Territory-wide Obstetrics and Gynaecology Audit (2004)

Background

(The full audit report of 2004 can now be downloaded here)

Following the two previous successful territory-wide audits in 1994 and 1999, the College conducted the third audit exercise in 2004. Besides all the public and private hospitals providing obstetric and/or gynaecological services in Hong Kong, the Family Planning Association of Hong Kong also participated in this exercise. This allowed a more comprehensive coverage of those
family planning procedures that required day hospitalization. The “Minimal Data Set”was further revised with addition of information on the Hong Kong residence status, threatened preterm labour, internal iliac artery ligation, uterine artery embolization in the obstetric side, and some new diagnoses and treatment procedures, especially under genital displacement/urinary disorders, in the gynaecology database. The obstetric data of all public hospitals were extracted from the Clinical Management System of the Hospital Authority. The gynaecological database program designed by Dr. Yuen Pong Mo for the 1999 audit was modified and used in all public hospitals for the gynaecological data entry. A web-based version of the database was developed by Prof. Daljit Sahota of the Department of Obstetrics and Gynaecology, Chinese University of Hong Kong and Dr. Yuen Pong Mo to capture both the obstetric and gynaecological data for the private hospitals. The data was first recorded in the audit forms and the forms were returned to the College for centralized data entry through the internet.

Data processing

After pooling of all the data, those records with incomplete and obvious inconsistent data were identified and returned to individual hospital for clarification and verification, if possible. Duplicated records were eliminated if known. The number of records with complete data in the final dataset was 93.7% for obstetrics and 98.6% for gynaecology. However, as the default value of various complications was set as “Nil” and the difficulties in cross-checking the occurrence of complications, especially those delayed complications, the completeness of the reporting of this information could not be verified. Similarly, information on fetal outcomes and neonatal complications relied very much on the effort of information tracing by the obstetricians and feedback from the paediatric colleagues, data accuracy is a great concern and might not reflect the real situation.

Obstetric Report

The total number of parturients in 2004 was 49,110 and the total number of births was 49,656. The number was similar to that in 1999 (48,459 and 48,918 respectively) but it was about 27% lower than that in 1994 (67,438 and 67925 respectively). According to the published data from the Census and Statistics Department of Hong Kong, the total number of registered births (live births and stillbirths) in 2004 was 48,930, meaning that there was an over-reporting of 1.5%. However, the number of stillbirths and neonatal death were under-reported by 28.7% and 19.7% respectively. There were 3 cases of maternal death reported in this exercise but only 2 in the official report.

Almost 20% of the parturients were not Hong Kong residents. The proportion of parturients aged ≥ 35 increased from 13.9% to 24.2% and those aged ≥ 40 increased from 1.5% to 4.5%. The incidence of elderly primigravidae increased from 4.0% to 9.1% while that of grand multiparae (parity ≥ 4) decreased from 0.87% to 0.45%.

The overall incidence of diabetes mellitus increased from 3.0% to 6.3% and this was mainly attributed by the increase in the incidence of gestational diabetes (including IGT). Although the overall incidence of hypertensive disorder in pregnancy remained unchanged, the severe form increased from 7.8% to 26.7% and the incidence of eclampsia increased from 0.027% to 0.035%. The proportion of parturients with previous uterine scar increased from 7.4% in 1994 to 9.2% in 1999 and 8.9% in 2004. While the incidence of preterm delivery (<37 weeks) remained at 6-7%, that of post-term delivery (≥42 weeks) reduced by almost 4-fold from 5.3% to 1.4%. There were no significant changes in the other medical or obstetric complications.

The incidence of spontaneous onset of labour reduced from 75.5% to 63.8% while that of parturients having no labour increased from 11.7% to 17.9%. The overall Caesarean section rate increased from 22.5% to 30.4% and almost 10% were performed for social reasons. While the spontaneous vertex delivery rate remained unchanged, the rate of instrumental delivery decreased
from 16.0% to 10.6%. Vaginal breech delivery became very uncommon and the incidence decreased from 0.7% to 0.2%. Post-partum complication rate remained low.

The incidence of very low birth weight (< 1500 gm) babies increased from 6.6 in 1994 to 7.7 in 1999 and 7.5 per 1,000 total live births in 2004 and that of low birth weight (< 2500 gm) babies increased from 5.4% to 6.0% and 6.5% of total live births respectively. The incidence of low Apgar score (< 7) at 1 minute decreased from 4.1% in 1994 to 3.8% in 1999 and 3.1% in 2004 while that at 5 minutes increased from 0.3% in 1994 to 0.4% in 1999 and 2004. The incidence of babies with congenital anomaly requiring neonatal ICU admission was increased from 2.7 in 1994 to 4.0 in 1999, and decreased back to 2.7 per 1,000 total live births in 2004. While there was a decrease in the incidence of all neonatal complications, the rate of neonatal ICU admissions markedly increased from 2.1% in 1994 to 12.8% in 1999 and 18.0% in 2004. The reasons for the increase in the neonatal admission rate were unclear. Although the 2004 data included all admissions irrespective of the duration while the previous data included only those admitted > 24 hours, the great difference could not purely be accounted for by the change in definition.

There was a general improvement in the mortality rates. Stillbirth rate decreased from 3.1 to 2.4 per 1,000 births and neonatal mortality rate decreased from 3.0 to 1.2 per 1,000 live births. Perinatal mortality rate also decreased from 5.0 to 3.3 per 1,000 births. Maternal mortality ratio decreased from 11.8 to 6.1 per 100,000 live births.

Gynaecological Report

The total number of gynaecological admissions increased from 60,809 in 1994 to 76,344 in 1999 and decreased slightly to 75,053 in 2004. Emergency admission accounted for 25-30% and
unplanned readmission rate increased from 0.4% to 1.2%. About 98% of the cases were discharged home. The rate of transfer to other specialties dropped from 0.7% to 0.3%. About 40% of the
admissions were discharged on the same day and the mean duration of hospital stay for non-day patients decreased from 4.0 to 3.0 days. The number of deaths remained low.

First trimester termination of pregnancy remained the most common diagnosis for admission, however the overall rate dropped from 28% in 1994 to about 20% in 1999 and 2004.
Despite the participation of the Family Planning Association of Hong Kong in the current exercise which provides a significant day surgery service for termination of pregnancy, the actual number of cases had not increased in 2004. The second most common diagnosis was spontaneous/silent miscarriage and the overall rate decreased from 13.5% to 9.7%. The rate of other pregnancy related problems remained unchanged. Fibroid became the third most common diagnosis and the rate increased from 6.6% to 9.6%. Threatened miscarriage was the 4th most common diagnosis and its rate remained abound 7%. The rate of admission for subfertility doubled between 1994 and 2004 and ranked the 5th. The ranking of dysfunctional uterine bleeding dropped from the 3rd to the 6th because of the addition of menorrhagia as a new diagnosis under the menstrual disorder.

There were minor changes in the ranking of the top ten most common treatment modalities in 2004. Observation and investigation was the most common modality and its rate increased from 16.3% to 24.3%. Suction termination of pregnancy was the second most common modality but its rate decreased from 28.6% to 19.4%. Total abdominal hysterectomy was the most common open procedure and the rate for benign conditions remained at 4.5-5%. However the actual number of hysterectomies (abdominal, laparoscopic and vaginal) performed for benign conditions actually increased by almost 50% from 3376 to 4992. Fibroid was the most common indication for hysterectomy, accounting about 60%, while only 4.3% of the hysterectomies were performed for dysfunctional uterine bleeding/menorrhagia. Laparoscopic ovarian cystectomy was the most common laparoscopic procedure and its rate increased from 1.5% in 1999 to 3.1% in 2004, making
it ranked the 7th in the list. There was a significant increase in the loop diathermy excision of the cervix and the rate increased from 0.4% to 2.7%. Whether there is a genuine increase in the
number of cases or a change in the practice from outpatient to inpatient management is unknown.

The overall complication rate increased from 0.88% to 1.15% of all admissions. The figures should be interpreted with care because of the high possibility of under-reporting based on the clinical experience and data from the literature. Fever remained the most common complications. Haemorrhage occurred in 0.25% which was much higher than the 0.16% reported in 1999 and 1994. The incidence of inadvertent organ injury remained at 0.02 to 0.08%, and there was no significant difference in the overall incidence among individual organ. The incidence of deep vein thrombosis however doubled when compared with 1999 ad 1994.

Previous Reports, Guidelines and Audit Forms and be download here:

1. Territory-wide audits in 1994 and 1999,
2. Obstetric Audit Guidelines and Obstetric Audit Form
3. Gynaecological Audit Guidelines and Gynaecological Audit Form

Working Group Members

Dr YUEN  Pong Mo (Chairman)
Dr CHAN Yuk May May 
Dr PUN Tin Chung
Dr TSANG Sing Wing
Dr TSE Hei Yee
Dr WONG Shu Pong

List of Hospitals Co-ordinators

Dr LEUNG Pui Ling (Alice Ho Miu Ling Nethersole Hospital)
Dr LEE Tat Choi Eric (Canossa Hospital)
Dr LEE Kai Wan (Caritas Medical Centre)
Dr WONG Ching Yin Grace (Family Planning Association of Hong Kong)
Dr LIU Yuk Kuen (Evangel Hospital)
Dr LEUNG Pui Ling (North District Hospital)
Dr CHAN Angela (Hong Kong Adventist Hospital)
Dr SUM Tak Keung (Hong Kong Baptist Hospital)
Dr LEE Kai Cheung Stephen  (Hong Kong Central Hospital Ltd.)
Dr CHAN Woon Tong Joseph (Hong Kong Santorium & Hospital Ltd.)
Dr WONG Kin Sun (Kwong Wah Hospital)
Dr SCHRADER Hans (Matilda & War Memorial Hospital)
Dr WONG Kin Sun (Our Lady of Maryknoll Hospital)
Dr NG Tai Keung (Pamela Youde Nethersole Eastern Hospital)
Dr CHAN Wing Kin (Precious Blood Hospital)
Dr LEUNG Pui Ling (Prince of Wales Hospital)
Dr LEE Kai Wan (Princess Margaret Hospital)
Dr CHAN Yuk May May (Queen Elizabeth Hospital)
Dr PUN Ting Chung (Queen Mary/TsanYukHospital)
Dr CHUNG Ka Leung (St Paul's Hospital)
Dr LAU Woon Chung (St Teresa's Hospital)
Dr TSANG Sing Wing (Tsang Kwan O Hospital)
Dr SO Kon Ping (Tsuen Wan Adventist Hospital)
Dr TSOI Chiu Wing (Tuen Mum Hospital)
Dr YU Kai Man (Union Hospital)
Dr FUNG Suk Yee Alice (United Christian Hospital)