Multidisciplinary approach to the perinatal care of families affected by fetal anomalies

The prenatal diagnosis of a congenital anomaly occurs in 2-3% of all pregnancies and affects 120,000 births annually. Prenatal diagnosis with ultrasound has dramatically changed the neonatal care of the affected infants,... [ view full abstract ]

The prenatal diagnosis of a congenital anomaly occurs in 2-3% of all pregnancies and affects 120,000 births annually. Prenatal diagnosis with ultrasound has dramatically changed the neonatal care of the affected infants, allowing for more effective matching of the delivery site with the neonate’s immediate post-delivery needs when hemodynamic or respiratory instability is anticipated. Coordination of fetal care is essential for optimal planning, education and consultation during the pregnancy (Howell, 2003). Ultrasound prenatal diagnosis has led to improved patient satisfaction and reduced stress in the setting of a baby with a congenital anomaly by providing more timely counseling of the family, optimized reproductive decision making, and reduced family and provider dissatisfaction, as well as “futile” interventions in fetuses with a lethal diagnosis. Here we describe the perinatal conference as tool for developing perinatal care plans for families affected by fetal anomalies.
Maternal and Fetal (MFM) conference
General description: This is a multidisciplinary conference staffed by Maternal Fetal Medicine and Neonatology and attended by the faculty, residents and medical students from the Department of Obstetrics and Gynecology at Texas Tech University Health Sciences Center School of Medicine, Odessa, TX. The conference is modeled on the traditional tumor board model as described by Porter (1988) with the dual aims of :
1) developing consensus on diagnosis and treatment
2) education.
Structure: MFM team presents ultrasound images and didactic information followed by review of the prenatal diagnoses on undelivered cases. Neonatology leads a discussion of anticipated needs and potential problems with delivery and neonatal resuscitation. We include fetuses with structural problems which require delivery at a higher level surgical center which are NOT planned for local delivery in case unanticipated pregnancy problems require emergent delivery and neonatal transport.
Specific Goals
1) Dissemination of information to all team members: (Labor and Delivery and NICU) of undelivered patients with maternal or fetal conditions which could complicate delivery or neonatal care
2) Facilitation of the two way communication of information between the obstetric and neonatal providers. This discourse prompts both an educational and logistic exchange of ideas and information culminating in a delivery plan and strategy to address unresolved issues.
3) Facilitation of the antenatal consultation with the family of the affected fetus, addressing diagnosis, anticipated outcome, diagnostic uncertainty, proposed plan of antepartum, intrapartum and neonatal care. Helping to align the family’s expectations with the delivery system plan of care.
4) Communication with the group on the status updates of delivered babies in the NICU, providing post-natal clarification of the antepartum diagnosis when necessary, report on the neonatal progress as well as diagnostic studies on delivered infants.
5) Facilitation of care transition of the stable infant with post discharge needs for follow up consultation, evaluation and surgical intervention.
6) Quality improvement opportunity for the health care system to optimize care plans on future infants with the same or similar conditions.
7) Education of the team members, sharpening diagnostic skills for the faculty and residents by combining case management with image review and didactic information on rare and unusual cases.
Potential benefits;
1) Minimize unplanned delivery of a baby with complex congenital anomalies or other high risk conditions in a community setting which lack the resources to effectively provide care particularly if “out-born delivery” and neonatal transport is associated with a lower survival compared to inborn infants.
2) Improved survival and reduced disability by coordinating delivery of select high risk fetuses at the appropriate surgical site.
3) Improved system based resource utilization by avoiding the costly and risky neonatal transport of critically ill infants to a surgical center when urgent treatment is required. ( Airway, Neurologic, or ductal dependent lesions)


4) Optimizing communication between the family and neonatal faculty ensuring that the plan of care is clarified for the parents, labor and delivery staff, and obstetric team when a fetus with a lethal condition is identified thus reducing the stress on all parties in this emotionally charged setting a fetus with lethal anomalies
Conclusion: Prenatal ultrasound diagnosis of congenital anomalies in combination with multidisciplinary management provides a critical opportunity to improve patients’ care and physician education