A retrospective review of Major Obstetric Haemorrhage cases in 2014 at the NMH Dr. Ingrid Browne, Dr. Joan Fitzgerald, Dr. Anthony Klobas, Ms. Alice Moynihan

Background MOH is defined as loss > 1.5L, or any loss with signs of hypovolaemic shock Antepartum or post partum – often both Figure from MBRACE-UK Maternal report 2015

HSE clinical practice guideline (2012) Collaboration between HSE and IAOG Focuses on PPH but applicable to all MOH Recommendations ▫Preventative measures  Oxytocics ▫Early activation of emergency protocols ▫Ongoing MDT training

Emergency protocols at NMH Massive haemorrhage pathway ▫Any haemorrhage > 1.5L  Alert from 1L ▫Ongoing loss >150ml/min ▫Clinical evidence of shock ▫Clinical concern Initiates cascade of events ▫Senior staff ▫Haemostasis ▫Documentation of events

Time of event

Staff members present/alerted

Treatment given

Total EBL Likely cause

Objectives Examine management of MOH at the NMH according to national guidelines with regard to ▫Relationship between known risk factors and MOH ▫Acute management: blood products and pharmacological agents used ▫Antenatal and postnatal management of anaemia in MOH cases ▫Compliance with MOH documentation ▫Comparison of management in/out of hours

Methods Retrospective chart review Inclusion criteria: ▫Haemorrhage > 1.5L ▫Occuring in NMH between 01/01/2014 – 31/12/2014 Exclusion criteria: nil Data collected using questionnaire created via Sphinx software 104 cases detected, 88 charts reviewed

Data obtained Demographics ▫Age ▫Booking BMI ▫Ethnicity Obstetric history ▫Parity ▫IVF conception ▫Placental risk factors Pre-haemorrhage haemoglobin Estimated blood loss Timing of event Blood products given ▫Red cell concentrate ▫Unmatched O negative ▫Platelets ▫Fibrinogen ▫Post partum top up transfusion on ward

Data obtained Pharmacological haemostatic agents ▫Carboprost ▫Misoprostol ▫Ergometrine ▫Tranexamic acid MOH form documentation Haemoglobin level on discharge Use of oral iron therapy on discharge

Results - Demographics Irish Caucasian Aged BMI: 20-25

Results – obstetric history 8 IVF conceptions (9.1%) Distribution of parity among cases Distribution of placental risk factors

Acute management

In hours vs out of hours 8am-6pm6pm-8am Blood loss No. of casesPercentage of cases Blood lossNo. of casesPercentage of cases 1.5-2L cases (29.5%) 62 cases (70.5%)

In hours vs out of hours

MOH form Poor adherence No of cases% Fully completed4753.4% Partially completed % No form2831.8%

Anaemia Pre-haemorrhage*Discharge 32 patients (39.5%) anaemic80 patients (90.9%) anaemic 33 (37.5%) severely anaemic 47 patients (54.3%) not documented to have been discharged on oral iron 8 patients (24.24%) with Hb < 9 not documented to have been discharged on oral iron Higher rate of transfusion in patients with pre-existing anaemia: 75% vs 48.7% * Not available in all patients

Transfer to tertiary centre Two patients were transferred to SVUH for further management ▫Both had placenta praevia ▫Both suffered loss in excess of 6.5L No mortalities during audit period

Conclusions Majority of MOH are not occurring in patients with major risk factors ▫Need for ongoing vigilance and high index of suspicion Significant differences in the use of blood products in/out of hours Antenatal period is opportunity for optimisation of Hb Discharge prescription of oral iron unclear Poor adherence to documentation via MOH form

References Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Surveillance of maternal deaths in the UK and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity Oxford: National Perinatal Epidemiology Unit, University of Oxford Institute of Obstetricians and Gynaecologists Royal College of Physicians of Ireland and Directorate of Strategy and Clinical Programmes Health Service Executive. Clinical Practice Guideline Prevention and Management of Primary Postpartum Haemorrhage. Dublin: 2012 S Pavord, B Myers, S Robinson, S Allard, J Strong, C Oppenheimer on behalf of the British Committee for Standards in Haematology. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol. 2012; 156(5): Human Fertilisation and Embryology Authority. Fertility treatment in 2011 – trends and figures