Saving Mothers' Lives: - Public Health Agency for Northern Ireland

acute bleeding situation although it should be considered. If a placenta percreta is clearly expected in an
elective procedure, then delivery of the baby through the upper part of the uterus may allow a procedure
which entails little blood loss. Some would then treat the patient with methotrexate to aid disintegration of
the placenta.
Interventional radiological techniques may be useful in both the elective and emergency situation. Balloon
tamponade of the internal iliac arteries is helpful in reducing the severity of haemorrhage whilst surgical
haemostasis is achieved. This procedure may be carried out in the operating theatre under image
intensifi cation using a portable C arm intensifi er. Although the procedure has been used successfully many
times, the precise place of uterine artery embolisation is not yet clearly defi ned, particularly if it requires
transfer of a sick and bleeding woman to the radiology department.
Ruptured uterus
This is the fourth successive triennial Report to include at least one case of uterine rupture in a parous
woman after induction of labour with repeated doses of vaginal prostin:
An older parous woman with a history of precipitate labour developed hypertension in the third
trimester, which worsened despite treatment. Her labour was induced with two 3mg prostin
pessaries. At full dilatation fetal bradycardia developed and the baby was delivered rapidly. Her
blood pressure subsequently fell but improved after infusion of gelfusin. She complained of
abdominal pain, her blood pressure fell again and a massive postpartum haemorrhage occurred.
The consultant attended and treated the bleeding with a vaginal pack but she sustained a cardiac
arrest. After resuscitation a laparotomy revealed a ruptured uterus but despite a hysterectomy
she died shortly afterwards.
Although 3mg is the dose recommended by the manufacturers, many obstetricians prefer lower doses
in parous women. The assessors consider this dosage of prostin to be high for a woman who has had a
previous precipitate labour. The classic picture of ruptured uterus – precipitate labour, fetal bradycardia and
maternal shock – was not recognised until cardiac arrest occurred.
Severe morbidity
Peripartum hysterectomy for severe obstetric haemorrhage
A case-control study of peripartum hysterectomy was carried out through the United Kingdom Obstetric
Surveillance System (UKOSS) from February 2005 to February 200610 . Peripartum hysterectomy is usually
carried out in the context of life-threatening obstetric haemorrhage and may therefore be regarded as a
“near-miss” event for maternal mortality from haemorrhage. All consultant-led obstetric units in the UK
participate in UKOSS and the results of this study therefore provide an indication of the maternal morbidity
underlying the deaths reported in this Chapter.
During the thirteen months of the study, 315 women were reported to have had a peripartum hysterectomy
to control haemorrhage, a rate of 41.0 per 100,000 maternities with a 95% confi dence interval from 36.6 to
45.8 oer 100,000 maternities. This suggests that more than 60 women undergo a peripartum hysterectomy
for each woman who dies from haemorrhage. The underlying factors identifi ed for the women who died
of haemorrhage are also refl ected in this group of women who underwent hysterectomy. Women who
had undergone a previous delivery by caesarean section were at higher risk of requiring a peripartum
hysterectomy, with an odds ratio of 3.52 with a 95% confi dence interval from 2.35 to 5.26. This risk
increased with the number of previous caesarean sections; women who had had two or more previous
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