiency, blood loss, abruptio placentae, loss of amniotic fluid, negative or positive discongruence, symphysiolysis, obstetric relevant uterus myomatosus, rhesus/iso immunisation, blood group antagonism, abnormal cervixcytology (HSIL), serotinity The ACOG (American College of Obstetrics and Gynaecology) guidelines of perinatal care (2002) mention three levels of in-hospital perinatal care. (cf. supra.): basic care (level I), specialty care (level II) and subspecialty care (level III). Basic care is more or less comparable with standard Belgian in-hospital obstetrical care; the two other levels will be discussed in the ‘intermediate care’ section. • Surveillance and care of all patients admitted to the obstetric service, with an established triage system for identifying high-risk patients who should be transferred to a facility that provide specialty or subspecialty care; • Proper detection and initial care of unanticipated maternal-foetal problems that occur during labour and delivery; • Capability to begin an emergency caesarean delivery within 30 minutes of the decision; • Availability of appropriate anaesthesia, radiology, ultrasound, laboratory, and blood bank services on a 24 hours basis; 11 Lodewyckx K, Peeters G, Spitz B, et al. KCE reports 6A: Nationale richtlijn prenatale zorg. Een basis voor een klinisch pad voor de opvolging van zwangerschappen. Brussel: KCE, 24.12.2004
Page 1 and 2: Soins maternels intensifs (Maternal
Page 3 and 4: Soins maternels intensifs (Maternal
Page 5 and 6: KCE Reports 94B Soins Maternels Int
Page 11 and 12: KCE Reports 94 Maternal Intensive C
Page 25: KCE Reports 94 Maternal Intensive C
Page 53 and 54: Number of women KCE Reports 94 Mate
Page 55 and 56: 45,00% 40,00% 35,00% 30,00% 25,00%
Page 67 and 68: Status KCE Reports 94 Maternal Inte
Page 77 and 78:
KCE Reports 94 Maternal Intensive C
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Percentage intermediate care women
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
kCE Reports 94 Maternal Intensive C
Page 117 and 118:
Fowler, S.J. (2005) kCE Reports 94
Page 119 and 120:
Schatz et al ( 15 bis kCE Reports 9
Page 121 and 122:
Zeeman, G., Wendel, G. & Cunningham
Page 123 and 124:
Ryan, M., Hamiltin, V., Bowen, M. &
Page 125 and 126:
Baskett, T. & Sternadel, J. (1998)
Page 127 and 128:
Lapinsky, S., Kruczynski, K., Seawa
Page 129 and 130:
Cohen, J., Singer, P., Kogan, A., H
Page 131 and 132:
Quah, T., Chiu, J., Tan, K., Yeo, S
Page 133 and 134:
Gilbert, T., Smulian, J., Martin, A
Page 135 and 136:
Mirghani, H., Hamed, M. & Weerasing
Page 137 and 138:
Selo-Ojeme, D., Omosaiye, M., Batta
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167:
Page 170 and 171:
Dépôt légal : D/2008/10.273/78
Page 172 and 173:
35. Etude relative aux coûts poten
show all

Soins maternels intensifs (Maternal Intensive Care) en Belgique - KCE

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?