Implementing NICE guidance Antenatal care Implementing NICE guidance ABOUT THIS PRESENTATION This presentation has been written to help you raise awareness of the NICE clinical guideline on antenatal care. The guideline has been written for midwives, doctors and other staff who care for healthy pregnant women. The guideline is available in a number of formats. You can download these from the NICE website or order printed copies of the quick reference guide by calling NICE publications on 0845 003 7783 or sending an email to publications@nice.org.uk. Quote reference number N1482. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters to help highlight key points to raise in your presentation and to provide supplementary information to the slides. Where necessary the recommendation will be given in full. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. 2008 NICE clinical guideline 62

What this presentation covers Updated recommendations Key priorities for implementation Costs and savings Discussion Find out more NOTES FOR PRESENTERS In this presentation we will start by providing a summary of the updated recommendations for antenatal care and why these are important. The NICE guideline contains 6 key priorities for implementation. You can find them in your quick reference guide and they cover the following 5 areas: Antenatal information Lifestyle considerations (vitamin D) Screening for haematological conditions (sickle cell disease and thalassaemias) Screening for fetal anomalies (congenital anomaly registers and testing for Down’s syndrome) Screening for clinical conditions (gestational diabetes) Costs and savings that are likely to be incurred in implementing both this guideline and the diabetes in pregnancy guideline are summarised, followed by a suggested list of questions to help prompt discussion. Information on how to find out more about the support provided by NICE is given at the end of this presentation.

Updated guidance This guideline replaces ‘Antenatal care: Routine care for the healthy pregnant woman’ (NICE clinical guideline 6, 2003) NOTES FOR PRESENTERS Key points to raise: In this update, the following recommendations have changed: antenatal information, gestational age assessment, vitamin D supplementation, alcohol consumption, screening for haemoglobinopathies, screening for structural anomalies, screening for Down’s syndrome, screening for chlamydia, gestational diabetes, pre‑eclampsia, asymptomatic bacteriuria, placenta praevia, pre-term birth and fetal growth and well-being, as well as the schedule of antenatal appointments. The new and updated recommendations are marked in the guideline as ‘New’; all other recommendations from the original guideline remain the same. Additional information: This update has been initiated earlier than planned owing to several important pieces of evidence becoming available. The update also provided an opportunity to look at a number of aspects of antenatal care, including: the ‘Antenatal assessment tool’ giving information to pregnant women While there has been some new evidence (for example, in screening for gestational diabetes), some of the updated recommendations reflect changes in national and/or international expert opinion (on vitamin D supplementation and on alcohol consumption), availability of national screening programmes already being rolled out (haemoglobinopathy screening, chlamydia screening) and improvements in technology and/or clinical expertise (ultrasound scanning). In addition, some recommendations on smoking cessation and mental health have changed because NICE has produced public health guidance on smoking cessation (NICE public health guidance 10) and the clinical guideline on antenatal and postnatal mental health (NICE clinical guideline 45). Following NICE protocol, we have incorporated the relevant recommendations verbatim into this guideline and have marked them clearly.

Updated recommendation; alcohol consumption Advise women to avoid alcohol in first 3 months of Pregnancy if possible If women choose to drink alcohol they should be advised to drink no more than 1 to 2 UK units once or twice a week Women should be informed that getting drunk or binge drinking during pregnancy may be harmful This advice is consistent with the advice issued in 2007 by the UK Chief Medical Officers NOTES FOR PRESENTERS: The updated recommendations on alcohol have been included for use by the presenter if clarity on these new recommendations would be beneficial. These recommendations are not identified as key priorities for implementation. Please remove this slide if it is unnecessary for your audience. Key points to raise: Drinking alcohol in the first 3 months of pregnancy may be associated with an increased risk of miscarriage. Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby. The recommendation regarding pregnant women and alcohol consumption is consistent with the advice issued in 2007 by the UK Chief Medical Officers. Recommendation in full: Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage. If women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week (1 unit equals half a pint of ordinary strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine is equal to 1.5 UK units). Although there is uncertainty regarding a safe level of alcohol consumption in pregnancy, at this low level there is no evidence of harm to the unborn baby. Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than 5 standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby. (NICE guideline 1.3.9)

Key priorities for implementation Providing antenatal information Lifestyle considerations (vitamin D) Screening for haematological conditions Screening for fetal anomalies Screening for clinical conditions (gestational diabetes) NOTES FOR PRESENTERS Key point to raise: The NICE antenatal care guideline contains many recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the most impact on care and are the most important priorities for implementation. All of these are new recommendations and they are divided into the 5 areas shown in the slide which we will consider in turn.

Providing antenatal information Offer information based on the current available evidence: At first contact At the booking appointment (ideally by 10 weeks) Before or at 36 weeks At 38 weeks Support women to make informed decisions relating to care pathway NOTES FOR PRESENTERS Key points to raise: Communication should be supported by evidence-based, written information tailored to the woman's needs. This includes being culturally appropriate, accessible to women with additional needs such as physical, sensory or learning disabilities, and to women who do not speak or read English. Information can also be given in other forms such as audiovisual or touch‑screen technology; this should be supported by written information. Additional information: The Quick reference guide and NICE Guideline (1.1.1.1) detail a schedule for providing antenatal information to pregnant women. This information can be supported by other relevant resources such as ‘The Pregnancy Book’ (Department of Health 2007 - please note this publication is provided free to first-time expectant mothers through primary care services [antenatal clinics, GPs or health visitors] in England and Wales; it is also available to purchase ISBN: 978 1 874602 57 6), the UK National Screening Committee publications and the Midwives Information and Resource Service (MIDIRS) information leaflets (www.infochoice.org). Pregnant women may also find of use ‘Understanding NICE guidance’ – a lay version of the antenatal care guideline For women who do not have the capacity to make decisions, healthcare professionals should follow the Department of Health guidelines – ‘Reference guide to consent for examination or treatment’ (2001) (available from www.dh.gov.uk). Since April 2007 healthcare professionals should also follow a code of practice accompanying the Mental Capacity Act (summary available from www.publicguardian.gov.uk). Recommendation in full: Pregnant women should be offered information based on the current available evidence together with support to enable them to make informed decisions about their care. This information should include where they will be seen and who will undertake their care. (NICE Guideline 1.1.1.4)

Lifestyle considerations (vitamin D) At the booking appointment inform all women: of the need for adequate vitamin D stores during pregnancy and whilst breastfeeding that taking 10 mcg daily, as found in the Healthy Start multivitamin, can help achieve adequate stores Enquire whether women at greatest risk of deficiency are following the advice NOTES FOR PRESENTERS Key points to raise: ‘Healthcare professionals’ should take particular care to check that women at greatest risk of vitamin D deficiency are following advice to take this daily supplement. These include: women of South Asian, African, Caribbean or Middle Eastern family origin women who have limited exposure to sunlight, such as women who are predominantly housebound, or usually remain covered when outdoors women who eat a diet particularly low in vitamin D, such as women who consume no oily fish, eggs, meat, vitamin D-fortified margarine or breakfast cereal women with a pre-pregnancy body mass index above 30 kg/m2. Additional information: The Department of Health has established that approximately 95,000 women are eligible for Healthy Start vitamins, based on the number of households with a pregnant woman or a child under 1 year old receiving Healthy Start vouchers. The number eligible through receipt of tax credits or benefits is currently unknown. Eligibility for the Healthy Start scheme can be determined by a tool on the Healthy Start website: www.healthystart.nhs.uk/en/qualifier/index.asp NICE public health guidance recommends that community pharmacists ensure the Healthy Start maternal vitamin supplements are available for purchase by women who are not eligible to receive them free of charge. (refer to ‘Maternal and Child Nutrition’ [NICE public health guidance 11], available from www.nice.org.uk/PH011). Recommendation in full: All women should be informed at the booking appointment about the importance for their own and their baby’s health of maintaining adequate vitamin D stores during pregnancy and whilst breastfeeding. In order to achieve this, women may choose to take 10 micrograms of vitamin D per day, as found in the Healthy Start multivitamin supplement. Particular care should be taken to enquire as to whether women at greatest risk (see key point above) are following advice to take this daily supplement. (NICE Guideline 1.3.2.4)

Screening for haemoglobinopathies Screen all women for sickle cell diseases and thalassaemias (ideally by 10 weeks) The type of screening depends upon the prevalence and can be carried out in primary or secondary care - high prevalence: laboratory screening - low prevalence: initial screening with ‘Family Origins Questionnaire’ NOTES FOR PRESENTERS Key points to raise: Prevalence and type of screening: Where prevalence of sickle cell disease is high (fetal prevalence above 1.5 cases per 10,000 pregnancies), laboratory screening (preferably high-performance liquid chromatography) should be offered to all pregnant women to identify carriers of sickle cell disease and/or thalassaemia. (NICE Guideline: 1.6.3.4) Where prevalence of sickle cell disease is low (fetal prevalence 1.5 cases per 10,000 pregnancies or below), all pregnant women should be offered screening for haemoglobinopathies using the Family Origin Questionnaire. (www.sickleandthal.org.uk/Documents/F_Origin_Questionnaire.pdf) If the Family Origin Questionnaire indicates a high risk of sickle cell disorders, laboratory screening (preferably high-performance liquid chromatography) should be offered. If the mean corpuscular haemoglobin is below 27 picograms, laboratory screening (preferably high-performance liquid chromatography) should be offered. (NICE Guideline: 1.6.3.5) Recommendation in full: Screening for sickle cell diseases and thalassaemias should be offered to all women as early as possible in pregnancy (ideally by 10 weeks). The type of screening depends upon the prevalence and can be carried out in either primary or secondary care. (NICE Guideline: 1.6.3.3)

Screening for fetal anomalies Screen for Down’s syndrome using: the ‘combined test’ between 11 weeks 0 days and 13 weeks 6 days a serum screening test (triple or quadruple test) between 15 weeks 0 days and 20 weeks 0 days Participate in regional congenital anomaly registers and/or UK National Screening Committee-approved audit systems NOTES FOR PRESENTERS Key point to raise: Detection rates should be audited, for example, through participation in congenital anomaly registers and/or UK National Screening Committee-approved audit systems. Additional Information: Ultrasound screening for fetal anomalies should be routinely offered, normally between 18 weeks 0 days and 20 weeks 6 days. (NICE Guideline: 1.7.1.1.) When it is not possible to measure nuchal translucency, owing to fetal position or raised body mass index, women should be offered serum screening (triple or quadruple test) between 15 weeks 0 days and 20 weeks 0 days. (NICE Guideline: 1.7.2.4) Recommendations in full: Participation in regional congenital anomaly registers and/or UK National Screening Committee-approved audit systems is strongly recommended to facilitate the audit of detection rates. (NICE Guideline: 1.7.1.8) The ‘combined test’ (nuchal translucency, beta-human chorionic gonadotrophin, pregnancy-associated plasma protein-A) should be offered to screen for Down’s syndrome between 11 weeks 0 days and 13 weeks 6 days. For women who book later in pregnancy the most clinically and cost-effective serum screening test (triple or quadruple test) should be offered between 15 weeks 0 days and 20 weeks 0 days. (NICE Guideline: 1.7.2.3)

Screening for clinical conditions At the booking appointment screen for risk factors associated with gestational diabetes Offer testing for gestational diabetes if any one risk factor identified NOTES FOR PRESENTERS Key points to raise: The following risk factors are associated with gestational diabetes: body mass index above 30 kg/m2 previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes (refer to ‘Diabetes in pregnancy’ [NICE clinical guideline 63], available from www.nice.org.uk/CG063) family history of diabetes (first-degree relative with diabetes) family origin with a high prevalence of diabetes: South Asian (specifically women whose country of family origin is India, Pakistan or Bangladesh) Black Caribbean Middle Eastern (specifically women whose country of family origin is Saudi Arabia, United Arab Emirates, Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt). Additional Information: The recommendation related to screening for diabetes in pregnancy is shared with ‘Diabetes in pregnancy’ (NICE clinical guideline 63). The antenatal care guideline makes a recommendation relating to screening for diabetes and the diabetes in pregnancy guideline makes recommendations about diagnosis and treatment. Recommendation in full: Screening for gestational diabetes using risk factors is recommended in a healthy population. At the booking appointment, the following risk factors for gestational diabetes should be determined: See above under ‘key points to raise’. Women with any one of these risk factors should be offered testing for gestational diabetes (refer to ‘Diabetes in pregnancy’ [NICE clinical guideline 63], available from www.nice.org.uk/CG063). (NICE Guideline 1.9.1.1)

Costs and savings per 100,000 population Recommendations with significant resource impact (+/- ) Costs/savings (£ in first year) Screening for fetal anomalies 12,700 Screening for Down’s syndrome 6,500 Screening and testing for gestational diabetes 2,900 Treatment of gestational diabetes 1,500 Avoidance of neonatal care for babies of women with diabetes – 2,300 Estimated net cost of implementation 21,300 NOTES FOR PRESENTERS: Key points to raise: This slide outlines the costs and saving per 100,000 population of implementing the NICE guidelines on antenatal care and diabetes in pregnancy (published in March 2008 and available from www.nice.org.uk). The costs and savings related to these two guidelines are linked, because screening, diagnosing and treating gestational diabetes cross the guidelines but are likely to be carried out by the same provider, so a combined costing tool has been produced. The information on this slide has been extracted from the NICE costing report, which has been provided by NICE to support implementation of this guidance. It was developed after careful consideration of the available data and by working closely with the guideline developers and other people in the NHS. It is not NICE guidance. Assumptions used in this report are based on assessment of the national average and it is recognised that local practice or circumstances may differ from this. The costs published in this report are estimates only and are not to be taken as the Institute's view of desirable maximum or minimum figures. ADAPTING THIS SLIDE FOR LOCAL USE: Local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact locally. We encourage you to calculate the local impact by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues. The estimated national annual change in costs and savings arising from implementing the Antenatal Care and Diabetes in Pregnancy guidelines is £11.6 million in the first year, net of savings. It is recognised that implementation of the recommendations may take place over a number of years. Compliance with NICE guidance is one of the criteria indicating good risk reduction strategies, and in combination with meeting other criteria could lead to a discount on contributions to the NHS Litigation Authority schemes, including the clinical negligence scheme for trusts (CNST). For further information please refer to the costing template and costing report for this guidance on the NICE website. This slide includes Diabetes in Pregnancy costs and savings

For discussion What is our current advice regarding vitamin D supplementation? How can we reach the ‘at risk’ groups? How can we ensure current referral patterns allow for early screening for haematological conditions? Who is best placed to offer this test? What changes will we need to make to ensure that we are screening all women at booking for gestational diabetes? NOTES FOR PRESENTERS These questions are suggestions that we have developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

Find out more Visit www.nice.org.uk/cg062 for: Other guideline formats Costing report and template Audit support Implementation advice NOTES FOR PRESENTERS The guideline is available in a number formats: Quick reference guide – a summary (You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it.) NICE guideline – all of the recommendations Full guideline – all of the evidence and rationale ‘Understanding NICE guidance’ – a version for pregnant women You can download the above documents from www.nice.org.uk/CG062. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk and quote: N1482 (quick reference guide) N1483 (‘Understanding NICE guidance’). NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved. Audit support – assists NHS trusts to determine how well they meet NICE recommendations. Implementation advice – gives details of how to put the guidance into practice and national initiatives that support this locally.