Fetal Medicine Unit/Day Assessment Unit

This unit at St Georges Hospital provides both a routine local ultrasound service and a high quality tertiary referral service to the South-West Thames region. The fetal Medicine Unit workload has been steadily increasing over the last five years, and this is a reflection of increasing delivery rate at St Georges Hospital. Not only has the number of routine scans increased, but referrals for fetal medicine and fetal echocardiography consultation has shown a sharper rise. This is almost certainly due to a combination of better screening quality at the referring hospitals and increased awareness amongst patients and healthcare workers alike.

The number of invasive procedures has steadily increased over time, possibly reflecting increased maternal age, parental awareness and better screening efficiency at referring hospitals. Fetoscopic Laser procedures for twin-twin transfusion syndrome (TTTS) have also showed a steady increase in numbers. This is almost certainly due to better and earlier identification of TTTS in referring hospitals. The referral base has also widened with referrals from hospitals in Ireland and Europe, suggestive of the poor availability of high level expertise.

Day Assessment Unit

The Day Assessment Unit was established in the year 2002 to manage acute non-labouring obstetric problems more effectively. The impact of this 7-day/wk service has been to reduce the workload on delivery suite as well as to reduce admission rates to the antenatal wards. The number of women seen has tripled in four years, showing the popularity and utilisation of this service. The timely physical expansion of the unit in April 2005 has helped to meet the increased demand.

Indication for referral to DAU

Raised blood pressure
Post-dates pregnancy clinic
Pre-labour ROM
Pre LSCS clinic
Reduced fetal movement
Research
Antenatal Fetal wellbeing concerns requiring a CTG
First trimester screening
Maternal Serum screening
Itching in pregnancy
Abdominal pain
ECR Antenatal Bookings
TRUFFLE study

Academic output

The Unit is producing high quality research output and supervision of postgraduate degrees and diplomas. It is participating in multi-centre collaborative research projects, currently ongoing in the Europe and North America. The Unit is an established training centre for sub-speciality training programs.

Thanks are due to all the staff of the Unit, and also to the multi-disciplinary team, who have worked hard all year round to produce support our activities.

Fetal Medicine Unit activity

The number of routine and referred scans has increased by over 30% over the last 3 years, when details of activity were separately recorded. The FMU now undertakes over 15,000 patient episodes per annum (excluding DAU activity).

Fetal Medicine Unit activity

Relevant Links:

Non-Invasive Prenatal Testing (NIPT) – The SAFE Test

Click here to learn more.

Laser Surgery for Twin-twin Transfusion Syndrome (TTTS):
http://www.nice.org.uk/nicemedia/pdf/IPG198publicinfo.pdf

Bladder outlet obstruction – Vesico-amniotic Shunt:
http://www.nice.org.uk/nicemedia/pdf/IPG202PublicInfo.pdf

Pleural Effusion – Thoraco-amniotic Shunt:
http://www.nice.org.uk/nicemedia/pdf/ip/IPG190publicinfo.pdf

Routine ultrasound activity

The FMU manages both routine ultrasound scans for the women booked to deliver at St Georges as well as tertiary referrals from several local and distant hospitals. Routine scans by sonographers are performed for the following indications:

1. Nuchal screening at 11-14 weeks
2. Late dating for maternal serum biochemistry
3. Anomaly scans at 21-23 weeks
4. Uterine artery Doppler screening at 21-23 weeks in high-risk women
5. Cervical length assessment at 21-23 weeks in high-risk women
6. Growth scans
7. Placental localisation
8. Reduced fetal movement
9. Post-dates pregnancy

Tertiary referrals

Referrals are made for diverse reasons in view of the broad spectrum of expertise available at St Georges. Referrals are made for the following indications:

1. Invasive procedures – chorion villus sampling and amniocentesis
2. Suspected fetal abnormality
3. Suspected fetal cardiac abnormality
4. Genetic predisposition to fetal problems
5. Fetal growth problems
6. Fetal therapeutic interventions – shunts, transfusions, fetoscopy
7. Previous pregnancy problems In 2005, referrals were made from the following hospitals:

South-West Thames Region Hospitals

Crawley and East Surrey Hospital, Crawley and Redhill
Epsom and St. Helier Hospitals, Epsom and Carshalton
Frimley Park Hospital, Camberley
Kingston and Queen Mary’s Hospitals, Kingston and Roehampton
Mayday University Hospital, Croydon
Royal Surrey County Hospital, Guildford
St. Peter’s Hospital, Chertsey
St. Richard’s Hospital, Chichester

Extra-regional Hospitals

Homerton Hospital, Hackney
Royal London Hospital, Whitechapel
Royal Maternity Hospital, Belfast
Surrey and Sussex County Hospital, Brighton
Uppsala University Hospital, Uppsala, Sweden
Worthing Hospital, Worthing
Dubai
Italy and Spain

Fetal Medicine Unit activity

Invasive procedures

Invasive procedures undertaken include:

1. Diagnostic tests Chorion villus sampling between 11 and 14 weeks, amniocentesis after 16 weeks and cordocentesis after 20 weeks gestation.

2. Theraputic procedures Fetal bladder or lung shunting, intrauterine fetal blood transfusions, fetoscopic laser ablation of placental inter-twin vascular connections in twin-twin transfusion syndrome and interstitial laser ablation of chorioangiomas and TRAP pregnancies.

Fetal echocardiography

Dr Julene Carvalho who is jointly appointed between St Georges and the Royal Brompton Hospital is the clinical lead for this service with the support of Dr Olga Patey, Dr Margarita Bartsota and Ms.Susana De Sousa (Clinical Nurse Specialist, RBH), referrals have continued to increase over the years.

UTERINE ARTERY DOPPLER

What is uterine artery Doppler?

Colour Doppler is a type of ultrasound that can be used to assess the flow in the blood vessels that supply your womb. It is done as a part of your routine anomaly scan around 21-23 weeks of pregnancy.

Why is this scan being done and what is the risk to my pregnancy?

Doppler scans can identify an altered flow pattern to the womb. If there is a low resistance flow pattern, you are at very low risk of having a small baby or developing high blood pressure in this pregnancy. You will not need any further scans.

Approximately 1 in 20 women will have a high resistance blood flow pattern. These women may be at a slightly increased risk for having a small baby or developing high blood pressure in this pregnancy. The majority of these pregnancies will have a perfectly normal outcome.

The presence of a high resistance flow pattern does not mean that there is a problem. It only means that we may need to monitor your pregnancy more closely.

What monitoring will I require?

We will arrange growth scans to monitor the growth of your baby. In addition you will need regular monitoring of your blood pressure in the antenatal clinic. The regular monitoring would help in identifying problems at an earlier stage.

Can I do something to make the blood flow better?

No – A change in the diet or life style would not significantly alter the blood flow pattern.

Is there any treatment?

No – this is not an illness, hence treatment is not required. Furthermore, there is no effective treatment and is therefore not recommended.

Will future pregnancies be similar?

The presence of a high resistance flow pattern in this pregnancy does not increase the chances of having this again in subsequent pregnancies.

Special Clinics run on DAU and FMU

A considerable amount of clinical activity is undertaken in specialised clinics runs mainly in the Day assessment unit. These clinics are run at the following times:

1. Post-dates Clinic: Every morning
2. Pre-Caesarean section clinic: Monday to Friday morning
3. Twins antenatal clinic: Tuesday and Wednesday morning
4. Twins ultrasound scanning Tuesday and Wednesday
5. Joint FMU-Genetics clinic: Wednesday afternoon
6. Joint Obstetric-Anaesthetic clinic: Thursday morning
7. Joint FMU-Paediatric surgery clinic: Thursday afternoon
8. Joint Paediatric Urology Clinic Monday afternoon

Within the Fetal Medicine Unit referrals are made directly from our referring Hospitals and the patients that are booked at St George’s. We aim to provide the highest standard of care for all women attending the Fetal Medicine Unit to enable them to have a positive experience.