Data collection form-case



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College Moeder Kind

Rare diseases and rare complications of pregnancy UTERINE RUPTURE






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Uterine rupture

DATA COLLECTION FORM-CASE

STUDY - IDENTIFICATION NUMBER: _________



Hospital name

Hospital case number

BACKGROUND INFORMATION on uterine rupture

Uterine rupture is a rare complication of pregnancy that is life-threatening to mother, fetus, or both. Whereas a uterine scar, mostly from a previous caesarean section, is the most common predisposing risk factor, it is well recognized that a rupture of an unscarred uterus is a far more dramatic event.

Rupture of an unscarred uterus is more common in low income countries in the presence of an obstructed labour. Yet, the last four CEMD reports in UK each includes at least one case of uterine rupture in a parous woman following induction of labour

According to the WHO, a uterine rupture occurs in 5 women for every 10,000 births. The incidence is lower in high income countries, the incidence being 3 for every 10,000 births. Moreover in Western countries the chance of the rupture to occur in an unscarred uterus is much lower being 0.6 for every 10,000 births (i.e. 1 in 6 cases of uterine rupture).

The definition used by UKOSS was rather restricted. The use of the LEMMoN definition allows the study of clinical symptoms preceeding uterine rupture.

As we aim at comparing the results obtained in Belgium with the results of the UK, as well as those found in the Netherlands, we decided to use the definition set by the LEMMON study in the Netherlands



Definition uterine rupture

The purpose in Belgium is to use a definition including all uterine rupture cases as defined by UKOSS, but also to consider all other forms of uterine rupture as defined by the LEMMoN study in the Netherlands.



LEMMoN defined “uterine rupture” as the occurrence of clinical symptoms (abdominal pain, abnormal fetal heart rate pattern, acute loss of contractions, vaginal blood loss), leading to an emergency caesarean delivery, at which the presumed diagnosis of uterine rupture was confirmed; or peripartum hysterectomy or laparotomy for uterine rupture after vaginal birth.

LEMMoN excluded cases of scar dehiscence found during elective caesarean section without preceding clinical symptoms.



Instructies

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  • Gelieve geen namen, noch adressen in te vullen op dit formulier.

  • Gelieve alle data te noteren als dd/mm/jj en voor alle tijden de 24uurs notatie te gebruiken.

  • Vink de hokjes aan , aan de hand van het dossier. Wil er op letten niet beide “yes” en”no” op dezelfde vraag te antwoorden

  • Indien er te weinig plaats voorzien is bij een vraag kan u verder aanvullen

in section 9.

  • Indien een vraag niet beantwoord kan worden, gelieve dit te vermelden in

SECTION 9.

  • Indien U problemen ondervindt bij het invullen van dit formulier, aarzel dan niet

om ons te contacteren.

  • Wil rekening houden met de betekenis van volgende afkortingen :

N.A. betekent “Not Applicable” = not relevant

N.R. betekent “Not Reported” = not registred

0 betekent “none”

U betekent “Unknown” – zou eigenlijk nooit mogen voorkomen



Instructions

Ce questionnaire a été élaboré de sorte que vous ne devez pas l’imprimer. Vous pouvez répondre aux questions directement sur l'ordinateur. Vous devez tout d’abord sauvegarder le questionnaire avant de l’envoyer électroniquement une fois rempli à B.OSSVlaanderen@gmail.com
- Veuillez remplir les noms et adresses sur ce formulaire.

- S’il vous plaît, notez toutes les dates comme ceci: jj / mm / aa et utilisez le format de 24 heures pour les heures.

- Cochez la case, selon le type de dossier. Vous ne pouvez pas, à la fois, cocher «oui» et «non» à la même question

- S’il y a peu de place pour répondre à la question, vous pouvez ajouter la suite de vos commentaires à la section 10

- Si vous ne pouvez pas répondre à une question, nous vous invitons à le mentionner dans la section 10

- Si vous avez des difficultés à remplir ce formulaire, n’hésitez pas à nous contacter.

- Veuillez prendre en compte la signification des abréviations suivantes:

N.A. signifie “Not Applicable” = not relevant

N. R. signifie “Not Reported” = not registred

0 signifie "none"

Vous voulez dire "Unknown" - inconnu

SECTION 1 : WOMAN’S DETAILS


    1. Year of birth



    1. Ethnic group woman



    1. Marital status



    1. Was the woman in paid employment at the start of pregnancy

If yes, please enter her occupation

If not, please enter the occupation of the partner



    1. Height at 1st visit cm

    2. Weight at 1st visit kg

    3. Calculate BMI

    4. Smoking status



1.9 Language skills:


SECTION 2: PREVIOUS PREGNANCIES

    1. Gravidity excluding the present pregnancy

Duration of the previous pregnancies Alive born Birthweight(g) Still alive

1st weeks days

2nd weeks days

3th weeks days

4th weeks days

5th weeks days

6th weeks days

Please take care not to indicate both “yes” and “no”

If no previous pregnancies, please go to section 3


    1. Did the woman have any previous pregnancy problems/complications

Please specify each complication




    1. Has the woman had previous caesarean sections

Was the immediately preceding delivery by caesarean section ?

If yes, please specify number in total

Please indicate the following for each previous caesarean section:


Date of c-section (mm/yy)













Gestation at delivery (weeks + days)













Indication for c- section













In labour at time of C-section

Yes













No













Type of uterine incision (low transverse/ corporal/other)













Type of uterine closure (single layer/double layer/not known)













Recorded postpartum Endometritis/ woundinfection/other
















    1. Give date of the last vaginal delivery: day month year

Give date of the last caesarean section: day month year

    1. Multiple pregnancies at 12 weeks gestation

 number:

 number:

number:


    1. Date of last delivery

day month year
SECTION 3 PREVIOUS MEDICAL HISTORY


    1. Previous or pre-existing medical problems

If any please specify



    1. Previous or pre-existing gynecological problems

If any please specify





    1. Previous uterine surgery

Number of interventions Total Number of fibroids

If yes, was the cavity breached?

Number

Number

Number

Number



    1. Did the woman have a previous uterine perforation (e.g. in case of D&C)

If yes, was any treatment given for the perforation, and specify



SECTION 4: CURRENT PREGNANCY

    1. Beginning of pregnancy

If assisted, please specify



    1. Final estimated date of delivery day month year



    1. Was this pregnancy a multiple pregnancy at 12 weeks gestation ?

If yes, please specify number of fetuses


    1. Were there any problems/complications in this pregnancy

If yes, please specify




    1. What was the planned mode of delivery for this pregnancy



    1. Pregnancy follow-up = during pregnancy (please indicate principle place where woman was seen by any type of caregiver / several caregivers are possible)


By Midwife

By Family Doctor


By Specialist


*= any place organized by a third party e.g. O.N.E / K&G / or Group Practice outside a hospital
SECTION 5A: LABOUR, DELIVERY and UTERINE RUPTURE

    1. Date and Time of admission of the patient

day month hour minutes

    1. Was the patient in spontaneous labour?



    1. Was labour induced/pre-induced?

If yes, please state indication

What was the Bishop score ad admission/prior to induction: Bishop score


CERVIX

SCORE - maximum is 13

0

1

2

3

Position cervix

Posterior

Midline

Anterior

-

Consistency

Firm

Medium

Soft

-

Effacement

0-30%

3-4cm long


not-effaced

40-50%

2cm
½ effaced



60-70%

1 cm or less


¾ effaced

>80%
Fully effaced

Dilatation

Closed

1-2cm

3-4cm

5cm

Head: station

Hodge 1
spine -3


Hodge 2
spine -2,-1

Hodge 3
spine 0

Hodge 4
spine +1,+2

Was prostaglandin used for induction/pre-induction?

If yes, please specify type of prostaglandin (name) given, dose and date & time:



Agent

Administration route


Dose (mg)
in case of IV:
max dose


Date (dd/mm/yy)

Time (hh:mm)












































































Other methods used for induction / pre-induction

  • Mechanical

day month hour minutes




  • Amniotomy to induce or pre-induce

day month hour minutes

Aspect of amniotic fluid


  • Did the woman receive syntocinon /oxytocin as part of the induction / pre-induction?

If yes, please specify start of syntocinon infusion:

day month hour minutes

If yes, please specify stop of syntocinon infusion:

day month hour minutes
-Duration of syntocinon: hours-min

-Maximal flow rate of syntocinon: mL/min

-Dilution of syntocinon: U/L

-Total dose of syntocinon: to be calculated




    1. Did the woman labour ?

If yes, please state date and time of diagnosis of labour

(i.e. 3cm dilatation and regular contractions)

day month hour minutes

What was the maximum contraction frequency (number of contractions in 10min)?


  • Did the woman receive syntocinon /oxytocin to augment labour contractions?

If yes, please specify start of syntocinon infusion:

day month hour minutes

If yes, please specify stop of syntocinon infusion:

day month hour minutes
-Duration of syntocinon: hours-min

-Maximal flow rate of syntocinon: mL/min

-Dilution of syntocinon: U/L

-Total dose of syntocinon: to be calculated




    1. Date and time of suspicion of uterine rupture

day month hour minutes

    1. Dilatation at the moment of suspicion of uterine rupture (cm)



    1. Fetal presentation at the moment of suspicion of uterine rupture




Fetal stage at the moment of suspicion of uterine rupture

    1. Please indicate what symptoms and signs were noted prior to diagnosis of rupture (thick all that apply)

If ticked please specify abnormality noted

Time first noticed (hh:mm)

Time first noticed (hh:mm)

Time first noticed (hh:mm)

Time first noticed (hh:mm)

Time first noticed (hh:mm)

Time first noticed (hh:mm)


    1. Was acute tocolysis administered because of suspicion of fetal distress



Preparation NAME
(dilution used)


Maximum
flow rate


Start time
(hh:mm)


Time of discontinuation















    1. Findings during laparotomy



    1. Was rupture diagnosed before or during laparotomy



    1. Date and time of diagnosis

day month hour minutes

    1. Position of rupture



    1. Position of fetus at time of laparotomy

SECTION 5B: MANAGEMENT OF UTERINE RUPTURE

    1. Indicate how the uterine damage was repaired

If ticked, please specify date and time

day month hour minutes



    1. How was the rupture closed



    1. Where any of the following organs damaged at rupture of removed during surgery? (thick all that apply)

Parametrium

Ovaries


Bladder

Ureter


Bowel

    1. Estimated blood loss ml



    1. Did the woman refuse blood products

If no, were blood products given

If yes, please state total units of each

Whole blood of packed red cells

Fresh Frozen Plasma

Platelets

Cryoprecipitate

Call salvaged blood ml


    1. Were there signs of DIC / clotting problems



SECTION 6: OUTCOME MOTHER

    1. Was the mother transferred to another hospital

Was the mother admitted to an ICU (Intensive Care Unit)

If yes,


Enter name Unit

Duration of stay of ICU (days)

days

Total duration of hospital stay (including on the maternity ward)



days

    1. What method of transport was used?



    1. Did the woman die

If yes

Specify date of death

day month hour minutes

What was the primary cause of death



    1. Did the woman have fever after the delivery

If yes, enter diagnosis



    1. Did any other major maternal morbidity occur

If yes, enter please



SECTION 7: OUTCOME CHILD

If more than one infant: please photocopy this section of the form and attach an extra filled in sheet to the form.



    1. Date & time of delivery

day month hour minutes

weeks days



    1. Birth weight g

    2. Mode of delivery

VAGINAL

C-SECTION

Reason for intervention


    1. Give 5 minute Apgar score

    2. Give umbilical cord pH

Arterial Base excess

Venous Base excess



    1. Fetal well-being assessed during labour

If yes, please specify

    1. Was the infant stillborn



If yes, please go to section 8

    1. Did the infant die after birth


Date and time

day month hour minutes

What was the primary cause

Was there a postmortem examination

Was primary cause of death confirmed


    1. Did any major complication occur

Please specify



    1. Was the infant transferred to another hospital ?

Was the infant admitted to a neonatal unit (N* or NICU)

If yes, please specify the unit

Admission –date & time

day month hour minutes

Discharge –date & time

day month hour minutes

Admission –date & time

day month hour minutes

Discharge –date & time

day month hour minutes

Was the infant retransferred to hospital of birth


    1. Which interventions were performed

Intubation/ventilation

Cooling


Transfusion

Other, specify



    1. Which imaging techniques were performed

Ultrasound

MRI


Findings

SECTION 8: DELIVERY OF THE PLACENTA


    1. Date & Time delivery of the placenta

day month hour minutes

Measure taken to enhance third stage

If yes, please indicate method(s) used:

SECTION 9: POST MORTEM EXAMINATION


    1. Was a maternal post mortem examination performed?

If yes, please summarize the report



    1. Was a post mortem examination performed on the fetus/infant?

If yes, please summarize the report



SECTION 10: PLEASE USE THIS SPACE TO ENTER ANY OTHER INFORMATION YOU FEEL MAY BE IMPORTANT

Name of person completing the form
Date

Signature


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