The effects of audit and research in
postpartum haemorrhage: benefits for all!
T Moses, D Leslie, SF Bell, RE Collis. University Hospital of Wales, Cardiff.
- Postpartum haemorrhage (PPH) remains an important cause of obstetric morbidity in the UK .
- The combination of audit cycles and original research in our institution has led to major changes in our PPH protocol for all patients, culminating in early, multidisciplinary management .
- Measure ANY abnormal blood loss (no estimating)
- Early senior obstetric, anaesthetic and midwifery review
- Prompt uterotonics +/- surgical intervention
- IV access and bloods (at 1000ml blood loss, or earlier)
- Point of care (POC): coagulation (FIBTEM), lactate and haemoglobin
- Laboratory bloods: FBC, clotting, U&E and crossmatch
- POC guided blood product usage
Information on blood transfusion, hysterectomy and level 3 ICU admission was collected from local databases (2010-2015). Individual case note review of patients admitted to ICU was performed and previous audit data used for comparison .
- The annual number of deliveries 2010 – 2015 ranged from 6530 - 5972.
ICU admissions and hysterectomy data
- Previous audit data in a two year period was 12 Level 3 ICU admissions (2004-05, 10713 deliveries) and then seven (2007-08, 12160 deliveries).
Blood product usage
- We have observed a > 80% reduction in the number women receiving FFP and ≥ 5 unit red blood cell transfusions since 2013 .
- Mean red blood cell transfusion has fallen slightly during 2010-12 and 2013-15, from 63 to 52 units per 1000 deliveries.
- Despite 12 patients receiving early fibrinogen concentrate as part of a research protocol , total fibrinogen administrated has remained stable:
- 2010 -12 a total of 102 g of fibrinogen concentrate were given
- 2013 -15 an estimated 108 g were transfused (including study recruits)
- Use of cell-salvage has remained unchanged.
- Since 2012 we have recruited about half of the women with PPH into a research protocol , yet changes to our approach has benefited all women (figure 2.).
- We have observed a reduction in the number of women with major adverse outcomes.
- We believe the adoption of POC coagulation testing as soon as abnormal bleeding is identified and a restrictive FFP policy (based on POC results), has driven the recent improvements for all women.
- Recognizing coagulopathy early or (more commonly) identifying normal clotting results enables timely and appropriate administration of blood products, whilst negating the need for empirical therapy.
 Scottish Confidential Audit of Severe Maternal Morbidity. 10th Annual Report. Healthcare Improvement Scotland. 2014.
 Evans A Collis R. Postpartum haemorrhage admissions to critical care: completing the audit cycle. Int J Obst Anesth 2009:18;S49.
 Aawar, N et al. Fibrinogen concentrate versus placebo for treatment of postpartum haemorrhage: study protocol for a randomised controlled trial. Trials 2015; 16:169.