- Email: [email protected]
W349 HOW EFFICIENT IS FIBRINOGEN CONCENTRATE IN THE MANAGEMENT OF MAJOR OBSTETRIC HAEMORRHAGE IN COMPARISON TO CRYOPRECIPITATE?
S818
Poster presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S531–S867
presentation. Elective CS should be the major delivery mode in nuliparous older females, while vaginal BD should be defined for younger multiparous health patients with estimated birth weight of 2500–3500g. Acknowledgement: This study was supported by project CEPV I and CEPV II co-financed from EU sources (ITMS: 26220120016, 26220120036). W349 HOW EFFICIENT IS FIBRINOGEN CONCENTRATE IN THE MANAGEMENT OF MAJOR OBSTETRIC HAEMORRHAGE IN COMPARISON TO CRYOPRECIPITATE? S. Ahmed1 , B. Byrne1 . 1 Obstetrics and Gyne, Coombe Hospital, Dublin 15, Ireland Objectives: In July 2009, the Irish Blood Transfusion Service (IBTS) replaced cryoprecipitate with fibrinogen concentrate with the aim of reducing the potential risk of pathogen transmission. Fibrinogen concentrate appears to have similar efficacy in treatment of major haemorrhage but there is limited data about its use in Major Obstetric Haemorrhage (MOH). The aim of this study was to assess the impact of this change on estimated blood loss (EBL) and blood product use in MOH. Materials: A Prospective detailed audit of MOH began at our institution in January 2009. Cases are defined by EBL of 2.5 litres, transfusion of 5 or more units of Red Cell Concentrate (RCC) or treatment of a coagulopathy. Methods: The EBL and the use of blood products were compared between those that sustained an MOH with associated hypofibrinogenemia before and after cryoprecipitate was replaced with fibrinogen. Results: 58 cases of MOH were identified in 2 years (3.3/1000 deliveries). 29 required treatment for hypofibrinogenemia; Cryoprecipitate (14) and Fibrinogen concentrate (15). The two groups were similar in age, parity, ethnicity and gestation at delivery. The main cause of bleeding was uterine atony followed by retained placental tissue and medical management was similar. Haemostasis was achieved in all cases. Conclusions: The replacement of cryoprecipitate with Fibrinogen concentrate in MOH was associated with a reduction in EBL and a reduction in use of RCC and Octaplas. These cases, however, were diverse and complex and fibrinogen replacement was only one factor in the overall management but replacement with a small volume bolus that can be administered rapidly without thawing may facilitate more rapid correction of coagulopathy and earlier haemostasis. Variables
Cryoprecipitate Fibrinogen concentrate (n = 14) (n = 15)
Minimum Fibrinogen level recorded (g/l) Average amount utilized Estimated blood loss (litres), mean±SD Red cell transfusion (units), mean±SD Octaplas transfusion (units), mean±SD Platelet transfusion (pools)
0.19 2.2 units 5±4 7.2±4.6 4.1±2.7 1
0.19 4.4 grams 3.5±2.6 5.4±4.3 2.6±3 1
W350 FETAL SCALP PH SAMPLING – IS IT FEASIBLE IN A BUSY COMMUNITY HOSPITAL? D. Chu1 , K. McMahon1 , V. Chow1 , N. Martin1 , B. Kerr1 , C. Badeau1 . 1 Obs and Gyne, U Of Toronto, North York General Hospital, Toronto, ON, Canada Objectives: To determine the feasibility of implementing fetal scalp pH sampling as part of the SOGC guideline. Materials: NYGH is a Community/Academic Hospital affiliated with the U of T. We are a busy Obstetrical unit with 6000 deliveries per yr.
Our department has a Quality Improvement Committee made up of nurses, midwives, and physicians. Methods: Using an Intrapartum Fetal Surveillance audit form we reviewed the FHR tracings and their management in June, September, October 2011. A multidisciplinary focus group was formed to review whether the guideline was followed. Results: During the study period, there were 489 tracings available for review. There were 46 Abnormal Tracings. According to the guideline, further actions included fetal scalp stimulation to elicit FHR acceleration and if absent a fetal scalp pH should be performed or delivery if appropriate. In the review there was poor documentation of response to scalp stimulation and only one scalp sample was performed. The major barrier the focus group identified was the general lack of familiarity with the process of scalp pH sampling, the processing of the scalp sample, and lack of confidence in the accuracy of the pH machine itself. The solutions are as follows: (1) We completely revamped the work station for the pH machine. (2) We performed simulations and trial runs, using umbilical cord blood, keeping record of nursing staff and physicians to ensure each individual is fully trained in the mechanics of the process. (3) To establish the accuracy of our pH machine, we collected extra samples from the umbilical cord and ran it through the machine. Utilizing a quality assurance process, with the main lab as our benchmark we established the pH values were within 0.03, acceptable by the machine standards. We posted these results on our Quality board to promote staff confidence in the machine. As an ongoing Quality Improvement project, we have seen success in the early phase of our project with general buy in for scalp pH sampling from both nursing staff and physicians. There was more awareness of the indication of the procedure as well the number of scalp pH samples done has increased from one over the three month review period to three in January 2012. Conclusions: Scalp pH sampling can be incorporated practically as part of the management guideline, especially in a busy Obstetrical Unit. A multidisciplinary approach is the best way to promote general buy in, continued simulations and trial runs are helpful in maintaining the skill level of the staff. W351 SKIN-TO-SKIN CONTACT: CLINICAL PEARLS AND EVIDENCE-BASED APPROACHES TO IMPLEMENTATION B. Kerr1 , K. McMahon1 , A. Finkel1 , M. Amato1 . 1 Labour and Delivery, North York General Hospital, Toronto, ON, Canada Objectives: Skin-to-skin contact (SSC) involves placing the naked infant prone on a parent’s bare chest. SSC has been linked to a number of benefits and is not known to have any adverse effects. The purpose of this poster is to briefly review the literature on SSC and to outline one community teaching hospital’s experience with its implementation. Materials and Methods: An evidence-based approach to SSC was established. A needs assessment survey was completed by staff (n = 70) to establish baseline knowledge, to elicit barriers and facilitators to SSC and to guide curriculum development for interdisciplinary sessions. Once the education was completed, all participants were resurveyed. Chart audits (n = 2447) have been conducted ongoing to identify rates of SSC immediately after birth as well as the rate of SSC transfers between labour & delivery and mother & baby units. Breastfeeding rates on discharge were compared pre-and-post SSC education sessions as well. Results: Studies show that SSC enhances maternal attachment, successful and continued breastfeeding, improves neonatal physiologic outcomes and stability, and provides analgesic effects on neonatal procedural pain. Our needs assessment revealed inconsistent understanding and apprehension to implementing SSC. Educational sessions consisted of in-services and grand rounds
Poster presentations / International Journal of Gynecology & Obstetrics 119S3 (2012) S531–S867
presentation. Elective CS should be the major delivery mode in nuliparous older females, while vaginal BD should be defined for younger multiparous health patients with estimated birth weight of 2500–3500g. Acknowledgement: This study was supported by project CEPV I and CEPV II co-financed from EU sources (ITMS: 26220120016, 26220120036). W349 HOW EFFICIENT IS FIBRINOGEN CONCENTRATE IN THE MANAGEMENT OF MAJOR OBSTETRIC HAEMORRHAGE IN COMPARISON TO CRYOPRECIPITATE? S. Ahmed1 , B. Byrne1 . 1 Obstetrics and Gyne, Coombe Hospital, Dublin 15, Ireland Objectives: In July 2009, the Irish Blood Transfusion Service (IBTS) replaced cryoprecipitate with fibrinogen concentrate with the aim of reducing the potential risk of pathogen transmission. Fibrinogen concentrate appears to have similar efficacy in treatment of major haemorrhage but there is limited data about its use in Major Obstetric Haemorrhage (MOH). The aim of this study was to assess the impact of this change on estimated blood loss (EBL) and blood product use in MOH. Materials: A Prospective detailed audit of MOH began at our institution in January 2009. Cases are defined by EBL of 2.5 litres, transfusion of 5 or more units of Red Cell Concentrate (RCC) or treatment of a coagulopathy. Methods: The EBL and the use of blood products were compared between those that sustained an MOH with associated hypofibrinogenemia before and after cryoprecipitate was replaced with fibrinogen. Results: 58 cases of MOH were identified in 2 years (3.3/1000 deliveries). 29 required treatment for hypofibrinogenemia; Cryoprecipitate (14) and Fibrinogen concentrate (15). The two groups were similar in age, parity, ethnicity and gestation at delivery. The main cause of bleeding was uterine atony followed by retained placental tissue and medical management was similar. Haemostasis was achieved in all cases. Conclusions: The replacement of cryoprecipitate with Fibrinogen concentrate in MOH was associated with a reduction in EBL and a reduction in use of RCC and Octaplas. These cases, however, were diverse and complex and fibrinogen replacement was only one factor in the overall management but replacement with a small volume bolus that can be administered rapidly without thawing may facilitate more rapid correction of coagulopathy and earlier haemostasis. Variables
Cryoprecipitate Fibrinogen concentrate (n = 14) (n = 15)
Minimum Fibrinogen level recorded (g/l) Average amount utilized Estimated blood loss (litres), mean±SD Red cell transfusion (units), mean±SD Octaplas transfusion (units), mean±SD Platelet transfusion (pools)
0.19 2.2 units 5±4 7.2±4.6 4.1±2.7 1
0.19 4.4 grams 3.5±2.6 5.4±4.3 2.6±3 1
W350 FETAL SCALP PH SAMPLING – IS IT FEASIBLE IN A BUSY COMMUNITY HOSPITAL? D. Chu1 , K. McMahon1 , V. Chow1 , N. Martin1 , B. Kerr1 , C. Badeau1 . 1 Obs and Gyne, U Of Toronto, North York General Hospital, Toronto, ON, Canada Objectives: To determine the feasibility of implementing fetal scalp pH sampling as part of the SOGC guideline. Materials: NYGH is a Community/Academic Hospital affiliated with the U of T. We are a busy Obstetrical unit with 6000 deliveries per yr.
Our department has a Quality Improvement Committee made up of nurses, midwives, and physicians. Methods: Using an Intrapartum Fetal Surveillance audit form we reviewed the FHR tracings and their management in June, September, October 2011. A multidisciplinary focus group was formed to review whether the guideline was followed. Results: During the study period, there were 489 tracings available for review. There were 46 Abnormal Tracings. According to the guideline, further actions included fetal scalp stimulation to elicit FHR acceleration and if absent a fetal scalp pH should be performed or delivery if appropriate. In the review there was poor documentation of response to scalp stimulation and only one scalp sample was performed. The major barrier the focus group identified was the general lack of familiarity with the process of scalp pH sampling, the processing of the scalp sample, and lack of confidence in the accuracy of the pH machine itself. The solutions are as follows: (1) We completely revamped the work station for the pH machine. (2) We performed simulations and trial runs, using umbilical cord blood, keeping record of nursing staff and physicians to ensure each individual is fully trained in the mechanics of the process. (3) To establish the accuracy of our pH machine, we collected extra samples from the umbilical cord and ran it through the machine. Utilizing a quality assurance process, with the main lab as our benchmark we established the pH values were within 0.03, acceptable by the machine standards. We posted these results on our Quality board to promote staff confidence in the machine. As an ongoing Quality Improvement project, we have seen success in the early phase of our project with general buy in for scalp pH sampling from both nursing staff and physicians. There was more awareness of the indication of the procedure as well the number of scalp pH samples done has increased from one over the three month review period to three in January 2012. Conclusions: Scalp pH sampling can be incorporated practically as part of the management guideline, especially in a busy Obstetrical Unit. A multidisciplinary approach is the best way to promote general buy in, continued simulations and trial runs are helpful in maintaining the skill level of the staff. W351 SKIN-TO-SKIN CONTACT: CLINICAL PEARLS AND EVIDENCE-BASED APPROACHES TO IMPLEMENTATION B. Kerr1 , K. McMahon1 , A. Finkel1 , M. Amato1 . 1 Labour and Delivery, North York General Hospital, Toronto, ON, Canada Objectives: Skin-to-skin contact (SSC) involves placing the naked infant prone on a parent’s bare chest. SSC has been linked to a number of benefits and is not known to have any adverse effects. The purpose of this poster is to briefly review the literature on SSC and to outline one community teaching hospital’s experience with its implementation. Materials and Methods: An evidence-based approach to SSC was established. A needs assessment survey was completed by staff (n = 70) to establish baseline knowledge, to elicit barriers and facilitators to SSC and to guide curriculum development for interdisciplinary sessions. Once the education was completed, all participants were resurveyed. Chart audits (n = 2447) have been conducted ongoing to identify rates of SSC immediately after birth as well as the rate of SSC transfers between labour & delivery and mother & baby units. Breastfeeding rates on discharge were compared pre-and-post SSC education sessions as well. Results: Studies show that SSC enhances maternal attachment, successful and continued breastfeeding, improves neonatal physiologic outcomes and stability, and provides analgesic effects on neonatal procedural pain. Our needs assessment revealed inconsistent understanding and apprehension to implementing SSC. Educational sessions consisted of in-services and grand rounds