Prospective Implementation of Multi-Disciplinary Obstetric Team Decreases the Mortality Rate of Pregnant Women with Sickle Cell Disease in Ghana

Introduction: Pregnant women with sickle cell disease (SCD) are at increased risk for both pregnancy and SCD related morbidity and mortality. At the Korle-Bu Teaching Hospital (KBTH), a national referral center in Accra, Ghana, the estimated maternal mortality ratio of women with and without SCD is 8,300 and 690 per 100,000 live births respectively (US, general population, maternal mortality ratio 14 per 100, 000 live births). In 2015, a multi-disciplinary obstetric SCD team was formed comprising obstetricians, hematologists, pulmonologists and nurses. In a before and after study design, we tested the hypothesis that implementing a multi-disciplinary team for care of pregnant women with SCD would significantly decrease maternal mortality.

Methodology: The study received ethical approval from the Ethical and Protocol Review Committee, College of Health Sciences, University of Ghana Institutional Review Board and Vanderbilt University Medical Center (Data Coordinating Center (DCC). The pre-intervention period was from January 2014 to April 2015, and the post intervention period was May 2015 to May 2016. During the intervention period, members of the multi-disciplinary team evaluated participants at enrollment, during outpatient visits and during acute illnesses (inpatient and outpatient). Simple protocols were implemented for preventing and treating Acute Chest Syndrome (ACS). Balloons were purchased (substituted for incentive spirometry devices) and used routinely during management of acute pain episodes and after surgery. Multiple pulse oximetry machines were integrated into routine clinical practice for monitoring of oxygen desaturation. Close maternal and fetal monitoring were implemented. During the pre-intervention period, pregnant women were admitted to multiple wards throughout the hospital. Post-intervention, pregnant women were primarily admitted to two designated wards at the Obstetrics Department, for better coordinated care. All participants in the post-intervention period were followed from enrollment until six weeks postpartum. Members of the clinical research team and DCC adjudicated every vaso-occlusive pain episode, ACS episode, and acute event requiring hospitalization. Pain was defined as an acute episode, unrelated to labor and requiring hospitalization. ACS was defined based on the presence of at least 2 of the following criteria: fever, increased respiratory rate, chest pain, pulmonary auscultatory findings, increased O₂ requirement or new radiodensity on chest roentgenogram.

Results: A total of 154 and 91 deliveries by women with SCD were evaluated in the pre- and post-intervention period, respectively. The median age for cases in the pre-intervention period was 29 (range 18- 43) years. The median age for cases in post-intervention period was 29 (range 18-41) years and 35 participants had hemoglobin SSand 56had HbSC. Among the 91 participants, rates of pain and ACS were 194.6 (64/32.89) and 42.6 (14/32.89) events per 100 patient-years, respectively. Median gestational age at enrollment was 24 (range 7 - 40) weeks. Median gestational age at delivery was 38 (range 26 - 41) weeks. Perinatal mortality rates pre- and post-intervention were 74.3 per 1000 total births (11/ 148 X 1000) and 54.9 per 1000 total births (5/91 X 1000) respectively. Maternal mortality pre- and post-intervention were 9.7% (15 of 154) and 1.1% (1 of 91) of total deliveries respectively. The maternal mortality ratio pre- and post-intervention were 10,949 (15/137) and 1,163 (1/86) per 100,000 live births respectively. Cause of death pre-intervention period included: cardiopulmonary disease-60.0%, preeclampsia-6.67%, acute kidney injury-6.67%, severe anemia-20.0%, hypovolemic shock-6.67%. During the post-intervention period, the only death was an autopsy confirmed massive pulmonary embolism four days postpartum.

Conclusion: In a low and middle income setting, a multidisciplinary team approach to care of pregnant women with SCD can dramatically decrease maternal mortality, as well as perinatal mortality. Further strategies must be employed to decrease the SCD related maternal mortality and perinatal mortality rates to levels expected in the non-SCD population and to implement multi-disciplinary SCD obstetric teams in other regions.