- Academic Editor
Background: To analyze the impact of a
multidisciplinary collaborative diagnosis and treatment (MDT) management in obstetric outpatient departments on the outcome of
high-risk pregnancies, and to summarize the experience and to improve the
diagnosis and treatment ability of for critically ill obstetric patients.
Method: Two hundred sixty-six pregnant and lying-in women with
multidisciplinary treatment were selected for retrospective analysis. According
to the criteria, 176 high-risk pregnant women were included, including 83 cases
of outpatient MDT and 93 cases of inpatient MDT. The classification of pregnancy
diseases and pregnancy risk was carried out. The source of high-risk pregnant
women, the distribution and number of collaborative clinics, the classification
of major diseases, the classification of pregnancy risk, the mode of delivery,
the condition of labor, and pregnancy outcome were all analyzed to determine the
impact of participating in MDT timing on adverse pregnancy outcomes through
logistic regression analysis. Result: (1) The top 3 diseases in high
risk pregnant women undergoing MDT were pregnancy with cardiac disease 42.6%
(75/176), pregnancy with hypertension 14.2% (25/176), and pregnancy with immune
system disease 11.9% (21/176). Among pregnant women with cardiac disease, 38
(50.7%) were mainly congenital cardiac disease. (2) The number of high-risk
pregnant women with MDT in the hospital was more than that in the outpatient
department (p
Maternal and child health is one of the elements reflecting the health, economic and cultural status of a country or region. One of the sustainable development goals of World Health Organization (WHO) is reducing the maternal mortality rate (MMR). With the economic and medical level improvement, China’s MMR has declined yearly [1]. However, with the opening of the fertility policy, the number of older pregnant women and the development of assisted reproductive technology have increased, and the number of high-risk pregnant women with multiple medical complications has increased significantly [2].
The multidisciplinary collaborative diagnosis and treatment (MDT) model was initially applied to the management of tumor patients and was later widely applied in various disciplines. The research of Chen et al. [3] in 2019 and Yang et al. [4] in 2021, found that treating critically ill pregnant women is one of the most necessary areas for MDT. MDT can effectively integrate obstetrics, surgery and anesthesiology. Medical resources such as neonatology give full play to the advantages of various disciplines, and establish interdisciplinary cooperative intervention for pregnancy health care, perinatal care, nursing, neonatal diagnosis and treatment in order to maximize the prevention and treatment effect of critical diseases of pregnant and postpartum women [5].
The application of MDT in obstetrics has gradually increased, and multidisciplinary joint diagnosis and treatment can improve the success rate of maternal care. Most relevant reports focus on a certain disease during pregnancy, and there are few reports related to comprehensive health care for high-risk pregnant women. When our hospital carried out MDT for hospitalized pregnant and postpartum women with critical illness, we also initiated outpatient MDT for high-risk pregnant women. All achieved good results in improving pregnancy outcomes. The relevant clinical data are summarized and analyzed as presented.
A total of 266 pregnant and lying women who received MDT in the Affiliated Hospital of Southwest Medical University from June 2020 to July 2022 were collected. Inclusive criteria: (1) MDT was carried out in the obstetrics department of the Affiliated Hospital of Southwest Medical University due to high-risk factors of pregnant and postpartum women; (2) Pregnancy was terminated in our obstetrics department after MDT; (3) Those who were compliant and able to complete follow-up. Exclusion criteria: (1) The pregnancy was not terminated; (2) Voluntary termination of pregnancy due to non-disease factors; (3) The pregnancy was not terminated in our hospital or the medical history was incomplete.
We excluded 40 cases of MDT due to fetal factors, 19 secondaries to nonhospital
termination or incomplete medical history, 22 cases not terminated as of the
study time, and 9 cases of MDT after the termination of pregnancy. Finally, 176
cases were included in the analysis. The average age of the pregnant women was
29.37
These were sources of high-risk pregnant women, gestational weeks, departments involved in MDT, disease classification, pregnancy risk classification, pregnancy outcomes, labor conditions and delivery methods.
Outpatient MDT refers to high-risk pregnant women who visited the clinic and seen by a doctor with a deputy senior professional title to evaluate them. The physician then determined the relevant departments to participate in MDT, communicated with the patient and their families in writing, completed relevant procedures, conducted MDT consultations, developed diagnosis and treatment options, informed the patient and their families in writing of the conclusions, and implemented the management of high-risk outpatient services. Inpatient MDT refers to the MDT for high-risk pregnant and postpartum women who were hospitalized. After discussion in the department or ward round by deputy high physician or above, a diagnosis and treatment plan was developed, the patients and their families informed, and the plan was implemented.
The classification of maternal diseases was carried out according to the Work Standards for Risk Assessment and Management of Pregnancy and Maternity issued by the National Health and Family Planning Commission of the People’s Republic of China in 2017 [6]. Red risk refers to the high risk of pregnancy and childbirth, including severe internal and external diseases, hepatitis, and placenta previa. Orange risk refers to the higher risk of pregnancy and childbirth, including preeclampsia, central placenta previa, mild complications, and comorbidities. According to the Expert Consensus on Diagnosis and Treatment of Pregnancy Complicated with Heart Disease (2016) [7] published by the obstetric group of the Branch of the Society of Obstetrics and Gynecology of the Chinese Medical Association, the pregnancy risk of heart disease was graded.
WPS excel 2022 (Kingsoft Corp., Beijing, China) was used to complete data
collection and develop pivot tables for analysis. SPSS 22.0 software (IBM Corp.,
Armonk, NY, USA) was used for statistical analysis of the data, and the
measurement data were (
The number of high-risk pregnant women with MDT from primary hospitals was more
than that from outpatient clinics (p
MDT time | Outpatient Department | Hospitalization | p | |
Total | 83 | 93 | ||
Pregnant women registered in our hospital | 65 (78.3) | 15 (16.1) | 68.4026 | |
Pregnant women transferred from primary hospitals | 13 (15.7) | 59 (63.4) | 41.4159 | |
Transferred from other tertiary hospitals | 5 (6) | 19 (20.4) |
MDT, multidisciplinary collaborative diagnosis and treatment.
The average number of departments involved in outpatient high risk pregnant
women undergoing MDT was 4.61
Outpatient Department | Internal Medicine-Cardiovascular Department | 51 |
Nutrition Department | 46 | |
Neonatology | 27 | |
Department of Hematology | 21 | |
Endocrine Department | 21 | |
Cardiac Surgery | 21 | |
Rheumatology Immunology Department | 19 | |
Department of Anesthesiology | 18 | |
Hospitalization | Internal Medicine-Cardiovascular Department | 74 |
Department of Anesthesiology | 72 | |
ICU | 67 | |
Neonatology | 48 | |
Cardiac Surgery | 25 | |
Department of Hematology | 25 | |
Respiratory Medicine | 25 | |
Endocrine Department | 20 |
ICU, intensive care unit.
Among high-risk pregnant women undergoing MDT, the top three diseases were heart disease 42.6% (75/176), hypertension 14.2% (25/176), and immune system disorders 11.9% (21/176) (Table 3).
Classification of main diseases | n |
Pregnancy with heart disease | 75 |
Hypertensive disorder of pregnancy | 25 |
Pregnancy with immune system diseases | 21 |
Pregnancy with hematological diseases | 15 |
Pregnancy with renal disease | 15 |
Pregnancy with digestive system diseases | 11 |
Pregnancy with nervous system diseases | 6 |
Pregnancy with respiratory diseases | 4 |
Pregnancy with endocrine diseases | 4 |
For high-risk pregnant women with pregnancy complicated by heart disease, the
main cardiovascular diseases were classified as congenital heart disease 38 cases
(50.7%), arrhythmias without cardiac structural abnormalities 15 cases (20%),
perinatal cardiomyopathy 7 cases (9.3%), valvular heart disease 6 cases (8%),
hyperthyroid heart disease 4 cases (5.3%), hypertensive heart disease 3 cases
(4%), rheumatic heart disease 1 case (1.3%), and infectious endocarditis 1 case
(1.3%). The pregnancy risk grade of outpatient MDT with heart disease was
I–III, which was higher than that of inpatient MDT (
MDT time | Outpatient Department | Hospitalization | p | ||||||
Total | 35 | 40 | |||||||
MDT gestational trimester | First | Mid | Third | First | Mid | Third | |||
Heart disease pregnancy risk classification |
I–III | 7 (20) | 12 (34.3) | 16 (45.7) | 2 (5) | 3 (7.5) | 17 (42.5) | 20.724 | 0.00001 |
IV–V | 0 | 0 | 0 | 3 (7.5) | 3 (7.5) | 12 (30) |
Note: ‘a’ is the percentage of the total number of MDT cases.
There were 25 cases of pregnancy-induced hypertension. These included 5 cases of outpatient MDT (20%) and 20 cases of inpatient MDT (80%). Among the hospitalized MDT patients with pregnancy-induced hypertension, 15 (75%) had serious complications.
The proportion of high risk pregnant women undergoing MDT with red pregnancy
risk grade in late pregnancy was higher than that during early and middle
pregnancy (p
MDT gestational age | First | Mid | Third | p | |||
Total | 28 | 41 | 107 | ||||
Pregnancy risk classification |
Yellow | 14 (50) | 20 (48.8) | 1 (0.9) | |||
Orange | 0 | 2 (4.9) | 38 (35.5) | ||||
Red | 14 (50) | 19 (46.3) | 68 (63.6) | 4.242 | 0.039 | ||
Pregnancy outcome |
Iatrogenic fetal loss | Induced abortion | 10 (35.7) | 12 (29.3) | 1 (0.9) | ||
Fetus delivered by cesarean section | 2 (7.1) | 3 (7.3) | 1 (0.9) | ||||
Non iatrogenic fetal loss | Inevitable abortion | 0 | 1 (2.4) | / | |||
Stillbirth | 0 | 0 | 3 (2.8) | ||||
Childbirth | Premature delivery | 4 (14.3) | 7 (17.1) | 53 (49.5) | 7.506 | 0.023 | |
Term birth | 12 (42.9) | 18 (43.9) | 49 (45.8) |
Note: ‘a’ is the percentage of the total number of cases at the same MDT gestational age.
There were 68 cases of red risk in late pregnancy, 63 cases of live birth, and 5 cases of adverse pregnancy outcomes. All of them were MDT pregnant women with severe pregnancy-induced hypertension and multiple organ dysfunction. Because of this critical condition, 2 cases were delivered by cesarean section and induced labor with the other 3 cases having fetal death and stillbirth.
There were 33 cases of pregnant women with MDT in early and middle pregnancy, of
which 28 cases terminated their pregnancy in time, and the remaining 5 cases and
their families who had MDT in the outpatient department insisted on continuing
their pregnancy. Under the management of outpatient MDT, 1 case of chronic
hypertension had a premature cesarean section due to pulmonary hypertension at
35
There was a higher the rate of premature delivery, multiple organ damage, and
ICU monitoring in high-risk pregnant women with a later gestational age of MDT
(p
MDT gestational age | First | Mid | Third | p | |
Total | 28 | 41 | 107 | ||
Multiple organ injury |
8 (28.6) | 13 (31.7) | 57 (53.3) | 8.931 | 0.012 |
ICU monitoring | 3 (10.7) | 8 (19.5) | 54 (50.5) | 22.02 | 0.004 |
Death | 0 | 0 | 2 (1.7) |
Note: ‘a’ is the percentage of the total number of cases at the same MDT gestational age.
The later the gestational week of MDT, the higher the proportion of cesarean
section (p
MDT gestational age | First | Mid | Third | p | ||
Live birth | 16 | 25 | 102 | |||
Mode of delivery |
Vaginal delivery | 5 (31.3) | 6 (24) | 7 (6.9) | ||
Cesarean section | 11 (68.7) | 19 (76) | 95 (93.1) | 11.062 | 0.004 |
Note: ‘b’ is the percentage of total cases in each group.
Group | Outpatient Department | Hospitalization | p | ||
Live birth | 34 | 68 | |||
Mode of delivery |
Vaginal delivery | 6 (17.6) | 1 (1.5) | ||
Cesarean section | 28 (82.4) | 67 (98.5) | 9.28 | 0.002 | |
Asphyxia neonatorum |
1 (2.9) | 14 (20.6) | 5.628 | 0.018 |
Note: ‘b’ is the percentage of total cases in each group.
We constructed a multivariate logistic regression equation for gestational age
and hospital admission at the time of inclusion in MDT. The results showed that
the later the gestational age during MDT, the higher the risk of adverse
pregnancy outcomes being statistically significant (odds ratio (OR) = 2.903, 95%
confidence interval (CI): 1.743–4.836, p
Factor | S.E | Wald | p | OR | 95% CI | |
Gestational week | 1.066 | 0.260 | 16.750 | 0.000 | 2.903 | 1.743–4.836 |
Hospitalization or not | 1.584 | 0.363 | 19.088 | 0.000 | 4.876 | 2.395–9.925 |
OR, odds ratio; CI, confidence interval; S.E, standard error.
In this review, the classification of high-risk maternal diseases for MDT is mainly pregnancy with heart disease and pregnancy induced hypertension. Therefore, the multidisciplinary consultation departments were concentrated in cardiology, anesthesiology, ICU, and neonatology. This indicates that there are many high-risk pregnant women with a complicated by cardiovascular disease, who are seriously ill, whose disease may have a greater impact on their newborn, and who deliver predominately by cesarean section [8].
Congenital heart disease is a major cause of maternal death. In this study, 2 pregnant women who expired were affected by congenital heart disease. They were transferred to our hospital from the primary institution due to pulmonary artery hypertension and massive hemorrhage from placenta previa. Most health care providers agree on the importance of multidisciplinary treatment of pregnancy with heart disease [7, 9]. In 2021, the Journal of the American Heart Association (JACC) suggested in the management of women with congenital heart disease that such pregnant women should be identified by asking for medical history in the outpatient department or by conventional electrocardiogram and color Doppler echocardiography. When the patient is identified in the early pregnancy period, MDT management should be initiated for pregnant women with low risk of heart disease from early pregnancy to the delivery. For pregnant women with a high risk of heart disease or pulmonary hypertension, the association suggested that pregnancy should be terminated promptly [10]. If there is a strong desire to have children, MDT assessment or treatment can be prior to pregnancy, and pregnancy can be resumed after the condition improves.
Hypertensive disorders of pregnancy are characterized by rapid deterioration in
the third trimester of pregnancy. In this study, 5 cases of pregnancy induced
hypertension with adverse pregnancy outcomes were treated with MDT after
hospitalization, and multiple organ function damage had occurred prior to
transfer to our hospital. The International Federation of Obstetricians and
Gynecologists (FIGO) recommends that all pregnant women should pass the early
pregnancy joint test at 11–13
The obstetric MDT team should be led by the obstetrics department, with the participation of senior doctors or experts from other relevant departments. It should examine pregnant women, formulate diagnosis and treatment plans, and participate in their treatment. According to the changes in the condition of the patient, new expert members may be added at any time, and the plan can be updated. The statistical results of this study demonstrate that the main departments involved in MDT include obstetrics, cardiology, anesthesiology, ICU, and neonatology. In addition, the nutrition department, endocrinology department, and hematology department have a high frequency of participation in outpatient MDT. It is apparent that there are many internal medicine departments involved in the treatment of high-risk pregnant women, all playing a very important role in the management and treatment of pregnancy complications [13, 14]. This viewpoint has been affirmed multiple times in past reports. In a study by Piani et al. [15], it was demonstrated that if a professional internist intervenes in prenatal care, the pregnancy outcomes of high-risk pregnant women will be significantly improved.
Nutrition management has a decisive impact for high-risk pregnant women with diabetes, heart disease, pregnancy induced hypertension, kidney disease and rheumatic immune disease. In 2014, Brantsæter et al. [16] found in the study of maternal-infant cohort (MoBa) of maternal diet, that a healthy and balanced diet can reduce pregnancy complications, reduce the incidence of preeclampsia, preterm birth, and fetal growth restriction. Most et al. [17] pointed out that compliance with nutrition management in early pregnancy can ensure normal fetal development and reduce the risk of adverse consequences for the mother and baby. An online survey report on local pregnant women by Brown et al. [18] found that less than half of pregnant women have enough knowledge about nutrition intake, and obstetricians and nurses are not able to provide professional and perfect nutrition guidance [19]. The participation of the nutrition department in this study greatly benefited the pregnant women.
The disease classification of this study revealed that 19 pregnant women with blood system diseases and endocrine diseases participated in MDT 46 times and 41 times respectively in the departments of hematology and endocrinology. This suggests that some basic diseases may develop into serious pregnancy complications, which requires the participation of relevant departments. Many studies have shown that endocrine imbalance is significantly related to maternal and infant outcomes [20, 21]. In a practice guide [22] issued by the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), a multidisciplinary team composed of obstetrics, anesthesiology, blood transfusion, and hematology departments made recommendations based on existing research evidence. High-risk pregnant women should maintain adequate hemoglobin levels, strengthen hemostasis and reduce bleeding, to ensure the safety of both mothers and children. In addition, Alfirevic et al. [23] found that using Doppler ultrasound to screen umbilical arteries in high-risk late pregnancy can reduce the risk of perinatal death. Sharma et al. [24] pointed out that a complete MDT team should improve the outcome of high-risk pregnant women as much as possible, and balance the risks and benefits of pregnancy treatment and postpartum recovery. Anesthesiology, blood transfusion, and ultrasound use are also essential. In addition to the relevant clinical departments, the MDT team needs the joint participation of imaging, testing, blood transfusion, pharmacy, and other auxiliary disciplines as needed. Therefore, it can be stated that the establishment of an obstetric MDT team is similar to an expert pool, including experts from clinical departments and auxiliary departments. The MDT team should be able to be constituted at any time on short notice to participate in consultation and treatment of the patient.
According to the statistical data from this study, early and middle pregnancy outpatient MDT can timely assess, diagnose and treat high-risk pregnant women, and provide adequate pregnancy supervision to achieve a satisfactory outcome. However, most of the pregnant women with MDT in late pregnancy, or MDT after hospitalization when their condition is critical, are transferred from primary hospitals when their condition deteriorates, resulting in a high rate of cesarean section, premature delivery, neonatal asphyxia, stillbirth, and maternal death. The reasons may be the lack of an MDT team, the delay in identification and referral of the patient by the primary medical institution, insufficient perinatal health care and risk awareness by the pregnant women and their families. All of these events can lead to the failure of timely and accurate intervention for these high-risk pregnant women, leading to adverse pregnancy outcomes. Therefore, it is necessary to strengthen the recognition ability and MDT awareness of high-risk pregnant women in primary medical institutions. Training can be conducted in primary hospitals through network meetings and lectures, so that patients can receive MDT treatment in primary hospitals or qualified hospitals during early and middle pregnancy. Media publicity and health education on obstetric critical diseases for women of childbearing age should be provided through the Internet, television, community activities and other channels [25], in order to improve the medical awareness and compliance for high-risk pregnant women.
For high-risk pregnant women, early outpatient MDT intervention is beneficial in order to improve pregnancy outcomes. Health care providers should actively promote outpatient MDT in obstetrics, include high-risk pregnant women in MDT management as early as possible, provide them with timely, comprehensive, and continuous diagnosis and treatment. This approach has the potential to improve pregnancy outcomes, reduce complications, and ensure the health of mothers and infants.
Outpatient MDT management can effectively improve the pregnancy outcome of high-risk pregnant women, and this mode of management should be actively promoted. A comprehensive and professional MDT team should be established to improve the rescue rate of critically ill pregnant women and reduce adverse pregnancy outcomes.
The data that support the findings of this study are available from the Affiliated Hospital of Southwest Medical University but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Affiliated Hospital of Southwest Medical University.
JL undertook conceptual design, data collection, data analysis and interpretation, statistical analysis, and manuscript drafting. LB and QS participated in data collection and data analysis. HL and YZ mainly provided management technology and material support. XF undertakes research method design and data analysis, critically revised manuscripts, provided financial support, and supervised the entire process. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.
Written informed consent was obtained from the subject and/or guardian. The study was approved by the Ethics Committee of the Affiliated Hospital of Southwest Medical University (Ky2022237).
This study was supported by data provided by the Outpatient Office of the Affiliated Hospital of Southwest Medical University.
This work was funded by the Sichuan Provincial Science and Technology Department (No.2021JDR0185).
The authors declare no conflict of interest.
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