The association between guidelines adherence and clinical outcomes during pregnancy in a cohort of women with cardiac co-morbidities.

BACKGROUND/AIMS: Maternal and infant morbidities associated with pregnant women with cardiac conditions are a global issue contingent upon appropriate care. This study aimed to describe the clinical variables and their association with the adherence scores to perinatal guidelines for pregnant women with cardiac conditions. The clinical variables included cardiac, perinatal, and neonatal outcomes and complications. METHODS: Using a retrospective cross-sectional medical record audit, data were abstracted and categorised as cardiac, obstetric, and neonatal predictors. Linear regression modelling was used to find the mean difference (MD) in adherence scores for each predictor, including a 95% confidence interval (CI) and a significance value for all the three categories' clinical outcomes. RESULTS: This maternal cohort's (n = 261) cardiac complications were primarily arrhythmias requiring treatment (29.9%), particularly SVT (28%), a new diagnosis of valvular heart disease and congenital heart disease (24%) and decompensated heart failure (HF) (16%). Women with HF had associated increased adherence scores (MD = 3.546, 95% CI: 1.689, 5.403) compared to those without HF. Elective LSCS mode of delivery was associated with a higher adherence score (MD = 5.197, 95% CI: 3.584, 6.811) than non-elective LSCS subgroups. Babies admitted to intensive /special care had greater adherence to the guidelines (MD = 3.581, 95% CI: 1.822, 5.340) than those not requiring the same care. CONCLUSIONS: Some pregnancy associated complications and morbidities were associated with higher adherence scores, reflecting that a diagnosis, identification of morbidities or risk factors, initiation of appropriate multidisciplinary involvement and adherence to guidelines were associated. Conversely, potentially avoidable major complications such as sepsis were associated with a low adherence score. TRIAL REGISTRATION: ACTRN12617000417381.

Adherence to clinical practice guidelines for South Australian pregnant women with cardiac conditions between 2003 and 2013.

BACKGROUND: For pregnant women with a known cardiac condition or those who develop cardiac disease during pregnancy, there is an increased risk of complications during pregnancy, to both mother and foetus. To reduce this risk, best practice guidelines have been developed and available in South Australia for several years. Measuring clinical practice against the guideline recommendations verifies real-life practice and an essential part of any clinical practice quality improvement project by identifying gaps. This study is the first report on adherence to statewide perinatal guidelines for these women in South Australia. OBJECTIVES: To evaluate adherence to evidence-based clinical practice perinatal guidelinesTo identify predictors of adherence.Make comparisons across three practice settings examined. DESIGN: A retrospective cross-sectional observational design that analysed data from medical records. SETTING: Three SA Health public metropolitan, university-affiliated teaching hospitals with an obstetric service within a ten-year timeframe (2003-2013). PARTICIPANTS: 271 admissions of women who were categorised as 'pre-existent' or 'newly acquired' cardiac condition during their pregnancy. OUTCOME MEASURES: Adherence to guidelines was measured using a purposefully designed scoring system across the three sites. The researcher chose a minimum acceptable score of 17 applicable to the 'newly acquired' group and 35 for the 'pre-existent' group. RESULTS: Overall adherence to the perinatal guidelines for the combined groups (n = 271) reported a mean score of 16.3, SD ± 6.7, with a median score of 17. Women in the 'newly acquired' group scored less compared to women in the 'pre-existent' group (Estimate -2.3, CI -3.9,-0.7). Variance in adherence was observed across the three hospitals (P value <0.0001). The most significant predictor of adherence to guidelines was pre-pregnancy cardiac consultation which increased the likelihood of preconception care by Odds ratio 18.5 (95%, CI 2, 168). Similarly, compliance with mental health screening was associated with improved adherence to antenatal assessments (OR: 11.3(95% CI 4.7, 27.3). CONCLUSION: There was overall suboptimal adherence to the statewide guidelines for women with cardiac conditions in pregnancy. The variance in the level of adherence across the three hospitals correlated with the exposure to higher acuity cases, and that appropriate up- referral to a higher acuity hospital was intrinsically linked to better adherence. Recommendations include preconception counselling, and to ensure that all health practitioners have the skills, sufficient training and time to complete a comprehensive initial antenatal assessment. TRIAL REGISTRATION: ACTRN12617000417381.

Cardiac conditions in pregnancy and the role of midwives: A discussion paper.

AIM: This paper provides an overview of the two broad categories of cardiac conditions observed in pregnancy (congenital and acquired). It also identifies the midwives' role in the childbirth continuum and includes assessment, track and trigger systems and management during labour and delivery. DESIGN: Discussion paper. METHODS: Data were collected by reviewing international evidence and by searching computerized databases. RESULTS: Research has identified that women with associated risk factors of a cardiac condition who delay pregnancy have an increased risk of experiencing cardiovascular complications in pregnancy with poorer outcomes. The Three Ps in a Pod clinical initiative in the United Kingdom highlights working as a team in multidisciplinary programmes to improve mothers' care and save lives. Midwives play a key role during pregnancy and need to be appraised in relation to cardiovascular disease observed in pregnancy, its potential risks and anticipated problems and within the continuum of care.