Guidance

Infectious diseases in pregnancy screening: learning from incidents

Published 21 June 2021

Applies to England

1. Failsafe in screening programmes

When things don’t go as planned, failsafe processes help to identify these in real time so that action can be taken before harm occurs. Here’s an example.

Mrs. Russell books for maternity care and accepts HIV screening at 8 weeks of pregnancy. Her blood sample is taken and dispatched to the screening laboratory.

Do you have processes to check that you have her results within 8 working days? Screening laboratories will report most results within 8 working days from sample receipt (IDPS-S04).

Do you have processes to follow up with the screening laboratory if you don’t have a result within 8 working days? Or do you wait until her next appointment which might be around 16 weeks of pregnancy?

Mrs. Russell’s blood sample taken at 8 weeks was lost and never arrived in the laboratory. If you only checked her results before her appointment at 16 weeks you would have lost 8 weeks and delayed any potential intervention she may need. Consider what would happen if she was found to be HIV positive on subsequent screening.

We have evidence from screening safety incidents that some providers do not have processes in place for checking screening results in line with national standards. They therefore do not find out if a screening sample was inadequate, needs repeating or never arrived in the screening laboratory sometimes; until reporting on key performance indicators 3 months later.

For failsafe processes to be effective, they must be timely.

2. Learning scenarios

We provide the following real scenarios to demonstrate situations where the screening pathway was not delivered as specified. We hope that you will be able to use these scenarios to look at your local pathway and confirm you have failsafe processes or to address any gaps that may exist.

2.1 Women known to be living with HIV or hepatitis B

A woman booked at 9 weeks of pregnancy and disclosed to the midwife that she was hepatitis B positive. Screening tests were offered and accepted and taken at the booking appointment, but the midwife did not inform the screening team of the known positive status. The screen positive result for hepatitis B was also not communicated by the laboratory to the screening team. The woman was not referred for a screening assessment appointment. The woman was eventually referred at 36 weeks pregnant.

2.2 Communicating results to maternity services

Example 1

A woman booked at 9 weeks of pregnancy, screening for infectious diseases was offered and accepted. On the initial screening test, she was found to be HIV positive. This result was communicated to maternity services and subsequently to the woman before the screening laboratory had confirmed the result. The confirmatory test found the woman to be HIV negative. Unfortunately, the false positive result was already communicated to the woman causing her unnecessary anxiety and distress.

Example 2

A woman booked at 12 weeks of pregnancy, screening for infectious diseases was offered and accepted. Her screening result was positive for syphilis. Things did not go as planned and this result was not communicated to the screening team. The non-communication of the result was discovered when the woman was 30 weeks pregnant.

2.3 Baby born to woman with hepatitis B positive result requiring HBIG but not given

A baby was identified as requiring hepatitis B vaccine and immunoglobulin (HBIG) within 24 hours of birth. A plan was made antenatally, including a paediatric alert. The vaccine and HBIG were ordered and kept in the fridge. Following delivery, the baby only received the hepatitis B vaccine. There were checks by the screening team and by the paediatricians but both did not identify the HBIG was not given. By the time the missed HBIG was identified it was outside the time frame for having any benefit to the infant.