Greater Manchester Neurosciences, Stroke & Obstetric Pathway

Greater Manchester Neurosciences, Stroke & Obstetric Pathway

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The Greater Manchester Neurosciences, Stroke and Obstetric Pathway was developed in order to clarify clinical pathways for pregnant women who have pre-existing neurological conditions or develop neurological problems in the course of their pregnancy. The need for such pathways was highlighted by the introduction of the major trauma system in April 2012. However, it should be noted that such cases are extremely rare and that the pathways identified below cannot cover every possible scenario. The pathways were ratified by the Maternity Network on the 25 th January 2013 and by the Neurosciences Network on the... The pathway describes: Four clinical scenarios for pregnant women with: 1. Pre-existing neurological conditions; 2. New acute but non-life threatening neurological conditions; 3. New acute life threatening neurological conditions. 4. Stroke. General considerations. 1. Pre-existing neurological conditions 1.1 Where possible and relevant preconception counselling should be offered to support proactive management of the neurological condition through pregnancy and childbirth. 1.2 The Epilepsy Action shared care plan should be considered for women with epilepsy who become pregnant. 1.3 Continue with best (current) practice of consultant to consultant referrals and communication. 1.4 Women who are admitted to SRFT and need non-urgent maternity assessment may attend the Antenatal Day Assessment Unit at SRFT from Monday to Friday. 1.5 Women below 20 weeks gestation who need investigations and procedures for their neurological condition which carry a potential risk of pregnancy complications e.g. lower abdominal pain, vaginal bleeding, can be managed at SRFT and referred to the gynaecology service as necessary.

1.6 For women over 20 weeks gestation who need investigations and procedures for their neurological condition, which carry a potential risk of pregnancy complications e.g. premature labour, a clinical decision should be made on the appropriateness of undertaking the procedure at SRFT or transferring the woman to either CMFT, RBH or Preston depending on the needs of the individual. 2. New acute but non-life threatening neurological conditions 2.1 Women who are admitted to SRFT and need non-urgent maternity assessment have the option of attending the Antenatal Day Assessment Unit at SRFT from Monday to Friday. 2.2 Women who are admitted to a maternity service will be referred to the appropriate clinician as per current practice. 2.3 Women below 20 weeks gestation who need investigations and procedures for their new neurological condition which carry a potential risk of pregnancy complications e.g. lower abdominal pain, vaginal bleeding, can be managed at SRFT and referred to the gynaecology service as necessary. 2.4 For women over 20 weeks gestation who need investigations and procedures for their new neurological condition, which carry a potential risk of pregnancy complications e.g. premature labour, a clinical decision should be made on the appropriateness of undertaking the procedure at SRFT or transferring the woman to either CMFT, RBH or Preston depending on the needs of the individual. Where the patient is a surgical case e.g. acute lumbar disc, referral should be made to neurosurgery at Preston. 3. New acute life threatening neurological conditions 3.1 Women below 20 weeks gestation with acute life threatening neurological conditions including head injury and trauma will be treated at SRFT and referred to the gynaecology service if necessary i.e. if there is lower abdominal pain or vaginal bleeding, and for assessment of viability of the pregnancy. 3.2 For women over 20 weeks gestation who need investigations and procedures for their new acute life threatening neurological condition, which carry a potential risk of pregnancy complications e.g. premature labour, a clinical decision should be made on the

appropriateness of undertaking the procedure at SRFT or transferring the woman to either CMFT, RBH or Preston depending on the needs of the individual. 3.3 For pregnant women over 20 weeks gestation with acute intracranial pathology: Those admitted to SRFT as part of the major trauma pathway will be stabilised following which a decision will be made at consultant level between neurosciences and obstetrics clinicians on further action i.e. transfer to CMFT or an acute trust with co-located neurosciences and obstetric services e.g. Preston. For other intracranial pathology a decision will be made by the neuroscience consultant as to whether immediate treatment is required at SRFT to minimise morbidity or mortality. In such cases the appropriate treatment will be carried out with transfer to the Preston Neurosciences Centre once the patient is stabilised. NB: The family should be advised that in such circumstances the mother s life is prioritised over that of the baby who will not be monitored during this stage of treatment. Those admitted to a maternity service will be discussed with a consultant neurologist or consultant neurosurgeon at SRFT to support the decision to transfer to SRFT for stabilisation, which may include acute neurosurgical intervention or interventional neuroradiology or transfer to an acute trust with co-located neurosciences and obstetric services e.g. Preston. NB: If the patient needs initial transfer to SRFT for stabilisation, the family should be advised that the mother s life is prioritised over that of the baby who will not be monitored during this stage of treatment. 4. Pregnant women presenting with stroke 4.1 Pregnant women (any gestation) presenting with a positive Face Arm and Speech Test indicating stroke will be admitted to the nearest operating Hyper-acute Stroke Centre i.e. SRFT, Fairfield Hospital or Stepping Hill, as per agreed stroke pathway with NWAS for investigations and stabilisation of their stroke pathology. Patients will then be transferred to an acute trust with co-located stroke and obstetric services i.e. Stepping Hill for Greater Manchester or Preston.

4.2 Where stabilisation involves acute neurosurgical intervention or interventional neuroradiology patients will be transferred to an acute trust with co-located neurosciences and obstetric services e.g. Preston. 4.3 In all situations where investigations and procedures for stroke carry a potential risk of pregnancy complications e.g. premature labour, a clinical decision should be made on the appropriateness of undertaking the procedure at the Hyper-acute Stroke Centre or transferring the woman to Stepping Hill or Preston depending on the needs of the individual. 4.4 For pregnant women presenting at a Primary or District Stroke Centre, the case should be discussed with the Consultant on-call for the stroke team at an Hyper-acute Stroke Centre and they may be transferred in for further assessment and investigation before transfer to an acute trust with co-located neurosciences and obstetric services e.g. Preston. 5. General considerations 5.1 In all cases transfer to a specialist facility may involve level 3, critical care input. 5.2. Where pregnant women are admitted under 20 weeks gestation but go above that timescale whilst in hospital a care plan should be established between the different specialist teams i.e. obstetrics, stroke, neurosurgery, neuro-rehabilitation, to ensure all aspects of care are provided for the patient and to safeguard the unborn and new-born baby.

Clinical contributors Dr Karen Bancroft Dr Chris Brookes Dr David Gow Dr Steve Jones Dr Mark Kellett Dr Teresa Kelly Professor Andrew King Dr Vanessa Lawton Dr Jane Molloy Network support Julie Maddocks Julie Rigby Clinical Lead GM Maternity Network Consultant Obstetrician/Gynaecologist, Bolton NHS FT Executive Medical Director, SRFT Consultant Neurologist, SRFT Clinical Director Emergency Services, CMFT Consultant Neurologist, SRFT Consultant Obstetrician/Gynaecologist, CMFT Professor of Neurosurgery Consultant Obstetrician/Gynaecologist, SRFT Consultant Neurologist, SRFT Assistant Director, Greater Manchester Children s, Young People and Families NHS Network From the 1 st April 2013: Quality Improvement Programme Lead for Maternity and Children Strategic Clinical Network Director, Greater Manchester Neurosciences Network From the 1 st April 2013: Quality Improvement Programme Lead Strategic Clinical Network

Major Trauma Neurological Under 20 weeks gestation Over 20 weeks gestation Major Trauma Centre, SRFT Major Trauma Centre, SRFT Tests and stabilisation Treat and deliver if necessary Transfer to... Neurosurgery Transfer to Bolton FT CMFT or PRESTON Obstetrics / Gynaecology

Stroke Under 20 weeks gestation Over 20 weeks gestation +ve FAST Comprehensive Stroke Centre OR Primary Stroke Centre Investigations and treat as required Delivery if necessary Obstetrics / gynaecology Transfer to... Stroke Service SHH or PRESTON

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