1. CWIUH 25.2.2010 Bridgette Byrne Senior Lecturer in Obstetrics and Gynaecology, RCSI and CWIUH

2.  Near miss maternal morbidity. Lynch et al IMJ May 2008.  Severe maternal morbidity for 2004 – 2005 inthe three Dublin maternity hospitals. Murphy et al EJOG March 2009.  Prediction of peripartum hysterectomy and endorgan dysfunction in major obstetrichaemorrhage. O’Brien et al (submitted)

3. Definition – Acute transfusion of ≥ 5 units of RCC Incidence –117 (124) / 93291= 1.25 /1000 Hysterectomy25 End organ dysfunction19 Both11

4.  Uterine atony50%  Placenta praevia/accreta19%  Cervical/vaginal trauma17%  Retained placental tissue15%  Broad ligament/uterine10%

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

9. Ultrasound localization of placenta26(100%) Upper 5 Praevia21 Ultrasound suspicion of Placenta accreta13 False positive3/13 False negative1/8 Magnetic Resonance Imaging 6 False Positive 0 False Negative3/6

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

11. Oxytocin Bolus 20(77%) Oxytocin infusion16(62%) Ergotmetrine11(42%) Misoprostol16(62%) Haemabate10(39%)

12. EUA3 Laparotomy4 Uterine pack0/2 Hydrostatic balloon1/3 Internal iliac artery ligation3/5 Hysterectomy(Accreta)18/19(13) End organ dysfunction (Accreta)8(6)

13. 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

14. AnaesthesiaGeneral11 Spinal 8 Both 7 Intraarterial line21 Central Venous Pressure Line16 Both15 None 2 Missing data 2

15. Obstetrician 88% Anaesthetist84%

16.  The morbidly adherent placenta is rare with anincidence of 0.3 /1000 deliveries in Dublin.  Clinical suspicion very important as currentmodalities for prenatal diagnosis are limited.  Currently almost 50% of cases are delivered asemergencies.  There should be greater use of uterotonics as anadjunct to surgery.  The efficacy and safety of surgical interventionsand blood products need constant evaluation.  Senior staff involvement critical.

17.  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