ABSTRACT
BACKGROUND: Emergencies in obstetrics and gynecology are important causes of morbidity and mortality. Consequently, the World Health Organization introduced the concept of emergency obstetrical and newborn care aimed at reducing maternal mortality by 75%. Worldwide, 15% of all births result in life-threatening complications during pregnancy. The Women's Hospital in Doha, Qatar, experienced a steady increase in births from approximately 13,000 in 2013 to more than 17,000 in 2016. This was accompanied by a rapid increase in the number of visits to the emergency unit-the main provider of emergency obstetrics and gynecology care to approximately 70,000 patients a year-overstretching the services and affecting the quality of care. To address this rapid increase, a redesign of the emergency services was undertaken and implemented in 2012. OBJECTIVE: This study aimed to present a 5-year audit of the emergency department's structural process redesign. STUDY DESIGN: We redesigned the emergency department into one of consultant-led teams of trained obstetrics and gynecology physicians, residents, and specialized nurses with immediate support from ancillary services and direct access to operating and labor rooms and wards. The Canadian Triage and Acuity Scale (levels I-V) was used to triage patients and determine the rapidity with which they were seen. An electronic medical record was introduced as part of the redesign, and different matrices were used to measure outcomes regularly. RESULTS: During the 5-year study period, an average of 70,000 patients were seen annually. The obstetrics-to-gynecology ratio of cases was 3:1. Using the Canadian Triage and Acuity Scale, most patients (63.4%) had acuity level IV. Moreover, 97% of women were seen and triaged scored within 15 minutes of presentation; furthermore, all patients with acuity level I and 95% of patients with acuity level II were seen within 15 minutes by a physician, and 89% of patients with acuity level III were seen within 60 minutes. Approximately 2.5% of patients returned to the emergency department within 48 hours of discharge, and 0.5% of patients who had been seen and discharged returned to the emergency department. Key performance indicators were exceeded in all domains, with 90% of patients rating the care they received as either excellent or good. CONCLUSION: The growing population in Qatar required improvements and innovation in services. Our results showed that innovating how emergency services can be provided results in considerable improvements in outcomes and satisfaction. Considering the peculiarities of the environments, it should be possible to adopt this approach in other settings.
ABSTRACT
BACKGROUND: Consanguinity is the close union, sexual relationship or marriage between persons who have common biological ancestors usually up to about 2nd cousins. Contrary to general opinion consanguinity is quite common and is practiced worldwide. It is an important topic as while rates of consanguineous unions in certain society have decreased over time, rates have remained stable or increased in other societies with rates as high as 80.6% in some communities. Our aim was to conduct a review looking at general aspects of consanguinity and any published reproductive outcomes in literature. We also looked at possible future directions that could be relevant in the management of the consanguineous couple to help improve reproductive outcomes. METHOD: We conducted a PUBMED, CINAHL, Web of Knowledge and Google Scholar search looking at articles on consanguinity. Consanguinity articles related to pregnancy and reproduction were searched using additional filters looking at our specific areas of interest. All relevant publications up to March 2015 were reviewed. Additional search for relevant articles pertaining to pre implantation genetic diagnosis for future directions in the management of the consanguineous couple was done. Most publications were found in books, on line articles and journals. Most were retrospective, population or cohort studies. RESULT: Consanguinity is practiced by up to 10% of the world's population with rates ranging from 80.6% in certain provinces in the Middle East to less than 1% in western societies. It predates Islam and has been practiced since Old Testament times. The most commonly cited reason for consanguinity is sociocultural and socioeconomic although it is also more common in certain religions. In areas where rates of Consanguinity are reducing urban migration and increasing education rates are thought to be contributory. Congenital malformations have long been established to be higher in consanguineous couples above the background rate (4.5% Vs 1%).Due to "Founder effect" or a common ancestor, Consanguinity is most commonly associated with Inborn errors of metabolism most of which are autosomal recessive. Consanguinity increases the incidence of multifactorial disorders such as diabetes, cardiovascular disorders, obesity and certain types of cancers. These may in turn affect reproductive outcomes. It may also affect fertility rates. Pregnancy outcomes like increased pregnancy wastages and preterm labor have been reported with consanguinity. Other studies produced conflicting evidence on its effect regarding outcomes like hypertensive disorders of pregnancy and Intrauterine growth restriction. CONCLUSION: Consanguinity continues to be practiced worldwide and in some countries rates are increasing. The main reason for the practice appears to be sociocultural and socioeconomic although religious beliefs is a contributory factor. The most significant effects on reproductive outcomes are mostly due to autosomal recessive inherited conditions and inborn errors of metabolism. It also significantly increases the inheritance of certain multifactorial disorders like diabetes which may indirectly affect reproductive outcomes. In the future with the completion of the study of the whole human Genome and current advances in Pre implantation Genetic diagnosis and screening it may be possible to mitigate some of the adverse reproductive outcomes associated with consanguinity.
