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

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62 Maternal Intensive Care in Belgium KCE Reports 94 Indirect obstetrical complications: Cardiac and vascular disease (e.g. hypertension, thyrotoxicosis, plasmapheresis, anaemia, …), pulmonary disease (e.g. asthma or pneumonia, …), neurological disease , gastro-intestinal disease (e.g. diabetes mellitus, cholecystitis, pancreatitis, appendicitis, peritonitis, …), endocrine disease (e.g. thyrotoxicosis, …), infectious and parasitical disease, drug dependence, intoxication, trauma, psychiatric disease, … As mentioned above a widely used consensus list of indications for admission on a MICservice doesn’t exist, every country/hospital has its own way of referring and admitting high risk obstetrical patients. Therefore we try to develop a “Belgian” list. 5.2 METHODOLOGY The process of retrieving the indications (see annex) for admission to (in-hospital) obstetric intermediate care followed different systematically ordered steps, as explained below. First, the P.I.C.O. (Patient, Intervention, Comparison, Outcome) model for clinical questions was used to identify all relevant information and keywords about admission criteria for the maternal intermediate care unit and to get a clear view on the problem wherefore information was to be found. In this phase we mainly focused on (clinical) guidelines, due to the lack of evidence on the topic. The databases were accessed through CEBAM (a portal site that gathers up to date evidence based search engines, CEBAM digital library is the Belgian branch of the Cochrane collabouration). The following search engines were systematically used for evidence based guidelines on standards for maternal intermediate or intensive care (as defined in deliverable 1). In the Dutch-language databases (CBO, Nederlands Huisartsengenootschap, Richtlijnen Kenniscentrum (KCE), RIZIV richtlijnen and WVVH Domus Medica), all topics related to peripartal care were investigated for guidelines on intermediate obstetric care. Three guidelines concerning prenatal and postpartum care were identified. These guidelines provide standards for low-risk pregnancies, but very limited information about intermediate care for complicated or problematic pregnancies within a hospital setting. In other words no Dutch guideline fitted to the goal of the query. Furthermore, Anglo- Saxon guidelines search engines (Guideline Finder UK, National Guideline Clearinghouse, New Zealand Guidelines Group, Prodigy Guidelines and WHO) were used with keywords: obstetric (intermediate) care, peripartal care, pregnancy care and high risk, maternity services (and high risk), maternity care, disease and pregnancy, high dependency unit. These keywords were also combined with each other when the number of guidelines found was too large. Within the potential relevant guidelines we searched for everything related to high-risk, complication and problem. Time restrictions were set on 1995 to 2007. 5.2.1 Guidelines This extensive search resulted in two types of guidelines, general (low risk) maternity care guidelines and guidelines on a specific topic of complicated peripartal care e.g. diabetes & pregnancy, cardio-vascular problems, … . This same tendency was seen in the general literature search. We found no specific guidelines concerning overall intermediate obstetrical care, we did found some general guidelines concerning admission and discharge from general intensive care and high dependency/intermediate care units. Within these general admission and discharge criteria nothing was specifically mentioned for pregnancy and childbirth. Due to the poor results of the searches in the above mentioned guideline databases, the EBM search engines Tripdatabase and Sumsearch were subsequently searched and gave access to respectively evidence based synopses, clinical questions, systematic reviews, guidelines (North America, Europe and other), core primary research and e-textbooks related to a specific topic (see keywords). One relevant guideline was identified: Finnish Medical Society Duodecim (2006). Systemic diseases in pregnancy. Retrieved May 15, 2007 from Cebam, National guideline clearinghouse : www.guideline.gov.
KCE Reports 94 Maternal Intensive Care in Belgium 63 This guideline specifies management/treatment of pregnant women with heart and vascular diseases (hypertension, heart disease), thrombotic complications, metabolic disorders (diabetes, hypothyroidism, hyperthyroidism, obesity), neurological diseases (epilepsy, migraine, disturbances of cerebral circulation), renal diseases, rheumatic disorders, psychiatric problems, bronchial asthma, cancer. An important limitation of this valuable tool (and most other guidelines) was the lack of recommendations on the appropriate level of care for each pathology. No literature or guidelines where found that specifically mentioned on which level of care women with certain (combination of) pathology(ies) should be admitted. 5.2.2 Construction of the theoretical list of indications The extensive search for guidelines and evidence concerning obstetric intermediate care retrieved a few guidelines and articles of low accuracy. Therefore the construction of the list of indications had to be based on a clinically designed list of indications for admission on the MIC-service. Two resident obstetricians 48 , active within an academic tertiary setting, devised a clinical list as an answer to the daily problem of identifying MIC-patients. The list was divided into two groups, pregnancy related pathology and not-pregnancy related pathology. The rough structure of this list (organised by anatomical structures) served as a starting point and gradually more detailed information concerning the different pregnancy and not pregnancy related pathology was added. As mentioned above, guidelines concerning specific complications of pregnancy were relatively easy to find. Per problem cited in the clinical list, the Dutch and Anglo-Saxon search engines, were systematically explored for relevant evidence based guidelines. Where evidence based guidelines were found, information on specific problems was included. With the help of 2 gynaecologists and 1 epidemiologist proposals for indications for intermediate care admission, the disease classification types and risk stratification were formulated. Subsequently an intensive process of internal validation using the Delphi-method was started. During the first phase (written phase) the list was sent by email to all seven members of the research-group who were asked to send their written feedback to the coordinator. All feedback and comments were gathered, discussed and added to the list. In a second phase these written comments were discussed during a meeting. After the meeting the adaptations were made and sent back for additional feedback and approval to the research-partners. The list evoked a lot of discussion and this process had to be repeated four times to obtain consensus. The consensus-list was divided into three groups: not pregnancy related pathology, pregnancy related pathology and foetal pathology. The not pregnancy related pathology was grouped into endocrinologic, nephrologic, cardio-vascular, thrombotic, infectious, pulmonary, autoimmune, connective tissues, skeletal, neuromuscular, haematologic, oncologic, socio-economic, trauma, psychiatric, uro-genital and gastro-intestinal disorders. The pregnancy related pathology was grouped into pregnancy interruption, intra-uterine death, PPROM, preterm birth, IUGR (Intra Uterine Growth Retardation), immunisation, multiple pregnancies, hypertension, thromboembolism, haemorrhage and miscellaneous disorders. The foetal pathology was not stratified into different subgroups. The initial purpose of this list was to group woman (and their foetuses) suffering from a specific pathology (pregnancy or not-pregnancy related) and attribute them the level of care (standard, intermediate and intensive care) they ideally need. Later on, it became clear that the admission criteria for intensive care were clear-cut (see definition in literature review), but the criteria for admission to standard and intermediate care were very unclear. Therefore we decided to create three levels of care (standard care, ‘grey zone’ and intermediate care). The addition of the category ‘grey zone’ was made to increase the clinical applicability of the list of indications. 48 Dr. Kristien Roelens and dr. Ellen Roets, the Gent University Hospital
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