Maternal and perinatal mortality
Maternal death define as death of woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.Direct deaths:resulting from obstetric complications of the pregnant state(pregnancy,labor and puerperium),from interventions ,omissions,incorrect treatment or from achain of events resulting from any of the above(e.g.death from major postpartum haemorrhage in previously well woman).
Indirect death :resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes,but which was aggravated by physiological effect of pregnancy,that are due to direct or indirect maternal causes(e.g.death from cardiac lesion such us Ebstein,s anomaly)
Late death occurring between 42 days and 1 year after abortion ,miscarriage or delivery that are due to direct or indirect maternal causes.
Coincidental(fortuitous) deaths:from unrelated causes that happen to occur during pregnancy or in the puerperium (e.g. road traffic accidents).
Maternal mortality rate:
This is defined in the U.K.as the number of deaths from obstetric causes per 100000 maternities.
Maternities :are the numbers of mothers delivered of registerable live births at any gestation or stillbirth of 24 wks or later .
Adramatic fall in maternal mortality occurred between 1935 and 1985 ,when the maternal mortality halved every decade,the causes are:
1-Antibiotics:sulphonamides were introduced in 1937 and pencillin appeared during the second world war,death rates from puerperal sepsis quickly fell.
2-Blood transfusion become safe during 1940.
3-Ergometrin was introduced in 1940.
4-Reduced parity:the average family size had already begun to fall before the oral contraceptive pill was introduced in 1961.
5-Legalization of abortion in 1967 was followed by elimination of criminal abortion a acause of maternal death.
the main causes of maternal mortality.
A-Direct causes:
1-Thrombosis and thromboembolism.2-Hypertensive disease.
3-Haemorrhage.
4-Amniotic fluid embolism.
5-sepsis
6-complication of anesthesia
7-Early pregnancy deaths(before 24 wk of gestation)
B-Indirect causes:
1-Cardiac disease.
2-Psychiatric disorder.
3-Cancer.
4-Other indirect causes,coincidental deaths:such as road traffic accident,homicide and domestic violence.
Thromboembolism :
Almost equal numbers occurred antepartum and postpartum.
Identified risk factors were:
Obesity,immobilization,operative delivery,smoking,previous thrombo-embolism,age over 35 years.
Prophylactic anticoagulant in high risk mothers or even to institute full anticoagulation with heparin when there were clinical warning signs of pulmonary embolism(chest pain,dyspnia,hyperventilation and cyanosis).
Reducible by ahigher index of suspicion and the readier use of venography and ventilation perfusion lung scan.
Hypertensive disorders:
Causes of death:
Pulmonary complication or cerebral hemorrhage was usually the cause of death(intracranial hemorrhage,acute respiratory distress syndrome,pulmonary or cerebral oedema.
Other causes: ruptured liver,liver failure and pneumonia.
Amniotic fluid embolism:
Possible risk factors:
Age more than 35 years,high parity,uterine over distention,unusual strong uterine action ,uterine rupture.
Early pregnancy death:
Death occurring before 24 weeks of gestation include deaths due to ectopic pregnancy,spontaneous abortion and termination of pregnancy.
Sepsis
Puerperal sepsis was amajor causes of maternal deaths before1937 ,death caused by sepsis after abortion ,caesarean section or before or during labor.
Hemorrhage
Deaths are equally divided between antepartum and postpartum hemorrhage.
Deaths from APH are equally divided between placenta previa and abruption placenta.
Severe abruption placenta is usually complicated by coagulopathy.
Genital tract trauma:
Due to vaginal and uterine laceration after instrumental delivery,uterine rupture after induction of labor or during pregnancy in association with placenta percreta.
Anasthesia
The safety of obstetric anesthesia has improved due to greater use of epidural rather than general anesthesia.
Indirect deaths
Cardiac disease
Rheumatic heart disease is amajor cause of maternal mortality in many developing countries.
Other causes:congenital heart disease,myocardial infarction,cardiomyopathy and aortic aneurysm.
The increased cardiac output of pregnancy puts astrain on adiseased heart.
Psychiatric deaths almost due to suicide.
Other indirect deaths
The largest single cause epilepsy. Perinatal mortality
Perinatal death is about 100 times more common than maternal death.
Early neonatal death:death in the 1st week after birth.
Stillbirth :any fetus born with no signs of life after 24 weeks gestation.
Perinatal death :all stillbirths plus early neonatal death.
Late neonatal death:death of neonate from age of 7 days to 27 completed days of life.
Infant death:death at age under 1 year of ababy born alive.
Perinatal mortality rate :number of perinatal death per 1000 live births and stillbirths
Classification systems
Obstetric classification
This include 2
2 categories grouped under the following headings:
*Congenital anomally
*Isoimmunization.
*Pre eclampsia
*Antepartum haemorrhage.
*Mechanical (e.g.cord prolapse)
*Maternal medical disorder.
*Miscellaneous
*Unexplained.
Fetal and neonatal factors classification
This system has 24 categories grouped as follows:
*Congenital anomally.
*Isoimmunization.
*Asphyxia before birth.
*Birth trauma.
*Severe pulmonary immaturity.
*Hyaline membrane disease
*Intracranial haemorrhage
*Infection.
*Miscellaneous.
*Unclssifiable(unknown).
Immaturity:
Although only 8% of babies are born prematurely,this group contains50%of neonatal deaths.
The immediate causes of death amongst this group include respiratory distress syndrome ,infection,neurological causes and gastrointestinal causes.
Advances in neonatal care have improved the survival of many premature infants.