Department of Woman, New-Born and Child, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Mangiagalli Centre, Via della Commenda, 12, 20122 Milan, MI, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Festa del Perdono, 7, 20122 Milan, MI, Italy; Maternal-Infant Department, A.S.S.T. Rhodense, Via Carlo Forlanini, 95, 20024 Garbagnate Milanese, MI, Italy.
Department of Woman, New-Born and Child, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Mangiagalli Centre, Via della Commenda, 12, 20122 Milan, MI, Italy.
Eur J Obstet Gynecol Reprod Biol. 2022 Apr;271:152-157. doi: 10.1016/j.ejogrb.2022.02.017. Epub 2022 Feb 18.
To assess the effectiveness of the implementation of a multilevel institutional program to reduce the rate of emergency peripartum hysterectomy (EPH) secondary to postpartum haemorrhage (PPH) in a Western world referral centre for obstetrics.
Women who delivered at a tertiary care regional obstetric hub in Milan between 2012 and 2020 were retrospectively reviewed to identify cases of EPH. During the study period, several measures aimed at preventing EPH were progressively implemented: reduction of primary and repeated caesarean, update of PPH treatment protocol, implementation of massive transfusion protocol, dedicated clinical pathway for high-risk patients, regular educational sessions, daily review of critical cases with senior consultant, and periodical review of near miss cases by quality improvement committee. To investigate the possible benefits, we divided the detected cases into two groups based on the historical period (Period I, 2012-2016 vs. Period II, 2017-2020) with the main aim of comparing the rate of EPH calculated as EPH ratio per 1000 deliveries.
During Period I and II there were 30,241 and 21,270 births; a total of 60 and 25 EPH were performed, respectively. EPH incidence decreased from 2.0 to 1.2‰ across the study periods (p = 0.027). Between Period I and II, we observed a reduction of institutional caesarean section rate (44.4% vs. 40.4%, p < 0.0001); among cases undergoing EPH, we reported a significant reduction of massive blood transfusion (83.3% vs. 52.2%, p = 0.002), increased use (56.7% vs. 96.0%, p = 0.0004) and appropriate administration (25.0% vs. 88.0%, p < 0.0001) of tranexamic acid, increased use of non-invasive Bakri Balloon tamponade (3.3% vs. 32.0%, p = 0.0002) instead of surgical techniques (38.3% vs. 16.0%, p = 0.043).
A reduction of EPH incidence as a severe outcome of obstetric haemorrhage is achievable through a multilevel institutional effort. Our study may inspire a larger-scale program to improve the safety of patients experiencing PPH.
评估在西方转诊产科中心实施多层次机构计划以降低产后出血（PPH）导致的急诊剖宫产率（EPH）的效果。
回顾性分析 2012 年至 2020 年在米兰三级保健区域产科中心分娩的妇女，以确定 EPH 病例。在研究期间，逐步实施了多项预防 EPH 的措施：减少原发性和重复性剖宫产术、更新 PPH 治疗方案、实施大量输血方案、为高危患者制定专门的临床途径、定期教育课程、高级顾问每日审查重症病例、质量改进委员会定期审查近失案例。为了调查可能的益处，我们根据历史时期将检测到的病例分为两组（第 I 期，2012-2016 年与第 II 期，2017-2020 年），主要目的是比较每 1000 次分娩计算的 EPH 率。
第 I 期和第 II 期分别有 30241 例和 21270 例分娩；共发生 60 例和 25 例 EPH。研究期间，EPH 发病率从 2.0‰降至 1.2‰（p=0.027）。在第 I 期和第 II 期之间，我们观察到机构剖宫产率降低（44.4%比 40.4%，p<0.0001）；在进行 EPH 的病例中，我们报告了大量输血显著减少（83.3%比 52.2%，p=0.002）、氨甲环酸使用率增加（56.7%比 96.0%，p=0.0004）和适当使用（25.0%比 88.0%，p<0.0001）、非侵入性 Bakri 球囊填塞使用率增加（3.3%比 32.0%，p=0.0002）而不是手术技术（38.3%比 16.0%，p=0.043）。
通过多层次机构努力，可以降低作为产科出血严重后果的 EPH 发生率。我们的研究可能会激发一项更大规模的计划，以提高经历 PPH 的患者的安全性。
