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Problem based learning

Problem based learning. Antenatal screening programme. Factual learning objectives. What is screening? NICE guidelines Maternal screening: Haemoglobinopathies Infectious diseases Gestational diabetes Fetal anomaly screening Ultrasonography Downs syndrome screening.

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Problem based learning

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  1. Problem based learning Antenatal screening programme

  2. Factual learning objectives • What is screening? • NICE guidelines • Maternal screening: • Haemoglobinopathies • Infectious diseases • Gestational diabetes • Fetal anomaly screening • Ultrasonography • Downs syndrome screening

  3. Other learning opportunities and discussion points • Ethical issues around screening • Explanation skills and problems • Different roles in MDT • Children with disabilities • Communicating risk

  4. What is screening? ‘Screening may be described as the process of looking at a population perceived to be at risk from a condition in an attempt to identify those at higher risk, in whom some intervention may be made.’ Not diagnostic Looking at general asymptomatic population

  5. WHO screening criteria • The condition should be an important one. • There should be an acceptable treatment. • Facilities for diagnosis and treatment should be available. • There should be a recognised latent or early symptomatic stage. • There should be a suitable test which has few false positives and few false negatives. • The test or examination should be acceptable. • The cost, including diagnosis and subsequent treatment, should be economically balanced.

  6. Discussion point - screening • Advantages of screening • Problems with screening • Issues with this case • Age of patient • Involvement of partner • Understanding of issues

  7. Screening programme • In England, run by UK National Screening committee. • Antenatal: • Fetal anomaly screening programme • Infectious diseases in pregnancy • Sickle cell and thalassaemia screening programme • Gestational diabetes • Newborn: • Newborn and infant physical examination • Newborn blood spot • Newborn hearing screening

  8. Counselling • Mothers should be aware of all options available to them, including the option to decline testing • Mothers should be aware of the benefits and limitations of screening tests and should understand the meaning of results to be obtained.

  9. Discussion point – giving information • How much information do mothers want? • How do we give this? • Who should give it? • When do we give this? • Does everyone need the same information?

  10. Infectious diseases screening • Who - all women • When - at booking • Why - enable treatment, minimise risk of transmission • What - blood tests • HIV • Hep B • Syphilis • Rubella susceptibility

  11. Haemoglobinopathy screening • Who: • all women in units defined as high prevalence (fetal prevalence of sickle cell disorder greater than 1.5 per 10,000 pregnancies) • In low risk units to women from high risk origins • For all women inspection of blood indices • When: • At booking • Why: • Enable treatment, identify neonates at risk • What: • Blood test for haemoglobinopathy • Red cell indices

  12. Discussion point – ethical issue of justice and equality • Is it ethical to offer screening based on prevalence in an area? • What about women who are in area with low prevalence that don’t get screened? • What about women in a high risk area but that are personally low risk that get put through screening process?

  13. Gestational diabetes • Who: • body mass index above 30 kg/m2 • previous macrosomic baby weighing 4.5 kg or above • previous gestational diabetes • family history of diabetes • family origin with a high prevalence of diabetes - South Asian, Black Caribbean, Middle Eastern • Why:identify to enable optimum monitoring and treatment • What: • Previous gestational diabetes - early self-monitoring of blood glucose or oral glucose tolerance test at 16–18 weeks, followed by OGTT at 28 weeks if the first test is normal • Otherwise - OGTT to test for gestational diabetes at 24–28 weeks

  14. Fetal anomaly screening • All women should be offered: • A screening test for Down's syndrome that meets agreed national standards • An ultrasound scan between 18 – 20 weeks 6 days to check for physical abnormalities in their unborn baby • Information to help them decide if they want screening or not

  15. Downs syndrome screening • Who – all mothers • When – between 10 and 20 weeks • Why – to offer definitive testing and option for termination if desired • What…… • A detection rate for Down's syndrome of greater than 75% of affected pregnancies with a screen positive rate of less than 3%.

  16. What….. According to NICE appropriate tests include: • from 11 to 13 weeks 6 days - the combined test • (NT, hCG and PAPP-A) • Preferred method as gives early diagnosis and only needs one visit. • Includes NT scan (done with dating scan) and bloods. • from 11 to 13 weeks 6 days and 15 to 20 weeks - the integrated test • (NT, PAPP-A + hCG, AFP, uE3, inhibin A) • Need to attend twice for NT scan before 13 weeks and then for bloods after 15 weeks.

  17. What….. • from 11 to 13 weeks 6 days and 15 to 20 weeks - the serum integrated test • (PAPP-A + hCG, AFP, uE3, inhibin A) • Need to attend twice for bloods but does not include NT scan (used if cannot measure NT e.g. due to baby position or patient body habitus) • from 15 to 20 weeks - the quadruple test • (hCG, AFP, uE3, inhibin A) • Only option for late bookers • Some special cases e.g. NT only for multiple pregnancies

  18. Then… • Calculate risk depending on woman’s age and screening results (need to know gestation to interpret) Woman's age (years) Risk as a ratio % Risk Below 20 1:1600 0.067 20 1:1500 0.066 30 1:800 0.125 35 1:270 0.37 40 1:100 1.0 45 and over 1.50 and greater 2.0 • Categorise as high or low risk and offer invasive diagnostic testing to high risk. Cut offs: • 1st trimester combined – 1:150 • 2nd trimester - 1:200 • NT alone - 1:250

  19. Discussion point –communicating risk • Quantifying risk: • “There is a 5% chance that your baby will have Downs syndrome” • “Your baby is at high risk of having Downs syndrome” • “The risk of your baby having Downs syndrome is 0.05” • “Out of 20 babies, 1 would have Downs syndrome” • “There is a 95% chance that your baby won’t have Downs syndrome” • Relative v absolute risk: • “Taking the COCP doubles your risk of having a blood clot” v “Taking the COCP increases your risk of having a blood clot from 1 in 14000 to 2 in 14000” • “This drug will result in a 34% reduction in the risk of a heart attack” (88% took drug) v “This drug will result in 1.4% fewer people having heart attacks” (42% took drug)

  20. Any questions at this point?

  21. Discussion point to finish – community orientation • How do GP, midwife and consultant work together? What are their responsibilities? • What supporting services are available?

  22. Summary • Screening • NICE guidelines • Offering information and communicating risk

  23. Thank you for listening

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