Urgent Maternal Mortality Message from FL PAMR


2016 UPDATE: Urgent Maternal Mortality Message to Providers


Florida’s Pregnancy Associated Mortality Review committee has just released the first in a series of Urgent Maternal Mortality Messages.

Message #1: Hemorrhage and Placenta Accreta provides information for both providers and patients related to obstetric hemorrhage.


  • Hemorrhage is the leading cause of Pregnancy-Related maternal death in Florida
  • Placental disorders (including placenta previa, accreta/increta/percreta) accounted for 21% of hemorrhage related deaths > 20 weeks gestation
  • With the rising cesarean rate, the incidence of placenta accreta has increased

PAMR Message to Providers:


  • Essential before delivery
  • If placental disorder suspected, get a Maternal-Fetal Medicine consultation
  • Ultrasonography with supplemental MRI when necessary
  • No imaging modality is perfect. If you suspect an issue – transfer to tertiary facility

Know risk factors:

  • Discuss pregnancy and delivery risks with patients and family
  • The risk of accreta increases with repeat cesarean sections, myomectomy, presence of placenta previa, multiparty, repetitive dilation and curettages and with advanced maternal age
  • A low lying anterior placenta may be ominous with multiple prior cesarean sections


  • Develop and discuss with the patient, family and hospital staff an individual delivery plan
  • Consider early transfer to a tertiary center for access to sufficient blood bank supply and subspecialties
  • Contingency plan should be made for emergency delivery
  • Implementation of hemorrhage protocols in all Florida delivery hospitals is essential, and should include a massive transfusion protocol, simulation drills and hemorrhage carts. For details on implementing a Hemorrhage Initiative see Florida Perinatal Quality Collaborative’ s Toolkit

Delivery Plan: Essential elements include:

  • Preoperative counseling regarding risks
  • Timing of admission and delivery: see ACOG guidelines, may vary if patient unstable
  • Consult with neonatologist regarding corticosteroid administration, if applicable
  • Place blood bank on alert for potential massive transfusion protocol
  • When delivery is scheduled, discuss timing with a multispecialty team to optimize expert surgical and anesthesia assistance
  • Do not try to remove the placenta. Hysterectomy is usually the best option.
  • If you have called for help and cannot control the bleeding surgically, compress the aorta or uterine vessels while waiting for help to arrive.

PAMR Message to Community:

  • There is a high risk for bleeding due to placental disorders that can occur after having multiple cesarean sections.
  • Talk with your provider to understand your hemorrhage risk and about the plan for your delivery.
  • Your provider may recommend that you deliver at a different hospital.
  • Know when you should go to the hospital.
  • Before delivery, make plans for who will be caring for your children in your absence.