Australian and New Zealand Journal of Obstetrics and Gynaecology 2014
DOI: 10.1111/ajo.12254
Short Communication
Antenatal management of at-risk pregnancies from a distance Tesa L. IVEY,1 Dawn HUGHES,1 Nafisa K. DAJANI1 and Everett F. MAGANN1,2 1
Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas, USA, and 2School of Women’s and Infants’ Health, University of Western Australia, Western Australia, Perth, Australia
This study was undertaken to determine whether antenatal care can be achieved in women with at-risk pregnancies residing in rural areas with limited access to antenatal care and maternal fetal medicine (MFM) specialists. Over a period of 15 months, 156 women with high-risk pregnancies (diabetes, hypertensive disorders, suspected fetal anomalies, prior caesarean complications) from six different healthcare units had 350 visits managed by telemedicine. Key words: high-risk pregnancy, telemedicine, rural medicine.
Introduction Telemedicine permits the management of health care across distances and is being closely evaluated because of its potential to reduce costs and improve access to specialty care. In obstetrics, telemedicine has been used to report ultrasounds and interpret nonstress tests, counsel patients and provide consultations, manage diabetes, manage postpartum depression and support parents and children postpartum from remote sites.1 Telemedicine has the potential to provide obstetric treatment to at-risk and low-risk women without an obstetric provider living in rural areas with limited resources. In some rural areas of the United States, pregnant women live many kilometres from their nearest obstetric provider. Currently, 49% of the 3107 counties in the United States, in which 9.5 million Americans reside, do not have a single obstetrician/gynaecologist.2 Providing obstetric care to these women is challenging to the healthcare system. In Arkansas, we observed that many referred at-risk pregnancies to the University for obstetric care and maternal fetal medicine (MFM) consultations were not compliant and were not travelling to the University for their appointments. Instead, these women were ‘dropping’ into local hospitals with limited or no prenatal care. Additionally, local health units have very strict policies/ protocols for patient care and this excludes most high-risk obstetric patients. Furthermore, many local healthcare providers would not accept these patients into their
Correspondence: Everett F. Magann, Department of Obstetrics and Gynecology, UAMS, 4301 W. Markham ST. Slot # 518, Little Rock, AR 72205, USA. Email: [email protected] Received 22 April 2014; accepted 2 August 2014.
practice because they were uninsured and/or too high risk. The purpose of this review was to determine whether and how antenatal care can be provided to women in rural areas with limited access to antenatal and MFM care without increasing patient costs and the burden of driving long distances.
Materials and Methods A literature search was undertaken using PubMed, Web or Science, EBSCOhost research databases and CINAHL Plus. The search terms used were ‘telemedicine’ OR ‘interactive video network’ OR ‘distance and network’ AND ‘pregnancy outcome’ OR ‘pregnancy management’. Tele-ultrasound was excluded. The number of years searched was unlimited. There were 32 article identified. The abstracts of these articles were read by one of the authors (EFM). The full articles of any abstracts associating the management of low-risk or at-risk pregnancies by telemedicine were read in their entirety. Additionally, the references for each of these articles were reviewed for any additional articles. The management of women who were seen in participating health departments, without Medicaid or any other insurance, or without insurance without maternity benefits, and had at-risk pregnancies were assessed. These women were being seen exclusively by an advanced practice nurses (APN) at the health unit. Women seen through this clinic, and subsequently seen via telemedicine, all had conditions warranting a consultation with or management by a MFM provider. The initial assessment was by an APN in the health unit and then by an APN at University hospital along with an MFM physician or general obstetrician under the supervision of a MFM. Women identified for telemedicine comanagement with an obstetrician/MFM were then scheduled with University telemedicine. After the history, vital signs and fetal
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
1
T. L. Ivey et al.
assessment were done at the local health unit site, laboratory work, glucose logs, and/or blood pressure logs were faxed to the University and the patient was seen via telemedicine. The University APN and obstetrician/MFM then discussed the management of the woman’s condition directly with the woman, ordered additional laboratory studies and make recommendations directly to her. All questions could be asked and answered in this ‘faceto-face’ encounter via telemedicine.
Results The literature search revealed six publications that described the management of at-risk patients via telemedicine with two additional publications identified from article references The use of telemedicine in the management of diabetes was primarily to transmit blood glucose levels between patients and their providers. These studies suggested that closer control was achieved with more frequent transmission of glucose values than that which could be achieved by weekly provider visits.3–5 Telemedicine has been used, in small studies with at-risk patients, to transmit self-administered fetal heart rate monitoring from home6,7 and from rural hospitals8,9 to tertiary centres for assessment rather than having the woman travel, in some cases, great distances, for testing. Between April 2011 and November of 2012, 156 pregnant women were seen in the Local Health Unit/ telemedicine clinic at the University of Arkansas for Medical Sciences (UAMS). The maternal races were white 71 (45.5%), Hispanic 36 (23.1%), black 35 (22.4%) and other 14 (9%). Seventy-two (46.1%) of the women were gravid 1 or 2, and 84 (53.9%) were ≥ gravid 3 The women averaged 4 visits in the health unit/telemedicine clinic with a range of 1–21 visits each, with a total of 350 visits amongst all the women included in the study. The women were seen for a variety of complications with the most frequent reasons being diabetes, hypertension, caesarean complications in prior pregnancies, desiring vaginal birth after caesarean (VBAC) and genetic referrals/ suspected fetal anomalies (Table 1). Of the 156 total women seen by telemedicine, 43 were subsequently referred to UAMS for delivery. Only 39 actually delivered at UAMS with 4 being delivered at local hospital due to preterm labour or were too unstable for transfer and delivered locally. The primary indicators for delivery at UAMS were obesity and chronic hypertension and that number accounted for over half of the UAMS deliveries. The next largest group of women who delivered at UAMS were patients who had had a previous caesarean with unknown scar type, complications related to a previous caesarean or women desiring VBAC. VBAC is attempted in very few hospitals in the State of Arkansas. The health units in which the women were seen and their distances from UAMS were Benton Health Unit (distance to UAMS 348 km), Jonesboro AHEC (distance to UAMS 214 km), Hempstead Health Unit (distance to UAMS 180 km), Independence Health Unit (distance to 2
Table 1 Pregnancy complications of women seen by telemedicine
Reason for visit Diabetes (Type 1, Type 2, GDM) Hypertension and Pregnancy (chronic hypertension, chronic hypertension and pre-eclampsia, pre-eclampsia, gestational hypertension) Caesarean section (caesarean with complications, repeat caesarean, patient desires VBAC Genetics and anomalies (advanced maternal age, abnormal serum screen, prior child with anomaly, maternal genetic disorder, Maternal cardiac disease (maternal congenital heart disease, chest pain and shortness of breath) Maternal obesity Preterm labour, preterm delivery, cervical incompetence Liver disease, cholelithisis, Seizure disorder Thyroid dysfunction (hyperthyroidism, hypothyroidism) Maternal kidney disease Mental illness (anxiety, depression) Anaemia Recurrent spontaneous abortions Others (recurrent UTI, positive antibody screen, myomas, abnormal amniotic fluid volume, pyelonephritis, sickle cell disease, abnormal pap smear, migranes, HIV, HSV, previous still birth, recurrent urinary tract infections,
Number of referred patients for this diagnosis 69 46
43
40
21
19 14 12 10 8 8 8 8 7 17
Total number of diagnosis is 294, which exceeds the number of women seen, but many women were referred for more than one diagnosis.
UAMS 156 km), Miller Health Unit (distance to UAMS 230 km) and Sevier Health Unit (distance to UAMS 232 km). An example of the time spent driving and distance driven by these patients is illustrated by the women seen at the Hempstead Health Unit, which is 180 km from UAMS. Local women with at-risk pregnancies being seen at UAMS for a face-to-face visit were compared with patients driving from their home and being seen at the Hempstead Unit (regional telemedicine) and women from the Hempstead area driving to UAMS for obstetric care (traditionally referred patients). For a face-to-face visit by women in Little Rock attending the UAMS clinic, the mean miles per round trip was 34 km versus 114 km for the regional telemedicine program and 449 km if the patient travelled to UAMS rather than being seen by telemedicine.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
At-risk pregnancy management from a distance
Discussion The use of telemedicine has been limited to pregnancies complicated by diabetes, in which the provider has been supplied with more frequent glucose assessments, and in pregnancies followed with antenatal testing, telemedicine has allowed at home or remote hospital data transmission of the nonstress test to a tertiary care centre for interpretation. This study demonstrates that telemedicine can be used to deliver obstetric care and MFM consultations to women whose prenatal care has previously been limited because distance, the high-risk category of the pregnancy and the lack of personal resources or insurance of the patient. A variety of pregnancy complications, including hypertension, diabetes, maternal cardiac disease, maternal genetic diseases and pregnancies at risk for fetal anomalies, were managed by telemedicine. Despite the number of high-risk pregnancies, 75% of the women delivered in their local hospital. We speculate that the availability of telemedicine increased the number of kept appointments by the patients and permitted timely referrals and recommendations still permitting many women to deliver closer to their hometowns. One of the many advantages of a telemedicine program is increased convenience for the woman and her family due to decreased travel time and distance. For a face-to-face visit by women in Little Rock attending the UAMS clinic, the distance travelled was 92% less for the patients with local face-to-face visits and 75% less for patients in the Regional telemedicine program compared to the distant women making a trip to UAMS. One of the limitations in this pilot project is that we do not have pregnancy outcomes for the 75% of the women delivering at local hospitals. However, the purpose of this pilot study was to determine the feasibility of delivering care to high-risk pregnancies in rural areas. Further studies are needed to determine the overall safety and cost-effectiveness of this care and if it is equivalent to care provided to similar at-risk women in a
traditional clinic setting. A prospective randomised trial would be the best strategy to answer this question but it would be very difficult in the current setting to randomise these women. Telemedicine can provide obstetric care and MFM consultations to women at low risk and those at high risk for pregnancy complications, who, because of lack of insurance or resources or distance, have had limited perinatal care in the past.
References 1 Magann EF, McKelvey SS, Hitt WC et al. The use of telemedicine in obstetrics: a review of the literature. Obstet Gynecol Surv 2011; 66: 170–178. 2 2012 ACOG workforce fact sheet. Available at https://www. acog.org/~/media/Sections/DE/2012_DE_Workforce_Fact_Sheet. pdf. Assessed February 17,2014 3 Homko CJ, Deeb LC, Rohrbacher K et al. Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus. Diabetes Technol Ther 2012; 14: 624–629. 4 Dalfra MG, Nicolucci A, Lapolla A; TISG. The effect of telemedicine on outcome and quality of life in pregnant women with diabetes. J Telemed Telecare. 2009; 15: 238–242 5 Homko CJ, Santamore WP, Whiteman V et al. Use of an internet-based telemedicine system to manage underserved women with gestational diabetes mellitus. Diabetes Technol Ther 2007; 9: 297–306. 6 Hod M, Kerner R. Telemedicine for antenatal surveillance of high-risk pregnancies with ambulatory and home fetal heart rate monitoring–an update. J Perinat Med 2003; 31: 195–200. 7 Kerner R, Yogev Y, Belkin A et al. Maternal self-administered fetal heart rate monitoring and transmission from home in highrisk pregnancies. Int J Gynaecol Obstet 2004; 84: 33–39. 8 Di Lieto A, De Falco M, Campanile M et al. Four years’ experience with antepartum cardiotocography using telemedicine. J Telemed Telecare 2006; 12: 228–233. 9 Di Lieto A, De Falco M, Campanile M et al. Regional and international prenatal telemedicine network for computerized antepartum cardiotocography. Telemed J E Health 2008; 14: 49–54.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
3
DOI: 10.1111/ajo.12254
Short Communication
Antenatal management of at-risk pregnancies from a distance Tesa L. IVEY,1 Dawn HUGHES,1 Nafisa K. DAJANI1 and Everett F. MAGANN1,2 1
Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas, USA, and 2School of Women’s and Infants’ Health, University of Western Australia, Western Australia, Perth, Australia
This study was undertaken to determine whether antenatal care can be achieved in women with at-risk pregnancies residing in rural areas with limited access to antenatal care and maternal fetal medicine (MFM) specialists. Over a period of 15 months, 156 women with high-risk pregnancies (diabetes, hypertensive disorders, suspected fetal anomalies, prior caesarean complications) from six different healthcare units had 350 visits managed by telemedicine. Key words: high-risk pregnancy, telemedicine, rural medicine.
Introduction Telemedicine permits the management of health care across distances and is being closely evaluated because of its potential to reduce costs and improve access to specialty care. In obstetrics, telemedicine has been used to report ultrasounds and interpret nonstress tests, counsel patients and provide consultations, manage diabetes, manage postpartum depression and support parents and children postpartum from remote sites.1 Telemedicine has the potential to provide obstetric treatment to at-risk and low-risk women without an obstetric provider living in rural areas with limited resources. In some rural areas of the United States, pregnant women live many kilometres from their nearest obstetric provider. Currently, 49% of the 3107 counties in the United States, in which 9.5 million Americans reside, do not have a single obstetrician/gynaecologist.2 Providing obstetric care to these women is challenging to the healthcare system. In Arkansas, we observed that many referred at-risk pregnancies to the University for obstetric care and maternal fetal medicine (MFM) consultations were not compliant and were not travelling to the University for their appointments. Instead, these women were ‘dropping’ into local hospitals with limited or no prenatal care. Additionally, local health units have very strict policies/ protocols for patient care and this excludes most high-risk obstetric patients. Furthermore, many local healthcare providers would not accept these patients into their
Correspondence: Everett F. Magann, Department of Obstetrics and Gynecology, UAMS, 4301 W. Markham ST. Slot # 518, Little Rock, AR 72205, USA. Email: [email protected] Received 22 April 2014; accepted 2 August 2014.
practice because they were uninsured and/or too high risk. The purpose of this review was to determine whether and how antenatal care can be provided to women in rural areas with limited access to antenatal and MFM care without increasing patient costs and the burden of driving long distances.
Materials and Methods A literature search was undertaken using PubMed, Web or Science, EBSCOhost research databases and CINAHL Plus. The search terms used were ‘telemedicine’ OR ‘interactive video network’ OR ‘distance and network’ AND ‘pregnancy outcome’ OR ‘pregnancy management’. Tele-ultrasound was excluded. The number of years searched was unlimited. There were 32 article identified. The abstracts of these articles were read by one of the authors (EFM). The full articles of any abstracts associating the management of low-risk or at-risk pregnancies by telemedicine were read in their entirety. Additionally, the references for each of these articles were reviewed for any additional articles. The management of women who were seen in participating health departments, without Medicaid or any other insurance, or without insurance without maternity benefits, and had at-risk pregnancies were assessed. These women were being seen exclusively by an advanced practice nurses (APN) at the health unit. Women seen through this clinic, and subsequently seen via telemedicine, all had conditions warranting a consultation with or management by a MFM provider. The initial assessment was by an APN in the health unit and then by an APN at University hospital along with an MFM physician or general obstetrician under the supervision of a MFM. Women identified for telemedicine comanagement with an obstetrician/MFM were then scheduled with University telemedicine. After the history, vital signs and fetal
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
1
T. L. Ivey et al.
assessment were done at the local health unit site, laboratory work, glucose logs, and/or blood pressure logs were faxed to the University and the patient was seen via telemedicine. The University APN and obstetrician/MFM then discussed the management of the woman’s condition directly with the woman, ordered additional laboratory studies and make recommendations directly to her. All questions could be asked and answered in this ‘faceto-face’ encounter via telemedicine.
Results The literature search revealed six publications that described the management of at-risk patients via telemedicine with two additional publications identified from article references The use of telemedicine in the management of diabetes was primarily to transmit blood glucose levels between patients and their providers. These studies suggested that closer control was achieved with more frequent transmission of glucose values than that which could be achieved by weekly provider visits.3–5 Telemedicine has been used, in small studies with at-risk patients, to transmit self-administered fetal heart rate monitoring from home6,7 and from rural hospitals8,9 to tertiary centres for assessment rather than having the woman travel, in some cases, great distances, for testing. Between April 2011 and November of 2012, 156 pregnant women were seen in the Local Health Unit/ telemedicine clinic at the University of Arkansas for Medical Sciences (UAMS). The maternal races were white 71 (45.5%), Hispanic 36 (23.1%), black 35 (22.4%) and other 14 (9%). Seventy-two (46.1%) of the women were gravid 1 or 2, and 84 (53.9%) were ≥ gravid 3 The women averaged 4 visits in the health unit/telemedicine clinic with a range of 1–21 visits each, with a total of 350 visits amongst all the women included in the study. The women were seen for a variety of complications with the most frequent reasons being diabetes, hypertension, caesarean complications in prior pregnancies, desiring vaginal birth after caesarean (VBAC) and genetic referrals/ suspected fetal anomalies (Table 1). Of the 156 total women seen by telemedicine, 43 were subsequently referred to UAMS for delivery. Only 39 actually delivered at UAMS with 4 being delivered at local hospital due to preterm labour or were too unstable for transfer and delivered locally. The primary indicators for delivery at UAMS were obesity and chronic hypertension and that number accounted for over half of the UAMS deliveries. The next largest group of women who delivered at UAMS were patients who had had a previous caesarean with unknown scar type, complications related to a previous caesarean or women desiring VBAC. VBAC is attempted in very few hospitals in the State of Arkansas. The health units in which the women were seen and their distances from UAMS were Benton Health Unit (distance to UAMS 348 km), Jonesboro AHEC (distance to UAMS 214 km), Hempstead Health Unit (distance to UAMS 180 km), Independence Health Unit (distance to 2
Table 1 Pregnancy complications of women seen by telemedicine
Reason for visit Diabetes (Type 1, Type 2, GDM) Hypertension and Pregnancy (chronic hypertension, chronic hypertension and pre-eclampsia, pre-eclampsia, gestational hypertension) Caesarean section (caesarean with complications, repeat caesarean, patient desires VBAC Genetics and anomalies (advanced maternal age, abnormal serum screen, prior child with anomaly, maternal genetic disorder, Maternal cardiac disease (maternal congenital heart disease, chest pain and shortness of breath) Maternal obesity Preterm labour, preterm delivery, cervical incompetence Liver disease, cholelithisis, Seizure disorder Thyroid dysfunction (hyperthyroidism, hypothyroidism) Maternal kidney disease Mental illness (anxiety, depression) Anaemia Recurrent spontaneous abortions Others (recurrent UTI, positive antibody screen, myomas, abnormal amniotic fluid volume, pyelonephritis, sickle cell disease, abnormal pap smear, migranes, HIV, HSV, previous still birth, recurrent urinary tract infections,
Number of referred patients for this diagnosis 69 46
43
40
21
19 14 12 10 8 8 8 8 7 17
Total number of diagnosis is 294, which exceeds the number of women seen, but many women were referred for more than one diagnosis.
UAMS 156 km), Miller Health Unit (distance to UAMS 230 km) and Sevier Health Unit (distance to UAMS 232 km). An example of the time spent driving and distance driven by these patients is illustrated by the women seen at the Hempstead Health Unit, which is 180 km from UAMS. Local women with at-risk pregnancies being seen at UAMS for a face-to-face visit were compared with patients driving from their home and being seen at the Hempstead Unit (regional telemedicine) and women from the Hempstead area driving to UAMS for obstetric care (traditionally referred patients). For a face-to-face visit by women in Little Rock attending the UAMS clinic, the mean miles per round trip was 34 km versus 114 km for the regional telemedicine program and 449 km if the patient travelled to UAMS rather than being seen by telemedicine.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
At-risk pregnancy management from a distance
Discussion The use of telemedicine has been limited to pregnancies complicated by diabetes, in which the provider has been supplied with more frequent glucose assessments, and in pregnancies followed with antenatal testing, telemedicine has allowed at home or remote hospital data transmission of the nonstress test to a tertiary care centre for interpretation. This study demonstrates that telemedicine can be used to deliver obstetric care and MFM consultations to women whose prenatal care has previously been limited because distance, the high-risk category of the pregnancy and the lack of personal resources or insurance of the patient. A variety of pregnancy complications, including hypertension, diabetes, maternal cardiac disease, maternal genetic diseases and pregnancies at risk for fetal anomalies, were managed by telemedicine. Despite the number of high-risk pregnancies, 75% of the women delivered in their local hospital. We speculate that the availability of telemedicine increased the number of kept appointments by the patients and permitted timely referrals and recommendations still permitting many women to deliver closer to their hometowns. One of the many advantages of a telemedicine program is increased convenience for the woman and her family due to decreased travel time and distance. For a face-to-face visit by women in Little Rock attending the UAMS clinic, the distance travelled was 92% less for the patients with local face-to-face visits and 75% less for patients in the Regional telemedicine program compared to the distant women making a trip to UAMS. One of the limitations in this pilot project is that we do not have pregnancy outcomes for the 75% of the women delivering at local hospitals. However, the purpose of this pilot study was to determine the feasibility of delivering care to high-risk pregnancies in rural areas. Further studies are needed to determine the overall safety and cost-effectiveness of this care and if it is equivalent to care provided to similar at-risk women in a
traditional clinic setting. A prospective randomised trial would be the best strategy to answer this question but it would be very difficult in the current setting to randomise these women. Telemedicine can provide obstetric care and MFM consultations to women at low risk and those at high risk for pregnancy complications, who, because of lack of insurance or resources or distance, have had limited perinatal care in the past.
References 1 Magann EF, McKelvey SS, Hitt WC et al. The use of telemedicine in obstetrics: a review of the literature. Obstet Gynecol Surv 2011; 66: 170–178. 2 2012 ACOG workforce fact sheet. Available at https://www. acog.org/~/media/Sections/DE/2012_DE_Workforce_Fact_Sheet. pdf. Assessed February 17,2014 3 Homko CJ, Deeb LC, Rohrbacher K et al. Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus. Diabetes Technol Ther 2012; 14: 624–629. 4 Dalfra MG, Nicolucci A, Lapolla A; TISG. The effect of telemedicine on outcome and quality of life in pregnant women with diabetes. J Telemed Telecare. 2009; 15: 238–242 5 Homko CJ, Santamore WP, Whiteman V et al. Use of an internet-based telemedicine system to manage underserved women with gestational diabetes mellitus. Diabetes Technol Ther 2007; 9: 297–306. 6 Hod M, Kerner R. Telemedicine for antenatal surveillance of high-risk pregnancies with ambulatory and home fetal heart rate monitoring–an update. J Perinat Med 2003; 31: 195–200. 7 Kerner R, Yogev Y, Belkin A et al. Maternal self-administered fetal heart rate monitoring and transmission from home in highrisk pregnancies. Int J Gynaecol Obstet 2004; 84: 33–39. 8 Di Lieto A, De Falco M, Campanile M et al. Four years’ experience with antepartum cardiotocography using telemedicine. J Telemed Telecare 2006; 12: 228–233. 9 Di Lieto A, De Falco M, Campanile M et al. Regional and international prenatal telemedicine network for computerized antepartum cardiotocography. Telemed J E Health 2008; 14: 49–54.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
3
