Obstetric Anaesthesia Annual Scientific Meeting 2023

Introduction

Massive Obstetric Haemorrhage (MOH) is a leading direct cause of maternal death in the UK. MBRRACE reports have highlighted the problem of slow processing times for coagulation tests delaying blood product administration.1This is an ongoing issue in our unit, which delivers 5000 babies per year.

Point of care coagulation testing (POCCT) is recommended by the AAGBI, OAA and RCOA2 as a tool to speed up recognition and treatment of coagulation disorders in MOH.

After agreement in principle with the maternity leadership team to introduce POCCT we reviewed our local MOH management to support the bid.

Methods

Approval for a retrospective survey of reported MOH in 2021 was granted by the Trust governance committee. We reviewed the case notes of each patient who had a MOH and compared findings with 2018 data.

Results

•Our documented MOH incidence in our unit has risen - 19 cases were declared in 2021 compared with 11 cases in 2018

•QBL was over the local MOH threshold of 1.5L in 84% of cases (Range 1-5 – 7.4L)

•47% of MOH’s occurred during “out of hours” (6pm to 8am)

•16% occurred in elective theatres, the remainder in delivery suite/emergency theatre.

•Three unplanned hysterectomies and one admission to ICU

•Time taken to receive a coagulation profile deteriorated from a mean of 88 minutes (2018) to 106 minutes (2021).

•Wasted products cost on average £133 per patient.

Dicussion

MOH and its management remained problematic in our unit. It is a major factor in our patient morbidity, including unplanned hysterectomies, ICU admission, massive or inappropriate transfusion along with the risk of transfusion related adverse outcomes.

Blood products are a valuable resource and Northern Ireland is currently in a ‘pre-amber’ alert with low stocks available.

Our results show considerable delay in processing a coagulation profile during a MOH which may cause inappropriate transfusion or waste.

POCCT can yield results in 10-30 minutes and this project has helped support our bid for a ROTEM machine. Funding has now been approved, staff training has been carried out and ROTEM was installed to our unit in March 2023.

ROTEM training has involved:

•Anaesthetists, anaesthetic nurses, obstetricians, midwives, critical care scientists, haemovigilance team

•Online modules and face to face teaching

•Didactic lectures and multidisciplinary simulation training.

Changes to practice have included:

•Introduction of a ROTEM-guided MOH algorithm

•Modification of local MOH guideline

•Authorised immediate access to fibrinogen concentrate.

These measures will help to guide our rapid accurate management of coagulopathy during MOH as we embed their use into the culture and practice of our unit.

Obstetric Anaesthesia Annual Scientific Meeting 2023

Introducing ROTEM to Our Tertiary Obstetric Unit

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