audit of peripartum care

CWIUH 25.2.2010Bridgette ByrneSenior Lecturer in Obstetrics and Gynaecology,RCSI and CWIUH

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)

Definition – Acute transfusion of ≥ 5 units of RCC Incidence – 117 (124) / 93291 = 1.25 /1000

Hysterectomy 25

End organ dysfunction 19

Both 11

Uterine atony 50%

Placenta praevia/accreta 19%

Cervical/vaginal trauma 17%

Retained placental tissue 15%

Broad ligament/uterine 10%

Prenatal diagnosis of placenta accreta

Elective or emergency delivery

Oxytocics

Uterine conservation

O Negative blood

Invasive monitoring

Consultant presence

Ultrasound localization of placenta 26(100%)

Upper 5Praevia 21

Ultrasound suspicion of Placenta accreta 13False positive 3/13False negative 1/8

Magnetic Resonance Imaging 6False Positive 0False Negative 3/6

Elective CS (36 – 39 weeks) 13(50%)

Emergency CS (28 – 38 weeks) 11(42%)

Vaginal birth (34 and 39 weeks) 2( 8%)

Oxytocin Bolus 20(77%)

Oxytocin infusion 16(62%)

Ergotmetrine 11(42%)

Misoprostol 16 (62%)

Haemabate 10 (39%)

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)

Anaesthesia General 11Spinal 8Both 7

Intraarterial line 21Central Venous Pressure Line 16Both 15None 2Missing data 2

Obstetrician 88%

Anaesthetist 84%

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.

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