Hi there,
Apoplogies for the delay in blog posting- I have been busy with a major project which has now come to fruition. We have now introduced SFLP for TTTS (see earlier post for more info) to New Zealand. A very proud moment for me personally and for our Fetal Medicine Unit in Auckland. We couldn't have done it without lots of people, but in particular: Mercury Energy Star Supporters Club, Starship Foundation, ADHB management, Ministry of Health and all the fab staff in our unit and the theatre team on level 9 and 4.
There has been a bit of media interest around this and if you have time to kill have a look!.....
NZ Herald
http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10577770
East & Bays Courier
http://www.stuff.co.nz/auckland/local-news/east-bays-courier/2490935/High-tech-lifesaver-for-twins
TVNZ – online written version and video clip of news item
http://tvnz.co.nz/health-news/new-weapon-fight-twin-blood-condition-2778509
Waikato Times
http://www.stuff.co.nz/waikato-times/news/2488081/Familys-ordeal-won-t-be-relived
The Press
http://www.stuff.co.nz/the-press/news/2486658/Life-saving-surgery-in-NZ
FYI -- Tony Ryall’s speech:
http://www.beehive.govt.nz/speech/speech+launch+new+fetoscope+national+women039s+health
and next week the NZ women's weekly.
MFM moving fast in NZ and will try to post more regularly!
Emma
Thursday, June 11, 2009
Sunday, March 22, 2009
Working in Bhutan
It has been a while since my last post as I have been busy preparing for the RANZCOG ASM here in Auckland. I am on the organising committee and at last count had 4 talks and three sessions to chair!
I am talking on a project that I was lucky enough to get funding for in Bhutan- a small country in the Himalayas. As part of this I went to Bhutan in 2006 for 3 months with my family. It was an amazing experience and the work I was involved in is still continuing with increased uptake of ultrasound scanning by women. Below is a report I wrote for ASUM (Australasian Society of USS in medicine):
ASUM report on Magee Family project- Development of Perinatal Services for Bhutan
Dr Emma Parry FRANZCOG
I am an obstetrician from Auckland who is lucky to be involved in a project to improve perinatal outcomes in Bhutan. Bhutan is a small Buddhist Kingdom in the Himalayas with a population of around 600,000, which has high maternal and perinatal mortality. From April to July this year I went to Bhutan with my husband and two children to work in a number of areas of the project, the main one being ultrasound training.
In Bhutan there are no formally trained sonographers. There is one Obstetrician with training in high-risk obstetrics and ultrasound - Dr Phurb Dorji who spent 18 months at National Women’s hospital in Auckland, New Zealand. He is the main resource in obstetric ultrasound in the country. There are 5 other Obstetrician and Gynaecologists, though none with an interest in ultrasound.
Bhutan has a free health system, with 3 referral hospitals, around 12 district hospitals and a large number of Basic Health Units. The geography is a major challenge, it takes 3-4 days to travel from one end of the country to another although it is only around 600 km, and around 40% of the population are more than one hours walk from a road.
In the district hospitals some ultrasound scanning is available and is performed by 12 X-ray technicians. These technicians have formal X-ray training. They are then selected for further ultrasound training. This entails observing scanning for 3 months in India, with no formal teaching or hands-on experience. They then return home and start scanning and in most cases there is no support or supervision.
Within the project, provision has been made for formal sonographer training and currently two former X-ray technicians are in India part way through a formal two-year training programme.
Whilst I was in Bhutan I ran two 4-week training courses for all the X-ray technicians. As half came to the capital (Thimphu) for four weeks, others went out to the busiest units from Thimphu to provide the ultrasound service whilst their colleague was on the course. This way all technicians were able to attend.
The number of years spent scanning ranged from 1 month to 8 years. This meant there were some hard habits to break! All the technicians were keen and enjoyed having the first ever formal teaching in ultrasound. At the start of the course all the students were given an MCQ-, which they all failed! This was given to them again at the end of the course.
The course comprised of daily lectures from 9:00 until 10:30. Topics included physics of ultrasound and Doppler, which were kindly given by my husband- Dr Dave Parry- who is a medical physicist. I gave lectures on early pregnancy, dating, biometry, assessment of fetal wellbeing, Doppler and gynaecological scanning. I also gave a brief lecture on anomoly scanning and Dr Phurb Dorji gave lectures on fetal anomalies. We didn’t expect the students to be able to do anomoly screening, but hoped that they would be able to identify major anomalies so that decisions could be made about where to deliver and transfer for a second opinion to Dr Phurb Dorji as necessary. One needs to bear in mind that some of the units are a two-day drive away!
After the lecture the students split into two groups of mixed ability. Some went to the main hospital scan department where there were two machines. General scans, gynae and early pregnancy scans were done here. The other half went to the maternity outpatients where obstetric scanning was performed. As part of the project a portable ultrasound machine had been purchased- a Terason- and taken to Bhutan in our hand luggage! This machine proved to be excellent and we were able to have this and the small Aloka in the maternity outpatients, so two students could scan at once in both sites. I swapped between the two sites and provided hands-on supervision, which the students quickly got used to. Students were encouraged to critique each other whenever not being directly supervised by Phurb Dorji or myself.
Students kept a logbook and at the end of each week we reviewed their progress and range of cases. In the last week a series of tests were held including a practical exam. The MCQ was run again on the penultimate day. All twelve students passed the final exam and all improved! Student feedback was very good and despite having to come to Thimphu for a month they all really enjoyed the course.
Part of the concern is the ongoing lack of supervision and collegiality. We provided a number of support materials and are trying to maintain contact with the students via email. Thanks to ASUM, we were able to provide an excellent physics CD-rom for them free of charge. We very much appreciate this generous contribution.
Lessons learned:
• Linking theory and practice is important
• Relatively short interventions appear to be successful
• Both parties learn a lot from these activities
Also, Dave Parry (my husband and co-developer) has placed all our materials we used for the project on a server if you wish to use them. Please feel free to use, though we'd appreciate a mention and any feedback!
http://elena.aut.ac.nz/homepages/staff/Dave-Parry/docs.html
Emma
I am talking on a project that I was lucky enough to get funding for in Bhutan- a small country in the Himalayas. As part of this I went to Bhutan in 2006 for 3 months with my family. It was an amazing experience and the work I was involved in is still continuing with increased uptake of ultrasound scanning by women. Below is a report I wrote for ASUM (Australasian Society of USS in medicine):
ASUM report on Magee Family project- Development of Perinatal Services for Bhutan
Dr Emma Parry FRANZCOG
I am an obstetrician from Auckland who is lucky to be involved in a project to improve perinatal outcomes in Bhutan. Bhutan is a small Buddhist Kingdom in the Himalayas with a population of around 600,000, which has high maternal and perinatal mortality. From April to July this year I went to Bhutan with my husband and two children to work in a number of areas of the project, the main one being ultrasound training.
In Bhutan there are no formally trained sonographers. There is one Obstetrician with training in high-risk obstetrics and ultrasound - Dr Phurb Dorji who spent 18 months at National Women’s hospital in Auckland, New Zealand. He is the main resource in obstetric ultrasound in the country. There are 5 other Obstetrician and Gynaecologists, though none with an interest in ultrasound.
Bhutan has a free health system, with 3 referral hospitals, around 12 district hospitals and a large number of Basic Health Units. The geography is a major challenge, it takes 3-4 days to travel from one end of the country to another although it is only around 600 km, and around 40% of the population are more than one hours walk from a road.
In the district hospitals some ultrasound scanning is available and is performed by 12 X-ray technicians. These technicians have formal X-ray training. They are then selected for further ultrasound training. This entails observing scanning for 3 months in India, with no formal teaching or hands-on experience. They then return home and start scanning and in most cases there is no support or supervision.
Within the project, provision has been made for formal sonographer training and currently two former X-ray technicians are in India part way through a formal two-year training programme.
Whilst I was in Bhutan I ran two 4-week training courses for all the X-ray technicians. As half came to the capital (Thimphu) for four weeks, others went out to the busiest units from Thimphu to provide the ultrasound service whilst their colleague was on the course. This way all technicians were able to attend.
The number of years spent scanning ranged from 1 month to 8 years. This meant there were some hard habits to break! All the technicians were keen and enjoyed having the first ever formal teaching in ultrasound. At the start of the course all the students were given an MCQ-, which they all failed! This was given to them again at the end of the course.
The course comprised of daily lectures from 9:00 until 10:30. Topics included physics of ultrasound and Doppler, which were kindly given by my husband- Dr Dave Parry- who is a medical physicist. I gave lectures on early pregnancy, dating, biometry, assessment of fetal wellbeing, Doppler and gynaecological scanning. I also gave a brief lecture on anomoly scanning and Dr Phurb Dorji gave lectures on fetal anomalies. We didn’t expect the students to be able to do anomoly screening, but hoped that they would be able to identify major anomalies so that decisions could be made about where to deliver and transfer for a second opinion to Dr Phurb Dorji as necessary. One needs to bear in mind that some of the units are a two-day drive away!
After the lecture the students split into two groups of mixed ability. Some went to the main hospital scan department where there were two machines. General scans, gynae and early pregnancy scans were done here. The other half went to the maternity outpatients where obstetric scanning was performed. As part of the project a portable ultrasound machine had been purchased- a Terason- and taken to Bhutan in our hand luggage! This machine proved to be excellent and we were able to have this and the small Aloka in the maternity outpatients, so two students could scan at once in both sites. I swapped between the two sites and provided hands-on supervision, which the students quickly got used to. Students were encouraged to critique each other whenever not being directly supervised by Phurb Dorji or myself.
Students kept a logbook and at the end of each week we reviewed their progress and range of cases. In the last week a series of tests were held including a practical exam. The MCQ was run again on the penultimate day. All twelve students passed the final exam and all improved! Student feedback was very good and despite having to come to Thimphu for a month they all really enjoyed the course.
Part of the concern is the ongoing lack of supervision and collegiality. We provided a number of support materials and are trying to maintain contact with the students via email. Thanks to ASUM, we were able to provide an excellent physics CD-rom for them free of charge. We very much appreciate this generous contribution.
Lessons learned:
• Linking theory and practice is important
• Relatively short interventions appear to be successful
• Both parties learn a lot from these activities
Also, Dave Parry (my husband and co-developer) has placed all our materials we used for the project on a server if you wish to use them. Please feel free to use, though we'd appreciate a mention and any feedback!
http://elena.aut.ac.nz/homepages/staff/Dave-Parry/docs.html
Emma
Sunday, December 7, 2008
Twin to twin transfusion syndrome
I have an interest in complex twin pregnancies and have some information (probably more for health professionals) on a condition called Twin to twin transfusion syndrome. We are shortly starting a programme of laser treatment in Auckland. Follow the link to the Mercury Matters article from Mercury Energy who are supporting us through Starship Foundation in the Auckland MFM unit:
http://www.mercury.co.nz/Residential/news_story.aspx?id=1056
Twin to twin transfusion Syndrome (TTTS)
Twin pregnancy occurs in approximately 2% of pregnancies and the rate is increasing. This is thought to be due to increasing maternal age and increasing use of assisted reproductive technologies which are both known risk factors for multiple births. 1/3 of twin pregnancies are higher risk by virtue of having a single shared placenta (monochorionic placenta). It is estimated that 85% of all monochorionic placentas have anomalous vascular connections. Of these 15% have sufficient imbalance to produce Twin to Twin Transfusion Syndrome (TTTS). In this situation one twin receives more blood flow than the other by virtue of unidirectional flow along connecting vessels. This diagnosis carries an extremely poor prognosis and it can be responsible for up to 20% of all perinatal deaths in twins.
TTTS diagnosis peaks at 22-26 weeks gestation. This is one of the most ethically and medically challenging times of pregnancy as delivery at this time leads to poor outcomes.
The natural history of TTTS is associated with 80-100% mortality for both twins in the most severe cases. The most affected fetuses usually present with signs of TTTS before 20 weeks gestation. This is manifested with polyhydramnios/oligohydramnios (excess and reduced amniotic fluid), empty bladder/ full bladder, abnormal blood flow patterns within the two fetuses and heart failure. Stage 1 is where there is disparity between amniotic fluid volumes only. If there is any of the other features mentioned above the staging will be 2, 3 or 4 and considered severe. Treatment severe TTTS (stage 2, 3 or 4) is either serial amnioreduction or selective fetoscopic laser photocoagulation (SFLP).
Amnioreduction involves giving the woman a local anaesthetic into the anterior abdominal wall plus intravenous sedation if indicated. Following this, under aseptic conditions a large bore cannula (needle) is inserted into the amniotic fluid of the sac of the fetus with polyhydramnios under ultrasound guidance. After the needle is removed the cannula is attached to a wall suction unit and a volume of amniotic fluid is withdrawn. This usually takes around 1-2 hours. It is thought that the release of pressure on the placenta allows normal flow patterns to restore in the placenta, though the majority of women require repeat procedures.
SFLP involves giving the woman a local anaesthetic into the anterior abdominal wall plus intravenous sedation if indicated or rarely a general anaesthetic. Following this, under aseptic conditions an operating fetoscope of 3.2mm diameter is inserted into the uterine cavity under ultrasound guidance. The fetoscope is then used to identify the vascular connections along the placental surface and they coagulated individually using laser. This procedure effectively stops the process of TTTS by ‘separating’ the two fetus’s circulations within the placenta. Therefore only one procedure is performed.
A randomised controlled trial from the Eurofetus group (grade 1b evidence) comparing laser surgery with serial amnioreduction showed significant benefit in the laser group (1). It is the largest randomised controlled study to date. The laser group had a higher likelihood of survival of at least one twin to 28 days of age 76% vs. 56%. Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia (6% vs. 14%, number needed to treat (NNT) 12.5 cases) and were more likely to be free of neurological complications at 6 months of age (52% vs. 31%). The presence of cystic periventricular leukomalacia has been shown to have a very high correlation with the development of cerebral palsy in the neonate. A meta-analysis has been performed of all randomised controlled trials (RCTs) published to date and confirms the findings of the Eurofetus study (2).
Follow-up studies of pregnancies treated with SFLP have shown that at two years of age the rates of major neurological abnormality are 6% and minor neurological abnormality are 7.2% (3). This suggests there is no hidden morbidity from the procedure not apparent in the initial randomised controlled trial and confirms the relationship between cystic periventricular leukomalacia and the subsequent development of cerebral palsy. This is the largest study to date, but further studies continue to be published from centres that have been performing SFLP for some time and overall the outcomes are similar.
Initially this procedure was confined to a few specialised centres in the world. The Eurofetus randomised controlled trial was performed in Europe by experienced practitioners. In the late 1990s the fetoscopic equipment to perform the procedure was being developed and refined by two companies, Karl Storz and Wolf, in conjunction with the centres pioneering the technique. As other centres started to perform the procedure they underwent training and started to audit their own outcomes. It is now performed in many developed countries including Australia (three centres) and soon New Zealand.
(1)Senat, M.V., et al., Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. New England Journal of Medicine, 2004. 351(2): p. 136-44;
(2)Rossi, A.C. and V. D'Addario, Laser therapy and serial amnioreduction as treatment for twin-twin transfusion syndrome: A metaanalysis andreviewofliterature. American Journal of Obstetrics and Gynecology, 2007;
(3)Graef, C., Ellenrieder,B., Hecher,K., Hackeloer,B.J., Huber,A., Bartmann,P., Long-term neurodevelopmental outcome of 167 children after intrauterine laser treatment for severe twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology, 2005. 194: p. 303-308;
http://www.mercury.co.nz/Residential/news_story.aspx?id=1056
Twin to twin transfusion Syndrome (TTTS)
Twin pregnancy occurs in approximately 2% of pregnancies and the rate is increasing. This is thought to be due to increasing maternal age and increasing use of assisted reproductive technologies which are both known risk factors for multiple births. 1/3 of twin pregnancies are higher risk by virtue of having a single shared placenta (monochorionic placenta). It is estimated that 85% of all monochorionic placentas have anomalous vascular connections. Of these 15% have sufficient imbalance to produce Twin to Twin Transfusion Syndrome (TTTS). In this situation one twin receives more blood flow than the other by virtue of unidirectional flow along connecting vessels. This diagnosis carries an extremely poor prognosis and it can be responsible for up to 20% of all perinatal deaths in twins.
TTTS diagnosis peaks at 22-26 weeks gestation. This is one of the most ethically and medically challenging times of pregnancy as delivery at this time leads to poor outcomes.
The natural history of TTTS is associated with 80-100% mortality for both twins in the most severe cases. The most affected fetuses usually present with signs of TTTS before 20 weeks gestation. This is manifested with polyhydramnios/oligohydramnios (excess and reduced amniotic fluid), empty bladder/ full bladder, abnormal blood flow patterns within the two fetuses and heart failure. Stage 1 is where there is disparity between amniotic fluid volumes only. If there is any of the other features mentioned above the staging will be 2, 3 or 4 and considered severe. Treatment severe TTTS (stage 2, 3 or 4) is either serial amnioreduction or selective fetoscopic laser photocoagulation (SFLP).
Amnioreduction involves giving the woman a local anaesthetic into the anterior abdominal wall plus intravenous sedation if indicated. Following this, under aseptic conditions a large bore cannula (needle) is inserted into the amniotic fluid of the sac of the fetus with polyhydramnios under ultrasound guidance. After the needle is removed the cannula is attached to a wall suction unit and a volume of amniotic fluid is withdrawn. This usually takes around 1-2 hours. It is thought that the release of pressure on the placenta allows normal flow patterns to restore in the placenta, though the majority of women require repeat procedures.
SFLP involves giving the woman a local anaesthetic into the anterior abdominal wall plus intravenous sedation if indicated or rarely a general anaesthetic. Following this, under aseptic conditions an operating fetoscope of 3.2mm diameter is inserted into the uterine cavity under ultrasound guidance. The fetoscope is then used to identify the vascular connections along the placental surface and they coagulated individually using laser. This procedure effectively stops the process of TTTS by ‘separating’ the two fetus’s circulations within the placenta. Therefore only one procedure is performed.
A randomised controlled trial from the Eurofetus group (grade 1b evidence) comparing laser surgery with serial amnioreduction showed significant benefit in the laser group (1). It is the largest randomised controlled study to date. The laser group had a higher likelihood of survival of at least one twin to 28 days of age 76% vs. 56%. Infants in the laser group also had a lower incidence of cystic periventricular leukomalacia (6% vs. 14%, number needed to treat (NNT) 12.5 cases) and were more likely to be free of neurological complications at 6 months of age (52% vs. 31%). The presence of cystic periventricular leukomalacia has been shown to have a very high correlation with the development of cerebral palsy in the neonate. A meta-analysis has been performed of all randomised controlled trials (RCTs) published to date and confirms the findings of the Eurofetus study (2).
Follow-up studies of pregnancies treated with SFLP have shown that at two years of age the rates of major neurological abnormality are 6% and minor neurological abnormality are 7.2% (3). This suggests there is no hidden morbidity from the procedure not apparent in the initial randomised controlled trial and confirms the relationship between cystic periventricular leukomalacia and the subsequent development of cerebral palsy. This is the largest study to date, but further studies continue to be published from centres that have been performing SFLP for some time and overall the outcomes are similar.
Initially this procedure was confined to a few specialised centres in the world. The Eurofetus randomised controlled trial was performed in Europe by experienced practitioners. In the late 1990s the fetoscopic equipment to perform the procedure was being developed and refined by two companies, Karl Storz and Wolf, in conjunction with the centres pioneering the technique. As other centres started to perform the procedure they underwent training and started to audit their own outcomes. It is now performed in many developed countries including Australia (three centres) and soon New Zealand.
(1)Senat, M.V., et al., Endoscopic laser surgery versus serial amnioreduction for severe twin-to-twin transfusion syndrome. New England Journal of Medicine, 2004. 351(2): p. 136-44;
(2)Rossi, A.C. and V. D'Addario, Laser therapy and serial amnioreduction as treatment for twin-twin transfusion syndrome: A metaanalysis andreviewofliterature. American Journal of Obstetrics and Gynecology, 2007;
(3)Graef, C., Ellenrieder,B., Hecher,K., Hackeloer,B.J., Huber,A., Bartmann,P., Long-term neurodevelopmental outcome of 167 children after intrauterine laser treatment for severe twin-twin transfusion syndrome. American Journal of Obstetrics and Gynecology, 2005. 194: p. 303-308;
Friday, December 5, 2008
Conferences
We are looking at the various conferences happening next year at the moment. There are a few in Australasia which are of interest to the health professional interested in MFM:
http://www.fetus2009.com/
http://www.psanz.org.au/
The fetus as a patient in Sydney is mainly about fetal medicine, but also some maternal. PSANZ is a multi-disciplinary conference which attracts MFM health professionals and neonatologists and midwifery health professionals.
I should also plug:
http://www.aocogranzcog2009.co.nz/
This is a general O&G conference in Auckland which will be broad ranging, but has some high-tech and some developing world elements to it. I am part of the organising committee and running a workshop on IT so I think it will be great!
Have a good weekend
Emma Parry
http://www.fetus2009.com/
http://www.psanz.org.au/
The fetus as a patient in Sydney is mainly about fetal medicine, but also some maternal. PSANZ is a multi-disciplinary conference which attracts MFM health professionals and neonatologists and midwifery health professionals.
I should also plug:
http://www.aocogranzcog2009.co.nz/
This is a general O&G conference in Auckland which will be broad ranging, but has some high-tech and some developing world elements to it. I am part of the organising committee and running a workshop on IT so I think it will be great!
Have a good weekend
Emma Parry
Monday, November 17, 2008
Welcome to MFM New Zealand
Hi and welcome to MFM New Zealand. I hope that this blog will be of interest to women, their families/whanau, clinicians, midwives and anyone else who has anything to do with high risk pregnancy. I am an MFM subspecialist based in Auckland and have a keen interest in providing great care to women in New Zealand where pregnancy may not be going according to plan.
I hope to update this blog regularly with interesting information and links with issues related to MFM (if time allows!)
Any opinions expressed on this blog are my own and do not constitute medical advice.
I hope to update this blog regularly with interesting information and links with issues related to MFM (if time allows!)
Any opinions expressed on this blog are my own and do not constitute medical advice.
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