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Audit of peripartum care

CWIUH 25.2.2010 Bridgette Byrne Senior Lecturer in Obstetrics and Gynaecology, RCSI and CWIUH. Audit of peripartum care. Audit of severe maternal morbidity and major obstetric haemorrhage. Near miss maternal morbidity. Lynch et al IMJ May 2008.

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Audit of peripartum care

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  1. CWIUH 25.2.2010 Bridgette Byrne Senior Lecturer in Obstetrics and Gynaecology, RCSI and CWIUH Audit of peripartum care

  2. Audit of severe maternal morbidity and major obstetric haemorrhage • Near miss maternal morbidity. Lynch et al IMJ May 2008. • Severe maternal morbidity for 2004 – 2005 in the three Dublin maternity hospitals. Murphy et al EJOG March 2009. • Prediction of peripartum hysterectomy and end organ dysfunction in major obstetric haemorrhage. O’Brien et al (submitted)

  3. Audit of MOH CWIUH, NMH and Rotunda 2004 - 2007 Definition – Acute transfusion of ≥ 5 units of RCC Incidence – 117 (124) / 93291 = 1.25 /1000 Hysterectomy 25 End organ dysfunction 19 Both 11

  4. Causes of MOH (2004 – 2007) • Uterine atony 50% • Placenta praevia/accreta 19% • Cervical/vaginal trauma 17% • Retained placental tissue 15% • Broad ligament/uterine 10%

  5. Prenatal diagnosis of placenta accreta • Elective or emergency delivery • Oxytocics • Uterine conservation • O Negative blood • Invasive monitoring • Consultant presence

  6. Prenatal diagnosis of placenta accreta Ultrasound localization of placenta 26 (100%) Upper 5 Praevia 21 Ultrasound suspicion of Placenta accreta 13 False positive 3/13 False negative 1/8 Magnetic Resonance Imaging 6 False Positive 0 False Negative 3/6

  7. Elective or emergency delivery Elective CS (36 – 39 weeks) 13 (50%) Emergency CS (28 – 38 weeks) 11 (42%) Vaginal birth (34 and 39 weeks) 2 ( 8%)

  8. Oxytocic agents Oxytocin Bolus 20 (77%) Oxytocin infusion 16 (62%) Ergotmetrine 11 (42%) Misoprostol 16 (62%) Haemabate 10 (39%)

  9. Surgical treatments EUA 3 Laparotomy 4 Uterine pack 0/2 Hydrostatic balloon 1/3 Internal iliac artery ligation 3/5 Hysterectomy (Accreta) 18/19(13) End organ dysfunction (Accreta) 8(6)

  10. Blood products utilised • O Negative Blood • Used in 12(46%) of cases • Used in 7 (50%) of elective procedures. • Range of RCC transfused in these cases was 8 to 42 units • Wide range in transfusion practices

  11. Anaesthesia and Invasive monitoring Anaesthesia General 11 Spinal 8 Both 7 Intraarterial line 21 Central Venous Pressure Line 16 Both 15 None 2 Missing data 2

  12. Consultant presence Obstetrician 88% Anaesthetist 84%

  13. Summary • The morbidly adherent placenta is rare with an incidence of 0.3 /1000 deliveries in Dublin. • Clinical suspicion very important as current modalities for prenatal diagnosis are limited. • Currently almost 50% of cases are delivered as emergencies. • There should be greater use of uterotonics as an adjunct to surgery. • The efficacy and safety of surgical interventions and blood products need constant evaluation. • Senior staff involvement critical.

  14. Challenges • Better prenatal identification of cases • Optimal timing of elective delivery • Access to multidisciplinary team, interventional radiology and cell salvage • ?Centralisation of these cases • Continual high quality audit essential

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