SPECIAL FEATURE Vol.6 No.11 (January 2002)

Perinatal Care in Hong Kong

Dr. Bill H. CHAN
Department of Paediatrics, United Christian Hospital

Introduction

In 2000, Hong Kong celebrated a record low infant mortality rate of Hong Kong (2.9 per 1000 live births) and post neonatal mortality rate (1.2 per 1000 live births) since 1946.1 In fact, our infant mortality rate has been among the best in the world. This may be attributed to a multitude of factors. The improvement in obstetrical and neonatal care and the close collaboration among the health care professionals in the various facets of perinatal medicine must have played a key role in the success.

Antenatal Care

51 per cent of our expectant mothers attended the 50 Maternal and Child Health Centres (MCHC) of the Department of Health in 2000. In recent years, there had been shared care programs among the obstetrical and gynaecological departments of various regional public hospitals with these MCHCs. The primary perinatal care is provided by our colleagues in the MCHCs while the more sophisticated investigations and treatment for high-risk pregnancies are carried out in the respective regional hospitals through shared medical records and seamless referral systems. Obstetricians in the private sector are also part of the collaboration in many instances.

Antenatal Diagnosis

Refined antenatal ultrasonography expertise has enabled many fetal and neonatal conditions to be diagnosed well before the babies are born. This includes central nervous system anomalies, structural cardiac anomalies, gastrointestinal disorders, abnormalities of the urological systems, noncardiac thoracic anomalies, abdominal wall defects, skeletal anomalies, hydrops fetalis and anomalies peculiar to multiple gestations. This provides additional treatment options for our patients, the obstetricians and neonatologists. This also allows optimal timing and preparation for the delivery of these high-risk babies in our hospitals with neonatal intensive care units.

The Antenatal Thalassemia Screening Programme based on red cell indices run by the MCHC and prenatal diagnosis in the Hospital Authority (HA) have resulted in fewer number of new cases of beta-thalassemia major and Hb Bart's Disease among our newborns.

Fetal karyotyping through amniocentesis and chorionic villus sampling carried out in our prenatal diagnosis and counseling units had allowed pregnant women carrying fetuses with major chromosomal abnormalities to choose to terminate the pregnancy.

Care of an individual with Down's Syndrome imposes tremendous burden to the family and our society. Invasive prenatal diagnosis on the basis of advanced maternal age and previous history had been provided in our public hospitals. This might have decreased the new cases of Down's Syndrome by one-third. But two-thirds of fetuses with Down's syndrome pregnancies are carried by young women. With the accumulation of clinical evidence on screening strategies using multiple serum markers and ultrasonographic markers such as nuchal translucency and the absence of nasal bone,2 our perinatal medical community may soon have to decide our next screening policy.

Prevention of Perinatal Hypoxic-ischaemic Injuries

Improved intrapartum fetal surveillance expertise and equipment, availability of skilled medical professionals for neonatal resuscitation at delivery and the appropriate care of the at-risk newborn are pivotal in prevention and management of perinatal hypoxic-ischaemic injuries. In 1999, the obstetrical and paediatric departments of the HA hospitals agreed to adopt a set of basic indications for the presence of paediatricians to standby at delivery (Table 1). In 1997, the Hong Kong Society of Neonatal Medicine organized instructor course to train the trainers for the Neonatal Resuscitation Program in various hospitals. Since then, there were numerous refresher courses organized in various hospitals and by the Hong Kong Midwives Association with the aim to standardize and improve the skill of neonatal resuscitation in our front-line health-care professionals.

Table 1. Indications for Paediatric Standby at Delivery in HA Hospitals.
  1. Multiple gestation
  2. Premature labour (<34 weeks)
  3. Estimated fetal weight <2 Kg
  4. Vaginal breech
  5. Difficult delivery e.g. shoulder dystocia
  6. Suspected fetal distress (non-reassuring fetal heart rate patterns)
  7. Severe hypertension of the mother requiring i.v. sedation
  8. Thick meconium-stained amniotic fluid
  9. Oligohydramnios or no liquor
  10. Suspected intrauterine infection/chorioamnionitis
  11. Prolapsed cord
  12. Abruptio placenta
  13. Placenta previa
  14. Fetuses with known or suspected malformation that might require immediate medical attention at birth, e.g. exomphalos, hydrocephalus, diaphragmatic hernia
  15. Other conditions in which the obstetrician anticipates adverse neonatal outcome

 

Prematurity and Perinatal Infection

Use of antenatal steroids in women with premature labour significantly improved the outcome of the premature babies. The availability of surfactant therapy and better ventilatory strategies also enable the neonatologist to ventilate the premature babies with less mortalities and morbidities.

The Obstetrical & Gynaecological Society of Hong Kong and the Hong Kong Society of Neonatal Medicine jointly organized a series of joint scientific meetings for their members on important topics such as the prevention of RDS and perinatal Group B Streptococcal (GBS) Infection since 1998. These helped the obstetricians and the neonatologists to adopt a common practice3 or at least to understand each other's approach in dealing with common perinatal problems.

Team Approach and Sharing of Clinical Information

There are numerous clinical conditions of the mother that will significantly affect the fetus such as autoimmune diseases, endocrine disorders and haematological disorders, etc. Team approaches adopted by our obstetricians involving the physicians and the neonatologists have greatly improved the obstetrical, medical and neonatal outcome.

Information sharing is of paramount importance in any form of teamwork and collaboration. This year, the electronic clinical information of the mother and her babies can be shared in a seamless fashion on a common platform (the Clinical Management System) in the Hospital Authority hospitals. This initiative will make future perinatal audit, quality assurance and research much easier and more accurate.

New Challenges and Opportunities

Currently, there is significant number of pregnant women who are visiting from China in whom the antenatal care is lacking. Their babies are also prone to be lost to follow up.

On another front, from September 1, 2001, all clients attending the Maternal and Child Health Centres of the Department of Health and the Antenatal clinics of Hospital Authority hospitals will be offered the HIV test as part of routine antenatal blood testing without additional charge. It is hoped that with appropriate perinatal treatment, the number of HIV-infected newborn will decrease despite a potential rise in the number of HIV-infected female adults.

With the setting up of the Perinatal Chapter under the Obstetrical & Gynaecological Society of Hong Kong and the Hong Kong Society of Neonatal Medicine this year, our health-care professional involved in the care of the mother, the fetus and the newborn will have more opportunities to collaborate to improve the clinical outcome.

References

  1. Department of Health. Vital Statistics 2000 (Provisional). Public Health and Epidemiology Bulletin August 2000.
  2. American Academy of Pediatrics. Revised guidelines for prevention of early-onset group B streptococcal (GBS) infection. Pediatrics 1997;99(3):489-96.
  3. Time for total shift to first-screening for Down's Syndrome. Lancet 2001;358:1658-9.