Critical care in obstetrics: Clinical audit in the Republic of Ireland, 2014-2016.

INTRODUCTION: Admission to an Intensive Care Unit (ICU) in obstetrics is often used as a proxy for maternal near miss/severe maternal morbidity (MNM/SMM) events. Understanding incidence and management of pregnant or postpartum patients requiring critical care (CC) is thus important for continued improvement of maternity care. This study aims to describe provision of critical care in obstetrics in the Republic of Ireland. MATERIAL AND METHODS: The national clinical audit on critical care included 15 of 19 maternity units in Ireland (2014-2016). 960 pregnant or postpartum (within 42 days) individuals who required CC were included. Data were reported on all cases requiring level 2 or level 3 CC. We calculated basic descriptive statistics for diagnosis and process of care variables, and compared characteristics of women requiring level 2 care to those requiring level 3. Outcomes included diagnoses necessitating critical care; additional complications; level of care required; care process outcomes such as length of stay, consultation with non-obstetric specialties, location of maternal critical care, and neonatal care provision. RESULTS: Overall, the rate of critical care in obstetrics for these hospitals was 1 in 131 live births; 900 of the 960 cases required level 2 care only. Hypertensive disorders contributed to the need for critical care for 1 in 242; hemorrhage, 1 in 422; and infections, 1 in 926. A substantial minority (15.7%) had more than one diagnosis, accounting for 40% of level 3 care. Serious complications were rare (eg, hysterectomy, 1 in 3846). Parity, hospital size, and identification as high-risk antenatally (<50% cases) were associated with requiring level 3 care. Critical care was provided in multiple locations, including ICUs, HDUs, and operating theatres. Only 23.8% of patients received CC in an ICU, suggesting ICU admission is not an ideal method for identifying severe maternal morbidity. CONCLUSIONS: We reported rates of critical care admission and primary diagnoses within the range of other published estimates, but huge variability exists in the literature, and within our data. ICU admission in and of itself iss not a reliable proxy for having received level 2 or 3 obstetric critical care in Ireland.

Major obstetric haemorrhage: Incidence, management and quality of care in Irish maternity units.

OBJECTIVE: To assess major obstetric haemorrhage incidence, management and quality of care in Irish maternity units. DESIGN: In collaboration with Irish maternity units the National Perinatal Epidemiology Centre (Leitao et al., 2020) carried out a national clinical audit and surveillance of major obstetric haemorrhage (MOH). METHODS: MOH was defined as blood loss of at least 2500 ml, transfusion of five or more units of blood or documented treatment for coagulopathy. Co-ordinators in maternity units completed detailed case assessment forms. The denominator data obtained from the individual units was restricted to live births and stillbirths of babies weighing at least 500 g. International Classification of Diseases diagnostic codes from hospital discharge records were used to identify cases of postpartum haemorrhage (PPH) and blood transfusion. RESULTS: During the time period, 2011-2018, there was a 54 % increase in MOH, a 60 % increase in PPH and a 54 % increase in blood transfusion. For 497 reported cases of MOH in 2011-2013, the median estimated blood loss was 3000 ml (range: 600-13,000 ml) and uterine atony was the most common cause. At least one uterotonic agent was used to arrest the bleeding in 94 % of the 477 MOH cases associated with a vaginal or caesarean delivery. A blood transfusion was received in 93 % of cases. Regarding quality of care, the vast majority of reported cases were described as receiving appropriate care and were well managed. CONCLUSION: Internationally, obstetric haemorrhage and especially PPH and its increasing trend remains a major challenge for service providers and clinical staff. A standardisation of definitions of PPH/severe PPH/MOH and agreed approaches to quantitation of blood loss would be valuable developments to allow better investigation and shared learning. Reducing the burden of this morbidity through improvements in care should be a real focus of maternity services.

Peripartum hysterectomy incidence, risk factors and clinical characteristics in Ireland.

BACKGROUND: The incidence of peripartum hysterectomy (PH) shows fifty-fold variation worldwide (0.2-10.5/1000 deliveries) and risk factors include advancing maternal age and parity, previous caesarean section (CS) and abnormal placentation. OBJECTIVES: In this first national study of PH in Ireland, our objectives were threefold: to describe the national trend in PH incidence over 15 years since 1999; to assess risk of PH associated with morbidly adherent placenta (MAP), placenta praevia and postpartum haemorrhage (PPH) during 2005-2013; and to describe the causes, interventions and outcomes of PH cases during 2011-2013. STUDY DESIGN: For the 15-year time-trend analysis, PH cases and denominator data were extracted from Ireland's Hospital In-Patient Enquiry database. Multivariate Poisson regression analysis assessed risk of PH associated with MAP, placenta praevia and PPH. In collaboration with the 20 Irish maternity units we carried out a three-year national clinical audit of severe maternity morbidity. PH was a notifiable morbidity and the audit included detailed review of MOH cases. RESULTS: In 1999-2013 there were 298 PH cases, a rate of 0.32/1000 deliveries. During the period 2005-2013, the PH rate was 50 times higher in deliveries involving PPH, 100 times higher with placenta praevia and 1000 times higher with MAP. During the clinical audit (2011-2013) there were 65 PH cases, a rate of 0.33/1000 deliveries, increasing with advancing age and parity. The reporting of abnormal placentation, primarily the co-occurrence of placenta praevia and MAP, was linked with previous CS. Fifty-six of the 65 cases suffered MOH, most commonly associated with placenta praevia, MAP and uterine atony. Prophylactic and therapeutic uterotonic agents were appropriately used in the majority of cases. CONCLUSIONS: The incidence of PH in Ireland has been consistently low over 15 years, averaging one case every 3000 deliveries. The recognised risk factors of MAP, placenta praevia and PPH were independently associated with PH, with MAP being by far the strongest predictor. The vast majority of PH cases in our clinical audit were associated with MOH. Some deficiencies were noted in antenatal care, in certain elements of treatment and clinical governance protocols but adherence to guidelines was generally high.