ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10006-1934 |
Fetomaternal Outcome in Referral Obstetric Patients in Tertiary Care Hospital
1–4Department of Obstetrics and Gynaecology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
Corresponding Author: Shriya P Pandya, Department of Obstetrics and Gynaecology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India, Phone: +91 9773560441, e-mail: shriya.pandya92@gmail.com
How to cite this article: Khade SA, Pandya SP, Sarmalkar MS, et al. Fetomaternal Outcome in Referral Obstetric Patients in Tertiary Care Hospital. J South Asian Feder Obst Gynae 2021;13(4):207–211.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Aim and objective: To identify indication and fetomaternal outcome of emergency obstetric referral to our hospital so as to reduce fetomaternal morbidity and mortality.
Materials and methods: This retrospective observational study was done at the Department of Obstetrics and Gynecology, LTMMC and LTMGH, Sion, Mumbai, for a duration of 1 year from January 2020 to December 2020. All referred patients in emergency for obstetrics indications above 20 weeks were analyzed for fetomaternal outcome and their indication of referral.
Results: In our study, of a total of 7,751 delivered patients, 2,233 (28.8%) cases were referred. Maximum 1,711 (76.6%) cases were in the 21–30 years age-group and (66.86%) cases referred from secondary centers. The most common referral indication was fetal, meconium-stained amniotic fluid, and fetal distress 432 (19.4%), followed by preterm labor 291 (11.1%) as maternal indication. One thousand seven hundred twenty-seven (77.4%) patients delivered by lower segment cesarean section. Maternal morbidity was seen in 370 (16.6%) patients, of which 41 (11%) patients required intensive care unit admission. Maternal mortalities were 12. Total 1,832 (80.8%) neonates were shifted to mother and 325 (14.3%) required NICU admission.
Conclusion: To reduce unnecessary referrals and burden on tertiary care hospitals, first referral units (FRUs) should be strengthened and healthcare workers should be trained in essential and emergency obstetric care, which will help in reducing morbidity and mortality.
Keywords: Fetomaternal outcome, Maternal morbidity, Maternal mortality, Referral cases.
INTRODUCTION
Pregnancy is a normal physiological process. Low-risk pregnancy can be managed by primary healthcare centers. Regular antenatal visits and follow-up can identify high-risk factors, and early referral of such pregnancy to higher centers will avoid complications and may help to reduce fetomaternal morbidity and mortality. The present study was carried out to know the fetomaternal outcome and indications of emergency obstetric referrals to tertiary hospitals.
The RMNCH+A strategy is aimed at reproductive, maternal, newborn, child, and adolescent health under a broad umbrella and focusing on the strategic lifecycle approach to improve child survival in India.1 One of the “plus” within the strategy focuses on ensuring linkages, referrals, and counter-referrals between and among various levels of the healthcare system to create a continuous care pathway, and to bring an additive/synergistic effect in terms of overall outcomes and impact.1
The referral system is the basis of the healthcare delivery system.2 The term referral is used to indicate the recommendation of a healthcare provider at one level of the health system, having limited resources (medications, equipment, skilled professional) to manage a clinical condition for the assistance of an improved resourced facility, which is of similar or higher level to assist in or take over the management of patient.3 Usually, referral occurs in upward movements, i.e., persons are referred to higher institutions.4
Referrals in obstetrics can be categorized depending on type of healthcare facility (primary, secondary, tertiary, private), timing (antenatal, intranatal, or postnatal), and urgency (elective or emergency).2 Non-standardization of obstetric care at primary healthcare system and bypassing secondary healthcare system to get specialty services leads to unnecessary referrals to tertiary centers. Private hospitals shift high-risk pregnancies to avoid poor outcomes. As a result, tertiary centers are overcrowded with both high-risk and normal deliveries. This dilutes the quality of care, which would otherwise be provided for more critical conditions.5
The Government of India has introduced the referral system to improve the service delivery and reduce workload at tertiary healthcare facilities, allow maximal utilization of healthcare facilities, strengthen peripheral infrastructure, improve teaching standard, and promote research activities.6 The present study was carried out to evaluate the maternal and fetal outcomes of such emergency obstetric referrals.
MATERIALS AND METHODS
This retrospective observational study was done at the Department of Obstetrics and Gynecology, LTMMC and LTMGH, Sion, Mumbai, for a duration of 1 year (from January 2020 to December 2020).
Aim and Objective
To study indication and fetomaternal outcome (morbidity and mortality) of emergency obstetric referral patients.
Inclusion and Exclusion Criteria
All emergency referred antenatal and intranatal patients to our tertiary hospital are included. All registered antenatal cases, postpartum and gynecological referrals are excluded.
Methodology
Data were collected from case records and medical record books of hospital. The cases were analyzed with respect to obstetric profile, referral center and indication of referral, maternal and fetal morbidity and mortality. This study was cleared from the Institutional Ethics Committee. Data were entered in Google Sheets and analyzed using SPSS version 22.
RESULT
This was a retrospective observational study of 2,233 referred cases as per inclusion criteria during the study period from LTMMC and LTMGH, Sion, Mumbai. According to our study, out of a total of 7,751 delivered patients, 2,233 (28.8%) cases were referred.
As shown in Table 1, there were a total of 2,233 (28.8%) referred cases. Age-group 21–30 years was the commonest in 1,711 (76.6%). There were 1,051 (47%) primigravida and 1,182 (53%) multigravida. One thousand one hundred forty (51%) cases were in the gestational age-group of 37–40 weeks, and 947 (42.4%) were in gestational age-group of less than 34 weeks. The lower segment cesarean section 1,727 (77.4%) was the commonest mode of delivery, and 493 (22%) patients had vaginal delivery.
| Age-group (years) | Number 2,233 (%) |
| <21 | 234 (10.5) |
| 21–30 | 1,711 (76.6) |
| >30 | 288 (12.9) |
| Parity | |
| Primipara | 1,051 (47) |
| Multipara | 1,182 (53) |
| Gestational age (weeks) | |
| <37 | 947 (42.4) |
| 37–40 | 1,140 (51) |
| >40 | 146 (6.5) |
| Mode of delivery | |
| Vaginal delivery | 493 (22) |
| LSCS | 1,727 (77.4) |
| Instrumental delivery | 13 (0.6) |
Table 2 shows that the commonest referral indications were maternal obstetric 1,299 (58.17%), which includes preterm labor 291 (13.1%) and previous LSCS 262 (11.7%). Fetal indications were 718 (32.15%), which includes meconium-stained amniotic fluid with fetal distress 432 (19.4%), and 234 (10.5%) intrauterine growth retardation with oligohydramnios with unfavorable USG Doppler.
| Indications | 2,233 (%) |
|---|---|
| Maternal obstetric indication | 1,299 (58.17) |
| Preterm labor | 291 (13.1) |
| Previous LSCS (one or more) | 262 (11.7) |
| Postdatism | 198 (8.9) |
| Premature rupture of membranes | 118 (5.3) |
| Non-progress of labor + deep transverse arrest | 83 (3.8) |
| Cephalopelvic disproportion | 81 (3.6) |
| Malpresentation | 60 (2.7) |
| Antepartum hemorrhage | 58 (2.7) |
| Twins | 34 (1.5) |
| Labor | 25 (1.1) |
| Bad obstetric history | 14 (0.7) |
| Seropositive | 4 (0.2) |
| Genital warts | 1 (0.05) |
| Maternal medical conditions | 284 (12.71) |
| Preeclampsia | 97 (4.3) |
| Gestational diabetes mellitus | 80 (3.6) |
| Anemia | 59 (2.6) |
| Eclampsia | 43 (1.9) |
| HELLP | 4 (0.2) |
| Heart disease | 1 (0.05) |
| Fetal indication | 718 (32.15) |
| MSAF + fetal distress | 432 (19.4) |
| IUGR oligohydramnios with Doppler changes | 234 (10.5) |
| Intrauterine fetal distress | 48 (2.1) |
| Cord prolapse | 4 (0.2) |
Maternal medical conditions were 284 (12.71), including preeclampsia (4.3%), GDM (3.6%), and anemia (2.6%).
As shown in Table 3, majority of cases 893 (40%) were referred from secondary referral centers (specialty hospitals), 787 (35.2%) cases were referred from primary health centers (maternity homes), 185 (8.3%) from private hospitals, and 26 (1.2%) from tertiary centers.
| Center | Number 2,233 (%) |
|---|---|
| Primary HC | 787 (35.2) |
| Secondary center | 893 (40) |
| Tertiary | 26 (1.2) |
| Private | 185 (8.3) |
| Other than referral linkage | 342 (15.3) |
There were 342 (15.3%) patients referred from other than referral linkage.
Table 4 shows, out of all 2,233 cases, there were 370 (16.6%) cases of maternal morbidity. Out of 370 complications, 100 (27%) patients required blood transfusion. There were 59 (15.9%) cases of anemia, 43 (11.6%) cases of eclampsia, and 20 (5.4%) cases of postpartum hemorrhage. Forty-one (11%) patients required ICU admissions and ventilatory support. Fifteen (4%) cases had acute renal failure, and 16 (4.3%) had disseminated intravascular coagulation. In two cases, obstetric hysterectomy was done for atonic postpartum hemorrhage, and in three cases, vaginal exploration was done for vaginal wall hematoma.
| Causes | |
|---|---|
| Maternal morbidity | Numbers 370 (%) |
| Anemia | 59 (15.9) |
| Eclampsia | 43 (11.6) |
| ICU admission | 41 (11) |
| Blood transfusion | 100 (27) |
| Ventilatory support | 41 (11) |
| PPH | 20 (5.4) |
| Obstetric hysterectomy | 2 (0.5) |
| Vaginal exploration | 3 (3) |
| ARF | 15 (4) |
| DIC | 16 (4.3) |
| Infection | 30 (8.1) |
| Maternal mortality causes | Number 12 |
| 1 | Disseminated TB + COVID-19 |
| 2 | PPCM + pneumonia + septic shock |
| 3 | Pulmonary edema |
| 4 | Pneumonitis + sepsis + COVID-19 |
| 5 | PPH/PTE/PPCM + COVID-19 + HELLP syndrome |
| 6 | PPCM + HELLP syndrome + COVID-19 + hepatitis A |
| 7 | CVA + eclampsia + COVID-19 |
| 8 | ARDS + HELLP syndrome + hepatitis E |
| 9 | DIC |
| 10 | Lung collapse + PPCM |
| 11 | Hypovolemic shock + eclampsia |
| 12 | Hemorrhagic shock + PPH + ATN |
Maternal mortality was seen in 12 cases. The most common obstetric causes were eclampsia and HELLP syndrome. Out of 12 cases, 5 had COVID-19 infection. Three patients had postpartum cardiomyopathy (PPCM). Infections like tuberculosis (1) and hepatitis (2) also resulted in mortality.
As shown in Table 5, there were 34 cases of twins. So total birth count was 2,267, out of which 1,832 (80.8%) babies shifted to mother without any complication, 325 (14.3%) required NICU admission, and 110 (4.9%) had stillbirth. One thousand one hundred fifty-one (50.8%) neonates had birth weight more than 2.5 kg, and 1,116 (49.2%) neonates had birth weight up to 2.5 kg.
| Outcome | |
|---|---|
| Neonatal outcome | Number 2,267 (%) |
| Shifted to mother | 1,832 (80.8) |
| NICU | 325 (14.3) |
| Stillbirth | 110 (4.9) |
| Neonatal birth weight (kg) | |
| ≤2.5 | 1,116 (49.2) |
| >2.5 | 1,151 (50.8) |
DISCUSSION
In this study, there were 7,751 total deliveries, out of which 2,233 (28.8%) cases were referred, which is comparatively more than studies done by Jakhar and Choudhary6 (9.96%), Ghardallou et al.7 (15.23%), and Shenoy et al.8 (7.03%).
Obstetric Profile
In the present study, most of the patients (76.6%) were in the age-groups of 21–30 years, which is similar to studies done by Jakher and Choudhary6 (73%), Shenoy et al.8 (73.4%) and less as compared to studies done by Lakshminarayanan et al.5 (81.6%) and Roy et al.9 (86.8%). In our country, due to early marriages, maximum pregnancy occurs between 21 and 30 years of age. In this study, primigravida comprises (47%) of cases, which is in contrast to studies by Lakshminarayanan et al.5 (66.5%) and Roy et al.9 (62%). In our study, 57.6% of cases had gestational age of more than 37 weeks, which is less in comparison with studies by Lakshminarayanan et al.5 (83%) and Roy et al.9 (78.5%). Lower segment cesarean section required as mode of delivery in (77%) cases similar to Shenoy et al.8 (83%).
Referring Centers
Among the 2,233 referred cases, 893 (40%) cases referred from secondary centers (specialty hospitals), 787 (35.2%) from primary health centers (maternity homes), 185 (8.3%) from private hospitals, 26 (1.2%) from tertiary centers in contrast to Lakshminarayanan et al.5 study (38%) were referred from PHCs, (15%) secondary HC, (30%) tertiary hospitals, and (17%) private hospitals. Jakher and Choudhary6 and Roy et al.9 studies had (0.88%) and (14%) referrals from private hospitals.
For better patient care, there is a referral linkage system between major hospitals (tertiary care) attached medical colleges and peripheral hospitals (secondary care) and maternity homes (primary care). It helps to reduce the overburden of tertiary hospitals. There were 342 (15.3%) patients referred from other than referral linkage to our hospitals. During the COVID pandemic, many peripheral hospitals were converted into COVID hospitals, which affected antenatal care. Because of the lack of antenatal OPD and delivery services, many antenatal patients are directly referred to tertiary hospitals.
Referral Indications
The most common referral indications were maternal obstetric 1,299 (58.17%), which includes preterm labor 291 (13.1%) and previous LSCS 262 (11.7%). Fetal indications were 718 (32.15%), which includes meconium-stained amniotic fluid with fetal distress 432 (19.4%), and 234 (10.5%) intrauterine growth retardation with oligohydramnios with unfavorable USG Doppler.
Maternal medical conditions were 284 (12.71), including preeclampsia (4.3%), GDM (3.6%), and anemia (2.6%).
Lakshminarayanan et al.5 reported that the majority of indications were obstetric (76.3%), fetal (8.5%), and medical (12.8%). Jakher and Choudhary6 had referral indications labor 893 (40%) cases, (11.44%) previous LSCS, and (7.3%) preeclampsia.
Gupta et al.10 study had the majority of cases referred for anemia (18.05%), hypertensive disorders of pregnancy (22.27%), and malpresentations (15.19%).
The reasons for referral include the need of a neonatal intensive care unit for preterm and IUGR, medicine expert and intensive care unit to manage high-risk pregnancy, lack of blood bank services. Other reasons include lack of emergency operation theater services, lack of anesthetist, and pediatrician.
Maternal Morbidity
In this study, there were 370 (16.6%) cases of maternal morbidity. Out of 370 complications, 100 (27%) patients required blood transfusion. There were 59 (15.9%) cases of anemia, 43 (11.6%) cases of eclampsia, and 20 (5.4%) cases of postpartum hemorrhage. Forty-one (11%) patients required ICU admissions and ventilatory support. Fifteen (4%) cases had acute renal failure, and 16 (4.3%) had disseminated intravascular coagulation. In two cases, obstetric hysterectomy was done for atonic postpartum hemorrhage, and in three cases, vaginal exploration was required for vaginal wall hematoma.
Jakhar and Choudhary6 had (5.3%) ICU admissions less compared to our study. There were (51.09%) anemia, 38 (20.77%) eclampsia, (18.20%) PPH, and six cases of obstetric hysterectomy. Study by Goswami and Makhija11 showed that (12.34%) required ICU admissions. ICU admission rate in our study was higher than that of Sailaja and Renuka.12
All high-risk obstetric patients require a multidisciplinary approach with intensive care unit monitoring, medicine expert, and facilities for investigations, blood banks, and interventions if required. The morbidity was higher in referred patients because of inadequate antenatal care, failure to identify, and timely referral of high-risk obstetric patients antenatally. These morbidities are avoidable by providing adequate and proper antenatal care and timely referral to tertiary level.
Causes of Maternal Mortalities
In this study, maternal mortality was seen in 12 cases. The most common obstetric causes were eclampsia and HELLP syndrome. Out of 12 cases, 5 had COVID-19 infection. Three patients had postpartum cardiomyopathy (PPCM). Infections like tuberculosis (1) and hepatitis (2) also resulted in mortality.
Jakhar and Choudhary6 reported nine mortalities, and Gupta et al.10 reported 40 (2.72%) mortalities; common causes were hypertensive disorder (35%), severe anemia (20%), hemorrhage (20%), sepsis (10%), and medical disorders like malaria and hepatitis. According to Narsaria et al.,13 patients came with eclampsia that is a major preventable cause of maternal mortality.
The above studies show that hypertension and anemia are the most common causes of maternal mortality.
Fetal Outcome
One thousand eight hundred thirty-two (80.8%) babies shifted to mother without any complication, 325 (14.3%) required NICU admission, and 110 (4.9%) had stillbirth. Ghardallou et al.7 reported (98.2%) live birth, (1.8%) stillbirth, and (9.3%) NICU admission. Akaba and Ekele14 reported (16.4%) stillbirth. One thousand one hundred fifty-one (50.8%) neonates had birth weight more than 2.5 kg, and 1,116 (49.2%) neonates had birth weight up to 2.5 kg.
CONCLUSION
Referral helps healthcare seekers to reach a high level of care in the health system in a span of time. Identification of high-risk factors by health personnel and timely decisions about intervention is important.
In order to reduce unnecessary referrals and burden on tertiary care hospitals, strengthening of existing first referral units (FRUs) is necessary to provide better services, which include the provision of emergency obstetric services with 24 × 7 availability of operation theater facility, anesthetist, pediatrician, and blood bank facility.
Healthcare workers should be trained well in essential antenatal and emergency obstetric care. We must give emphasis on the correction of anemia and early diagnosis of hypertension in the antenatal period. Measures like routine blood pressure and hemoglobin estimation, iron and folic acid supplementation, early ANC registration, deworming, and educating women about contraception and birth spacing will reduce fetomaternal morbidity and mortality.
Every woman has the right to get good quality health care, and to achieve this, we should update our practice of maternal and child health (MCH) care services.
CLINICAL SIGNIFICANCE
Strengthening of the referral system is essential to improve fetomaternal outcome.
REFERENCES
1. RMNCH+A. National Health Portal Of India [Internet]. Nhp.gov.in. 2021. Available from: https://www.nhp.gov.in/reproductive-maternal-newborn-child-and-adolesc_pg.
2. De Brouwere V, Derveeuw M, Van Damme W, et al. Safe motherhood. Lancet 1999;354(9195):2085. DOI: 10.1016/S0140-6736(05)76831-8.
3. Referral systems–a summary of key processes to guide health services managers. WHO; 2015. Available from: www.who.int/management/Referralnotes.doc.
4. Chaturvedi S, Randive B, Diwan V, et al. Quality of obstetric referral services in India’s JSY cash transfer programme for institutional births: a study from Madhya Pradesh province. PLoS One 2014;9(5):e96773. DOI: 10.1371/journal.pone.0096773.
5. Lakshminarayanan S, Prathiba P, Niranjan R, et al. Referral chain of patients with obstetric emergency from primary care to tertiary care: a gap analysis. J Family Med Prim Care 2020;9(1):347. DOI: 10.4103/jfmpc.jfmpc_836_19. PMCID: PMC70148992.
6. Jakhar R, Choudhary A. Study of maternal outcome in referral obstetric cases in a tertiary care centre. J Family Med Prim Care 2019;8(9):2814. DOI: 10.4103/jfmpc.jfmpc_402_19. PMCID: PMC68204231.
7. Ghardallou M, Limam M, Khelifi A, et al. Obstetric referrals to a tertiary care maternity: a descriptive study. Pan Afr Med J 2019;33:306. DOI: 10.11604/pamj.2019.33.306.16906.
8. Shenoy HT, Shenoy ST, Krishnan R. Analysing maternal determinants and characteristics of obstetric referrals at a tertiary care centre in Kerala, India. Int J Commun Med Public Health 2019;6(12):5321. DOI: 10.18203/2394-6040.ijcmph20195492.
9. Roy P, Dutta I, Dasgupta S, et al. Obstetrics referrals: maternal and perinatal outcome in medical college hospital in eastern India. Indian J Obstet Gynecol Res 2020;7(1):91–99. DOI: 10.18231/j.ijogr.2020.019.
10. Gupta PR, Chaudhari SN, Gonnade NV. Maternal and fetal outcome in referred patients to tertiary care center. Sch J App Med Sci 2016;4(5C):1624–1631.
11. Goswami D, Makhija A. A study of high risk obstetric referrals to tertiary care hospital in Garhwal, Uttarakhand. IJSR 2015;4(10):1091–1093.
12. Sailaja B, Renuka MK. Critically ill obstetric admissions to an intensive care unit: a prospective analysis from a Tertiary Care University Hospital in South India. Indian J Crit Care Med 2019;23(2):78–82. DOI: 10.5005/jp-journals-10071-237121.
13. Narsaria K, Mukhopadhaya P, Kyal A, et al. Study of obstetric referrals–one year experience at a tertiary care centre in West Bengal HECS. Int J Com Health Med Res 2017;3(3):32–36.
14. Akaba GO, Ekele BA. Maternal and fetal outcomes of emergency obstetric referrals to a Nigerian teaching hospital. Tropical Doctor 2018;48(2):132–135. DOI: 10.1177/0049475517735474.
________________________
© The Author(s). 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.