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.