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UK Obstetric Surveillance System

Royal College of Obstetricians and Gynaecologists

Therapies or Prophylaxis for Peripartum HaemorrhageStudy 04/07

Data Collection Form - CASEPlease report all women delivering after 1st September 2007

and before 1st October 2008 CaseDefinition:

Awomantreatedwithanyofthefollowingtherapiesformanagementof peripartumhaemorrhage: EITHER FactorVIIa

OR B-Lynchorotherbracesuture

OR Arterialligationorembolisationorintra-arterialballons (includingprophylacticcatheterplacementpriortodelivery)

Pleasereturnthecompletedformto:

UKOSSNational Perinatal Epidemiology UnitUniversity of OxfordOld Road CampusOxfordOX3 7LF

Fax:01865289701Phone:01865289714

Casereportedin:

IDNumber:

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CASESection1:Woman’s details1.1 Year of birth Y Y Y Y

1.2 Ethnic group1* (enter code, please see back cover for guidance) 1.3 Marital status single married cohabiting1.4 Was the woman in paid employment at booking? Yes No

IfYes,whatisheroccupation

IfNo,whatisherpartner’s(ifany)occupation

1.5 Height at booking (cm) 1.6 Weight at booking (kg) .1.7 Smoking status never gaveuppriortopregnancy

current gaveupduringpregnancy

Section2:Previous Pregnancies2.1 Gravidity

Numberofcompletedpregnancies24weeksandbeyondNumberofpregnancieslessthan24weeksIf no previous pregnancies,please go to section 3.If the woman has had previous pregnancies please indicate whether any of the followingwerepresent:

Pregnancy or delivery problems2* Yes No IfYes,pleasespecify

Any previous deliveries by caesarean section Yes No IfYes,pleasespecifynumberintotalWastheimmediatelyprecedingdeliverybycaesareansection? Yes No

InstructionsPlease do not enter any personally identifiable information (e.g. name, address or hospital number)onthisform.PleaserecordtheIDnumberfromthefrontofthisformagainstthewoman’snameontheClinician’sSectionofthebluecardretainedintheUKOSSfolder.Fillintheformusingtheinformationavailableinthewoman’scasenotes.Ticktheboxesasappropriate.Ifyourequireanyadditionalspacetoansweraquestionpleaseusethespaceprovidedinsection7.PleasecompletealldatesintheformatDD/MM/YY,andalltimesusingthe24hrclocke.g.18:37Ifcodesorexamplesarerequired,somelists(notexhaustive)areincludedonthebackpageoftheform.Ifyoudonotknowtheanswerstosomequestions,pleaseindicatethisinsection7.IfyouencounteranyproblemswithcompletingtheformpleasecontacttheUKOSSAdministratororusethespaceinsection7todescribetheproblem.

1.

2.

3.4.

5.

6.

7.8.

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Section3:Previous Medical History3.1 Did the woman have any previous or pre-existing medical problems?3* Yes No

IfYes,pleasespecify3.2 Previous uterine surgery Yes No

IfYes,pleasespecifytypeandnumberofoperationsEvacuationofretainedproductsofconception(ERPC) Yes NumberDilatationandcurettage Yes NumberSurgicalterminationofpregnancy Yes NumberMyomectomy Yes NumberManualremovalofplacenta Yes NumberOther4* Yes Number

IfOther,pleasespecify

3.3 Previous uterine perforation Yes NoIfYes,pleasespecifytreatmentofperforation,ifany

Section4:This Pregnancy4.1 Final Estimated Date of Delivery (EDD)5* / /D M Y YMD

4.2 Was this pregnancy a multiple pregnancy? Yes NoIfYes,pleasespecifynumberoffetuses

4.3 Were there problems in this pregnancy?2* Yes NoIfYes,pleasespecify

4.4 Was placenta praevia diagnosed prior to delivery? Yes NoIfYes,pleasespecifygrade

4.5 Was placenta accreta/increta/percreta suspected prior to delivery? Yes NoIfYes,howwasitdiagnosed? Ultrasound MRI Other

IfOther,pleasespecify

Section5:Delivery5.1 Was delivery induced? Yes No

IfYes,pleasestateindicationWasvaginalprostaglandin/misoprostolused? Yes No

5.2 Did the woman labour? Yes No IfYes,pleasestatedateandtimeofdiagnosisoflabour / /D M Y YMD :h m mh

24hr

Wassyntocinonusedduringlabour? Yes NoDurationofsyntocinonduringlabour hrs mins

5.3 Was delivery by caesarean section? Yes No IfYes,pleasestategradeofmostsenioroperatorWhatwastheindicationforcaesareansection?Methodofanaesthesia (tick all that apply)

Epidural Single-shotspinal Continuousspinal CSE General

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5.4 What was used for third stage prophylaxis? (tick all that apply)None Syntocinon Syntometrine Other (please specify)

Haemorrhage5.5 What was the estimated blood loss (total mls)?5.6 Please indicate what treatments were undertaken

Tick all that apply

Please rank the therapies in the order in which they werefirstused(1,2,3etc)

Was this therapy used for prophylaxis (P) or treatment

(T)6*. Please tick (P) or (T)(P) (T)

Syntocinoninfusion

Ergometrine

Prostaglandin F2α

Misoprostol

Intra-abdominalpacking

Intrauterineballoons

Intrauterinepacking

RecombinantfactorVIIa

Vesselembolisation/ligation

Intra-arterialballoons

B-Lynchorotherbracesuture

Hysterectomy(pleasetick)Total Subtotal

Other(pleasespecify)

5.7 Was a B-Lynch or other compression suture used? Yes No IfNo,please go question 5.8IfYes,whattechniquewasused(please tick)

UnclearClassicalB-LynchModified B-Lynch (Two vertical sutures, uterus not opened) MultipleverticalcompressionsuturesSquaresuturesSystematicdevascularisationofuterusOther

IfOther,pleasespecifyDateandtimeofprocedure / /D M Y YMD :h m mh

24hr

Howmanyunitsofbloodhadbeentransfusedbythestartoftheprocedure?

Whatwasthetimebetweenthedecisiontouseacompressionsutureandthetimethesuturewasplaced(min)

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5.8 Was recombinant factor VIIa (Novoseven) used? Yes No IfNo,please go question 5.9

IfYes,please indicate total number of units transfused before rf VIIa was givenBloodFreshFrozenPlasma(FFP)PlateletsCryoprecipitateDate and time rf VIIa first used? / /D M Y YMD :h m mh

24hr

DoseofrfVIIagiven(first) (mg) . WhatwasthetimebetweenthedecisiontouserfVIIaand the time it was first given? (min)Totalnumberofdoses Totaldosegiven(mg) .

5.9 Is arterial embolisation (interventional radiology) routinely available in your unit? Yes No

IfYes,whenandwhereisitavailable(tick all that apply) Samehospital Differenthospital Duringnormalworkinghours Outofhours

5.10Was major blood vessel catheterisation or ligation carried out on this woman? Yes No

IfNo,please go to question 5.11IfYes,whichtechniquewasused? Balloon Embolisation Ligation Whenwerecathetersplaced? / /D M Y YMD :h m mh

24hr

Whichvesselswereoccluded?Ifembolisationwascarriedout,whatmaterialwasused?Wherewastheprocedureperformed? Samehospital DifferenthospitalDateandtimeofprocedure? / /D M Y YMD :h m mh

24hr

Howmanyunitsofbloodhadbeentransfusedbythestartoftheprocedure?

Whatwasthetimebetweenthedecisiontoperformembolisation/ligationandthetimetheprocedurewasperformed(min)

5.11What was the primary underlying cause of haemorrhage (please tick one only)UterineatonyPlacentapraeviaPlacentaaccreta/increta/percretaPlacentalabruptionUterineinfectionUterinerupture

IfYes,pleasespecify pre-labour duringlabour traumaticExtensionofincisionattimeofcaesareansectionExtensionofpreviouscaesareansectionscaratthetimeofcaesareansectionGenitaltracttrauma/tears

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CASESection6:OutcomesSection6a:Woman6a.1Please indicate whether any of the following morbidities occurred (tick all that apply)

AdultrespiratorydistresssyndromePulmonaryoedemaDisseminatedintravascularcoagulopathy(DIC)RenalfailurerequiringdialysisCardiacarrestPulmonaryembolismDVTOtherthrombosis

IfOtherthrombosis,pleasespecify6a.2Was the woman admitted to ITU? Yes No

IfYes,durationofstay(days)OrTickifwomanisstillinITUOrTickifwomanwastransferredtoanotherhospital

6a.3Did any other major maternal morbidity occur?8* Yes NoIfYes,pleasespecify

Othercause IfOther,pleasespecify

5.12 Did the woman refuse transfusion of blood products? Yes No5.13Please record the amounts of blood products received in total by this woman (units)

Total (units)

Wholebloodorpackedredcells

FreshFrozenPlasma(FFP)

Platelets

Cryoprecipitate

Cellsalvagedblood(ml)

5.14Was the woman actively warmed during treatment for haemorrhage? Yes No

5.15Weretheintravenousfluidsactivelywarmed? Yes No5.16Was the woman’s temperature monitored? Yes No

IfYes,whatwasherlowestrecordedtemperature? .5.17 Was CVP monitoring used? Yes No5.18 Was intra-arterial monitoring used? Yes No

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CASESection7Please use this space to enter any other information you feel may be important

Section8:Name of person completing the form

Designation Today’s date / /D M Y YMD

You may find it useful in the case of queries to keep a copy of this form.Ifyouareunabletomakeacopypleasetickthebox

6a.4Did the woman die? Yes NoIfYes,pleasespecifydateofdeath / /D M Y YMD

What was the primary cause of death as stated on the death certificate?

Section6b:Infant 1NB: If more than one infant, for each additional infant, please photocopy the infant section of the form (beforefillingitin) and attach extra sheet(s) or download additional forms from the website: www.npeu.ox.ac.uk/ukoss

6b.1Date and time of delivery / /D M Y YMD :h m mh24hr

6b.2Mode of deliveryspontaneousvaginal ventouse lift-outforceps rotationalforcepsbreech pre-labourcaesareansection caesareansectionafteronsetoflabour

6b.3Birthweight (g) 6b.4Was the infant stillborn? Yes No

IfYes,wasthis Antepartum OR IntrapartumPlease go to section 7

6b.5Was the infant admitted to the neonatal unit? Yes No

6b.6Did this infant die? Yes NoIfYes,pleasespecifydateofdeath / /D M Y YMD

What was the primary cause of death as stated on the death certificate?(please state if not known)

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Definitions

1. UK Census Coding for ethnic groupWHITE 01. British 02. Irish 03. AnyotherwhitebackgroundMIXED 04. WhiteandblackCaribbean 05. WhiteandblackAfrican 06. WhiteandAsian 07. AnyothermixedbackgroundASIANORASIANBRITISH 08. Indian 09. Pakistani 10. Bangladeshi 11. AnyotherAsianbackgroundBLACKORBLACKBRITISH 12. Caribbean 13. African 14. AnyotherblackbackgroundCHINESEOROTHERETHNICGROUP 15. Chinese 16. Anyotherethnicgroup

2. Current or previous pregnancy problems, including:Pre-eclampsia(hypertensionandproteinuria)EclampsiaThromboticeventAmniotic fluid embolism3ormoremiscarriagesPretermbirthormidtrimesterlossNeonataldeathStillbirthBabywithamajorcongenitalabnormalitySmallforgestationalage(SGA)infantLargeforgestationalage(LGA)infantInfantrequiringintensivecarePuerperalpsychosisPlacentapraeviaGestationaldiabetesSignificant placental abruptionPost-partumhaemorrhagerequiringtransfusion

3. Previous or pre-existing maternal medical problems,including:EssentialhypertensionCardiacdisease(congenitaloracquired)RenaldiseaseEndocrinedisorderse.g.hypoorhyperthyroidismPsychiatricdisordersHaematologicaldisorderse.g.sicklecelldisease,diagnosedthrombophiliaInflammatory disorders e.g. inflammatory bowel diseaseEpilepsy

DiabetesAutoimmunediseasesCancerHIV4.Examplesofotherpreviousuterinesurgery:MyomectomyEndometrialresection/ablationSeptalresectionPolypectomy

5.Estimateddateofdelivery(EDD):Usethebestestimate(ultrasoundscanordateoflastmenstrualperiod)basedona40weekgestation

6.Definitionofprophylaxisandtreatment:

(P)Prophylaxisorsupport:followinghaemorrhage,othertreatmentsgivenandconsideredsuccessful,butthistherapyadd‘justincase’tosupportotherinterventions.

(T)Treament/rescue:followinghaemorrhage,othertreatmentsgivenandconsideredtohavefailed,sothistherapyisgivenasrescue.

7. Major maternal medical complications, including:PersistentvegetativestateCerebrovascularaccidentPulmonaryoedemaMendelson’ssyndromeRenalfailureThromboticeventSepticaemiaRequiredventilation