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

84
4 Haemorrhage
caesarean section deliveries had more than an eighteen times higher odds of requiring a peripartum
hysterectomy than women who had not had any caesarean section deliveries. Assuming causality, an
estimated 28% of hysterectomies were attributable to prior caesarean delivery.
The causes of haemorrhage reported in the UKOSS study also refl ect those identifi ed in the women who
died. Of women requiring hysterectomy, 53% were reported to have uterine atony and 38% had a morbidly
adherent placenta, either placenta accreta, percreta or increta. The management of these women was
variable. One hundred and thirty seven women had haemorrhage due to uterine atony alone. Four of
these women (3%) did not receive any uterotonic therapy in the form of syntocinon infusion, ergometrine,
prostaglandin F2 or misoprostol. Eleven (8%) were not managed with a syntocinon infusion and only 84
(61%) were given ergometrine. Twenty three women with haemorrhage due solely to morbidly adherent
placenta (25%) did not receive any uterotonic treatment.
Fifty women were reported to have had a hysterectomy following a B-Lynch or other brace suture, twentyeight
following the use of activated factor VII and nine following arterial embolisation. It was noted in the
previous Report that no deaths occurred in women managed with arterial embolisation but the use of these
newer therapies requires further analysis and review.
Conclusions
The incidence of severe bleeding in childbirth has been estimated in various surveys to range between 4
and 5 per 1000 maternities, or one in 200 to 250 deliveries. In developed countries treatment is generally
effective and this gives an approximate case fatality rate between 1 in 600 and 1 in 800 cases of obstetric
bleeding1,3,11 . Nevertheless as both this Report and the UKOSS study have shown, obstetric haemorrhage
remains a problem both in terms of mortality and severe morbidity.
It is clear that previous caesarean section is a risk factor for haemorrhage and the operation is not as risk
free as many have thought. Whilst recognising its clinical benefi ts, women must be advised of the potential
risks of caesarean section for their current and future pregnancies, especially for those women who have
had more than one previous operative delivery. All women who have had a previous caesarean section
must have their placental site determined. If there is any doubt, magnetic resonance imaging (MRI) can be
used along with ultra sound scanning in determining if the placenta is accreta or percreta.
Box 4.1
Learning points: obstetric haemorrhage
Dealing with ill, bleeding women requires skilled teamwork between obstetric and anaesthetic
teams with appropriate help from other specialists including haematologists, vascular surgeons and
radiologists.
Senior staff should be involved as early as possible, and should have appropriate experience.
The management of placenta percreta requires a large multidisciplinary team and forward planning.