1. KBP 06/10 NOSS – more than surveillance

2. KBP 06/10 To develop a Nordic Obstetric Surveillance System to describe the epidemiology of a variety of serious complications at delivery. Objective:

3. KBP 06/10 Why collect data on rare serious obstetric complications? Hypothesis raised that there is an increase in rare serious obstetric complications due to the increasing rate of caeserean section worldwide. The low incidence imply that risk factors, treatment modalities and consequences are not well described. The rare serious complications can be considered “near-miss events” for maternal death.

4. KBP 06/10 Inspiration from UKOSS Acute fatty liver Amniotic fluid embolism Antenatal pulmonary embolism Eclampsia Peripartum hysterectomy TB Uterine rupture

5. KBP 06/10 What do we want to know? The incidence in the Nordic countries? The characteristics of the women? The impact of mode of delivery and previous caesarean section? Treatment modalities? The associated maternal and perinatal mortality and morbidity?

6. KBP 06/10 Why not use the Nordic Medical Birth registries?

7. KBP 06/10 Live born 1975-2008

8. KBP 06/10 Total fertility rate 1975-2008

9. KBP 06/10 Caesarean section 1975-2008

10. KBP 06/10 The Nordic Medical Birth registries Appropriate when complications are frequent and well defined – and with record linkage they also offer fantastic opportunities for longitudinal studies. Less useful when complications are rare, less well defined and especially when codes are lacking.

11. KBP 06/10

12. Collaboration: NOSS Team: Birth registers – Obstetricians Nordic countries Midwives and obstetricians participate UKOSS Team: Marian Knight and Peter Brocklehurst

13. KBP 06/10 Rare serious obstetric complications: Uterine rupture - Complete - Incomplete Placenta accreta/percreta Vaginal deliveries with incomplete or difficult removal of placenta and blood transfusion within 48 hours OR caesarean section where placenta was difficult to remove and was considered accrete or percrete Postpartum Hysterectomy (within 7 days after delivery)

14. KBP 06/10 Workshops - Hven, September 2008 - Skanör, Sweden, March 2009 Webpage (www.noss.nu)www.noss.nu Data collection forms (paper based and electronic) Nordic pilot study started 1. April 2009 Preparation:

15. KBP 06/10 Continued preparation: Workshop Bergen April 2010 Inclusion of ”Postpartum Haemorrhage” – Blood transfusion ≥ 6 units (DK Transfusion Database) Start of the official study 1. September 2010 Controls from the Nordic Birth Registers using routine data and – when specific questions arise that cannot be solved by register data – by ”control questionnaires”

16. KBP 06/10 Status – Nordic countries: All obstetric departments in four of five countries already participate and report prospectively Each department have appointed a contact person

17. KBP 06/10 All 28 obstetric departments participate and report prospectively Each department have appointed a contact person - Obstetrician or Midwife Data from Medical Birth Registry every 3. month (last update may 2010) –> request to obstetric department Status – Denmark:

18. KBP 06/10 Data from Denmark so far: 55Uterine ruptures 7Postpartum Hysterectomies 25Placenta accreta/percreta Status – Denmark:

19. KBP 06/10 Average Blood transfusions: Uterine ruptures: 0,44 (0-11) Postpartum Hysterectomies: 13,3 (0-30) Placenta accreta/percreta: 3,72 (0-20) Status – Denmark:

20. KBP 06/10 Future events: INOSS workshop Oxford, July 2010 NOSS workshop Helsinki Finland, April 2011 NFOG Congress, June 2012 – ”Hardcore data”

21. KBP 06/10 THANK YOU It looks so easy...