therapies or prophylaxis for peripartum haemorrhage study
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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.
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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