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The effects of audit and research in postpartum haemorrhage: benefits for all!
Board Board 1 / Wed 12:40, 11 May 2016

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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.

 

Introduction

  • Postpartum haemorrhage (PPH) remains an important cause of obstetric morbidity in the UK [1].
  • 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 .

 

PPH 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

 

Methods

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 [2].

 

Results

  • 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 [3], 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.

 

Discussion

  • Since 2012 we have recruited about half of the women with PPH into a research protocol [3], 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.

 

 

References

[1] Scottish Confidential Audit of Severe Maternal Morbidity. 10th Annual Report. Healthcare Improvement Scotland. 2014.

[2] Evans A Collis R. Postpartum haemorrhage admissions to critical care: completing the audit cycle. Int J Obst Anesth 2009:18;S49.

[3] Aawar, N et al. Fibrinogen concentrate versus placebo for treatment of postpartum haemorrhage: study protocol for a randomised controlled trial. Trials 2015; 16:169.

 

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