Furthermore, a systematic review by the authors found no critical evaluation of MDT models or impact on maternal or infant outcomes.
leadership, mode/frequency of meeting with each other and with women and their partners, pathways into and out of the MDT). However, implementation of guidance has not been audited, nor does the guidance specify how these MDTs should be operationalised (e.g. Similar recommendations for multidisciplinary management appear in guidelines globally ().
The European Society of Cardiology published consensus guidelines recommending that ‘high-risk patients should be treated by an MDT in specialised centres’, and the Royal College of Obstetricians and Gynaecologists (RCOG) recommend all women are at least initially referred for risk assessment by a core MDT including an obstetrician, cardiologist and anaesthetist (with midwives, neonatologists and intensivists involved when appropriate). Similarly, numerous publications recommend MDT management for women with pre-existing cardiac conditions. In the UK, National Institute for Health and Care Excellence (NICE) guidelines recommend women with pre-existing diabetes are referred immediately once pregnant to a ‘joint diabetes and antenatal clinic’ and a National Enquiry into diabetes in pregnancy recommended the minimum team composition ( obstetrician, diabetes physician, diabetes specialist nurse, diabetes midwife and dietician). These pregnancies are associated with increased risks of adverse outcomes for both mother and baby. Between 0.2–2% of pregnant women in the UK have pre-existing diabetes and 1% are affected by heart disease.
Two medical conditions that are increasingly common in pregnancy are diabetes and cardiac disease. Indeed the review of maternal deaths in the UK during 2009–2013 found that indirect causes (exacerbation or new onset of medical or psychiatric disease) accounted for two thirds of maternal deaths during or after pregnancy. Having a pre-existing maternal medical condition is a key risk factor for adverse pregnancy outcomes for mother and baby. Evidence is also required to support and better define the recommendations for MDT care. The wide diversity of organisational management for women with pre-existing diabetes or cardiac conditions is of concern and merits more detailed inquiry. Less than half of MDTs for women with diabetes met the recommendations for membership in national guidance, and although two thirds of MDTs for women with cardiac disease met the core recommendations for membership, most did not report having the extended members: midwives, neonatologists or intensivists. Reported membership was medically dominated and often in the absence of midwifery/nursing and other allied health professionals. These inconsistencies were evident within and between maternity units across the UK. 63% for cardiac) but there was wide variation in relation to MDT membership, timing of referral and working practices. MDT referral was reportedly standard practice in most hospitals, particularly for women with pre-existing diabetes (88% of responses vs. 132 (74%) related to women with diabetes and 123 (69%) to women with cardiac conditions. One hundred seventy-nine responses were received, covering all health regions in England (162 responses) and 17 responses from Scotland, Wales and Northern Ireland. Content was informed by national guidance. The survey comprised questions regarding the organisation of MDT management for women with pre-existing diabetes or cardiac conditions. National on-line survey sent to clinicians responsible for management or referral of women with pre-existing diabetes or cardiac conditions in UK National Health Service (NHS) maternity units. These conditions were selected as exemplars of increasingly common medical conditions in pregnancy for which MDT management is recommended to prevent or reduce adverse maternal and fetal outcomes. This study aimed to evaluate the implementation of guidelines for multidisciplinary team (MDT) management in pregnant women with pre-existing diabetes or cardiac conditions. Despite numerous publications stating the importance of multidisciplinary care for women with pre-existing medical conditions, there is a lack of evidence regarding structure or processes of multidisciplinary working, nor impact on maternal or infant outcomes.
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