The letter from fetal medicine units in London contains anecdotal evidence from the capital and across the country of patients being mismanaged and in some circumstances experiencing harm as a result.
The authors believe this is the result of changes to the way fetal medicine services are funded, which has provided a perverse incentive for district general hospitals to “hold on” to patients when complications arise, rather than referring them to a tertiary centre.
Three of the case studies they cite are provided below.
‘Increased emotional distress’
In one case, a termination of pregnancy was attempted by a local hospital because of “multiple fetal abnormalities”. However, the termination was technically difficult and the patient had to be referred to a tertiary centre the following day for the procedure to be completed.
“This obviously caused the patient increased emotional distress,” the letter says.
In a second case, a scan carried out at 20 weeks suggested a baby might have a brain abnormality. The scan was repeated at 22 weeks and the woman saw a local consultant at 24 weeks where the finding was confirmed. Then she was referred to a tertiary centre, which at 25 weeks diagnosed a rare neurological condition that was likely to mean the child would be born seriously handicapped. The woman then opted for termination of pregnancy.
According to the letter, an audit of referrals suggested that in previous years similar cases were referred and seen at an average of 21 weeks – four weeks earlier than in this instance.
‘Long term neurodevelopmental costs’
A third case refers to a woman with a baby with “fetal growth restriction” – when a baby’s growth slows or stops in the womb – who was referred for immediate delivery to a tertiary unit only because of a lack of cots in the local neonatal intensive care unit. The specialist unit judged it was too early for delivery and the baby would have a better neurodevelopmental outcome if it was born later. The woman was monitored as an inpatient and the baby was delivered three weeks later.
Previous FGR cases had been referred at the time of diagnosis, but the letter said it was “clear that this referral pattern is not necessarily continuing”.
The letter says: “We cannot attest to the possibility that many inappropriately early pre-term deliveries may have occurred in the region that we would not be aware of.
“One can only guess at the long term neurodevelopmental costs of such inappropriate management.”
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Case studies: Mismanagement of fetal medicine patients' care