The WHO developed an application of ICD-10 to standardize the classification of maternal deaths. It establishes 9 groups to categorize causes of maternal death based on ICD-10 codes. The groups were developed through expert consultation and then tested on maternal death databases from several countries. The goal is to improve consistency in identifying and reporting the underlying causes and contributing factors of maternal deaths.
This presentation describes approach to a patient presenting with early pregnancy bleeding. It also includes a brief outline about the management of miscarriage, molar pregnancy and ectopic pregnancy.
The document discusses various medical complications that can arise during pregnancy related to the cardiovascular, pulmonary, endocrine, and other body systems. It covers conditions like heart disease, deep vein thrombosis, asthma, diabetes mellitus, and how they can impact maternal and fetal health. Management of these complications during pregnancy involves close monitoring, controlling symptoms, treating any underlying conditions, considering timing of delivery, and managing labor and delivery to minimize risks.
Abdominal pain in pregnancy is a very common problem encountered in day to day practice. Although is can be benign at times great care should be exercised to dismiss as nothing significant.
This document discusses gestational diabetes and its management. It defines gestational diabetes as glucose intolerance first recognized during pregnancy. It recommends screening all pregnant women with a 50-g glucose challenge test and diagnosing based on thresholds from a 75-g oral glucose tolerance test. Treatment aims to lower risks of macrosomia, cesarean sections, and monitor blood glucose with diet and exercise as first line therapies and sometimes insulin. Diet should provide 30-40% calories from complex carbohydrates and monitor weight gain based on pre-pregnancy BMI.
This document discusses hypertensive disorders in pregnancy. It classifies hypertension into pre-existing (chronic) hypertension, pregnancy-induced hypertension (PIH), and superimposed pre-eclampsia/eclampsia. PIH includes transient hypertension, pre-eclampsia, and eclampsia. The document explores various theories of causation and provides details on pathological changes, diagnosis, screening tests, types of pre-eclampsia, complications, and treatment including prophylactic low-dose aspirin.
This document discusses amniotic fluid disorders including polyhydramnios and oligohydramnios. It defines polyhydramnios as excessive amniotic fluid over 2 liters and oligohydramnios as diminished fluid under 500 ml. Causes, diagnosis, and complications are described for each condition. Polyhydramnios can be caused by fetal abnormalities or diabetes and risks preterm labor and cord problems. Oligohydramnios risks pulmonary hypoplasia and deformities from compression and is often caused by renal issues. Management may include treating underlying issues, monitoring fetal wellbeing, and amnioinfusion.
This document discusses liver disease in pregnancy, specifically chronic hepatitis B and C. It notes that pregnancy is generally well-tolerated by women with chronic hepatitis B or C. The main concern is risk of transmission to the infant during childbirth. Screening pregnant women for hepatitis B and universal vaccination of newborns can interrupt transmission in over 90% of cases. Continuing lamivudine treatment during pregnancy may further reduce risk of transmission to 100%. Close monitoring is recommended for women with cirrhosis or portal hypertension due to risk of complications.
This document discusses cardiac diseases in pregnancy, including normal pregnancy physiology, symptoms of cardiac disease, preconception counseling, contraindications to pregnancy for certain heart conditions, genetic inheritance of cardiac conditions, and management of specific diseases. It covers topics like dilated cardiomyopathy, peripartum cardiomyopathy, congenital heart diseases involving left-to-right shunts or obstructive lesions, rheumatic heart disease including mitral stenosis, mitral valve prolapse, and Marfan syndrome. Pregnancy risks and management approaches are described for each condition. A team-based approach involving multiple specialists is recommended.
This presentation describes approach to a patient presenting with early pregnancy bleeding. It also includes a brief outline about the management of miscarriage, molar pregnancy and ectopic pregnancy.
The document discusses various medical complications that can arise during pregnancy related to the cardiovascular, pulmonary, endocrine, and other body systems. It covers conditions like heart disease, deep vein thrombosis, asthma, diabetes mellitus, and how they can impact maternal and fetal health. Management of these complications during pregnancy involves close monitoring, controlling symptoms, treating any underlying conditions, considering timing of delivery, and managing labor and delivery to minimize risks.
Abdominal pain in pregnancy is a very common problem encountered in day to day practice. Although is can be benign at times great care should be exercised to dismiss as nothing significant.
This document discusses gestational diabetes and its management. It defines gestational diabetes as glucose intolerance first recognized during pregnancy. It recommends screening all pregnant women with a 50-g glucose challenge test and diagnosing based on thresholds from a 75-g oral glucose tolerance test. Treatment aims to lower risks of macrosomia, cesarean sections, and monitor blood glucose with diet and exercise as first line therapies and sometimes insulin. Diet should provide 30-40% calories from complex carbohydrates and monitor weight gain based on pre-pregnancy BMI.
This document discusses hypertensive disorders in pregnancy. It classifies hypertension into pre-existing (chronic) hypertension, pregnancy-induced hypertension (PIH), and superimposed pre-eclampsia/eclampsia. PIH includes transient hypertension, pre-eclampsia, and eclampsia. The document explores various theories of causation and provides details on pathological changes, diagnosis, screening tests, types of pre-eclampsia, complications, and treatment including prophylactic low-dose aspirin.
This document discusses amniotic fluid disorders including polyhydramnios and oligohydramnios. It defines polyhydramnios as excessive amniotic fluid over 2 liters and oligohydramnios as diminished fluid under 500 ml. Causes, diagnosis, and complications are described for each condition. Polyhydramnios can be caused by fetal abnormalities or diabetes and risks preterm labor and cord problems. Oligohydramnios risks pulmonary hypoplasia and deformities from compression and is often caused by renal issues. Management may include treating underlying issues, monitoring fetal wellbeing, and amnioinfusion.
This document discusses liver disease in pregnancy, specifically chronic hepatitis B and C. It notes that pregnancy is generally well-tolerated by women with chronic hepatitis B or C. The main concern is risk of transmission to the infant during childbirth. Screening pregnant women for hepatitis B and universal vaccination of newborns can interrupt transmission in over 90% of cases. Continuing lamivudine treatment during pregnancy may further reduce risk of transmission to 100%. Close monitoring is recommended for women with cirrhosis or portal hypertension due to risk of complications.
This document discusses cardiac diseases in pregnancy, including normal pregnancy physiology, symptoms of cardiac disease, preconception counseling, contraindications to pregnancy for certain heart conditions, genetic inheritance of cardiac conditions, and management of specific diseases. It covers topics like dilated cardiomyopathy, peripartum cardiomyopathy, congenital heart diseases involving left-to-right shunts or obstructive lesions, rheumatic heart disease including mitral stenosis, mitral valve prolapse, and Marfan syndrome. Pregnancy risks and management approaches are described for each condition. A team-based approach involving multiple specialists is recommended.
Gestational trophoblastic disease (GTD) forms a spectrum of tumors arising from placental tissue. Most GTDs are benign, but some can become malignant. The tumors include molar pregnancies, invasive moles, and choriocarcinoma. Molar pregnancies are categorized as complete or partial based on morphology and karyotype. Complete moles lack fetal tissue and have paternal chromosomes only. Partial moles contain fetal tissue and are usually triploid. Invasive moles and choriocarcinoma can metastasize and secrete hCG. Treatment involves surgery and multi-agent chemotherapy, with cure rates near 100% even in metastatic cases. Prognosis depends on factors like hCG
A serious pregnancy complication in which the placenta detaches from the womb (uterus).
Placental abruption occurs when the placenta detaches from the inner wall of the womb before delivery. The condition can deprive the baby of oxygen and nutrients.
Symptoms include vaginal bleeding, stomach pain and back pain in the last 12 weeks of pregnancy.
Depending on the degree of placental separation and how close the baby is to full-term, treatment may include bed rest or a Caesarean (C-section).
Placenta previa is a condition where the placenta covers part or all of the cervical opening. It presents a high risk for both mother and fetus due to the potential for bleeding during pregnancy or delivery. The bleeding can range from light to profuse and be caused by internal exams, intercourse, or external versions of the baby. Risk factors include advanced maternal age, prior C-sections, and multiple pregnancies. Management may involve bed rest, monitoring, induction of labor, or surgical delivery depending on the severity of the placenta previa and stability of the mother and fetus.
Nutritional supplement on multiple pregnancymothersafe
Nutritional supplement recommendations for multiple pregnancies include:
1) Women with twin or triplet pregnancies should receive the same dietary, lifestyle, and supplement advice as women with singletons.
2) Women with multiples have a higher risk of anemia and should have their iron and folate levels checked at 20-24 weeks and 28 weeks.
3) A balanced diet with adequate calories is important, along with supplements of folic acid, iron, vitamin D, and DHA omega-3 fatty acids.
4) The optimal diet for multiples is uncertain due to lack of research evidence, but general guidelines are provided.
ADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANIDR SHASHWAT JANI
1. Adherent placenta occurs when there is a defect in the decidua basalis, resulting in abnormal invasion of the placenta directly into the uterus.
2. Diagnosis is usually made using ultrasound and MRI to detect irregularities in the placenta and loss of tissue planes between the placenta and uterus.
3. Treatment depends on the extent of invasion and patient desires, ranging from conservative surgeries like resection to hysterectomy, with the goal of managing blood loss and preserving the uterus if possible.
This presentation is all about the epidemiology of stillbirths, in India. It talks about the different challenges in controlling the stillbirths and the strategies of controlling it. The INAP guideline of Government of India, which is a stepping stone for controlling stillbirths in India, is also discussed here.
This document discusses antepartum hemorrhage (APH), specifically placenta previa and placental abruption. It defines APH as bleeding from or into the genital tract after 28 weeks of pregnancy but before birth. Placenta previa is when the placenta implants over the lower uterine segment or cervical os, while placental abruption is the premature separation of a normally implanted placenta. Both can cause painless vaginal bleeding and are medical emergencies. The document outlines risk factors, clinical features, diagnosis, potential complications, and management approaches for each condition.
Multiple pregnancies, especially twins, present special challenges in obstetric practice. The rate of multiple pregnancies varies widely around the world, from under 6 per 1,000 pregnancies in Japan to over 66 per 1,000 in parts of Nigeria. The increasing use of fertility treatments has led to higher rates of triplets and more. Twins can be either monozygotic (from one fertilized egg) or dizygotic (from two eggs) and determining zygosity helps manage risks. Complications of multiple pregnancies include preterm birth, anemia, preeclampsia, and growth problems for one or both babies. Careful monitoring and management of labor and delivery aims to deliver both babies safely.
Intrauterine growth restriction (IUGR), also known as small for gestational age (SGA), refers to a fetus whose weight is below the 10th percentile for gestational age. It can be caused by placental insufficiency, genetic factors, maternal medical conditions, infections, or other uteroplacental problems. Diagnosis involves serial ultrasounds to measure fetal growth curves, biophysical profile, and Doppler studies of umbilical and uterine blood flow. Management may include bed rest, corticosteroids to promote lung maturity, c-section delivery, and neonatal intensive care. Complications can include fetal distress, low birth weight, and long term issues with growth, development and learning.
This document discusses placental insufficiency, fetal hypoxia, and newborn asphyxia. It defines placental insufficiency as disorders of the placenta's trophic, endocrine, and metabolic functions that impair the exchange between the mother and fetus. Fetal hypoxia is a leading complication of pregnancy and cause of antenatal and intranatal death, referring to insufficient oxygen supply or utilization by tissues. Asphyxia in newborns is characterized by an absence of breathing but presence of heartbeat, and can be classified as mild, moderate or severe based on the Apgar score. The document outlines methods for diagnosing and treating placental insufficiency, fetal hypoxia and newborn asphyxia
This document provides information on menorrhagia (heavy menstrual bleeding), its pathological causes, associated symptoms, and investigations and treatments for abnormal uterine bleeding and menstrual disorders. It defines menorrhagia, dysfunctional uterine bleeding, and discusses pathological causes such as fibroids, endometriosis, and cancers. It also lists investigations that may be performed and a hierarchy of medical and surgical treatments available for different conditions.
Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions
Hi, myself Dipanwita Maity ,' Clinical Instructor ' of 'Shova Rani Nursing College ' (A unit of KPC Medical College & Hospital , Jadavpur , Kolkata ) , am sharing my PPT on "Cord Prolapse"( Subject: Midwifery & Obstetrical Nursing ) with all of you .
Robson classification Dr. Iqra Malik.pptJawad Awan
Cesarean section (CS) was introduced to obstetrical practice as a lifesaving procedure both for mother and her child. It gives an opportunity to evaluate the prevalence of CSs among various groups of women, to compare data between institutions, learn from each other and to create strategies for better results.
Based on the available knowledge, the Robson classification (the Ten-group classification system) meets the current needs the best.
Caesarean section (CS) rates have been increasing worldwide and have caused concerns. For meaningful comparisons to be made World Health Organization recommends the use of the Ten-Group Robson classification as the global standard for assessing CS rates.
The document provides details about the panel moderator Dr. Kiran Pandey and her qualifications and experience in the field of obstetrics and gynecology. It lists her positions held including as head of the department of obstetrics and gynecology at GSVM Medical College in Kanpur, and her contributions to several national conferences and publications. It also outlines her areas of interest and awards received for her work.
This document discusses hemorrhage in early pregnancy, miscarriage, ectopic pregnancy, and hydatidiform mole. It provides definitions, risk factors, clinical features, management, and pathogenesis for each condition. Key points include:
- Miscarriage (spontaneous abortion) occurs in 10-20% of pregnancies and is often due to fetal chromosomal abnormalities or maternal factors like age. Management depends on severity from expectant to surgical evacuation.
- Recurrent miscarriage is defined as 2 or more losses and can be caused by genetic, endocrine, immune, or inherited factors.
- Ectopic pregnancies implant outside the uterus, most commonly in the fallopian tubes. Risk factors
This document discusses decreased fetal movements (DFM) and provides guidance on evaluating and managing cases of reported DFM. Key points include:
- DFM can be an early sign of fetal compromise and is associated with 16.4% of stillbirths.
- There is no agreed upon definition of reduced fetal movements. Guidelines recommend focusing on qualitative maternal perception.
- Evaluation of DFM includes history, exam, NST, ultrasound to check growth, amniotic fluid and anatomy, and may include BPP, Doppler, biophysical profile if indicated.
- For persistent unexplained DFM, monitoring with NST and ultrasound twice weekly is suggested under 37 weeks, induction after 37 weeks if cervix is
The document discusses preterm labor and birth. It defines preterm birth as babies born alive before 37 weeks of pregnancy. It notes the main complications of preterm birth include neonatal death, respiratory distress syndrome, and other issues. Risk factors for preterm birth include multiple pregnancies, smoking, cervical insufficiency, and infection. The prevention and treatment of preterm labor focuses on identifying women at risk and using interventions like progesterone supplementation, cervical cerclage, and tocolytic drugs to delay birth.
This document is a report from the World Health Organization on the results of their second global survey on electronic health (eHealth) and mobile health (mHealth) initiatives. Some key findings include:
- Over 800 experts from 114 countries provided information on over 1,000 mHealth initiatives in low and middle income countries.
- The most common types of mHealth initiatives were using mobile phones to raise health awareness, manage treatment compliance, conduct health surveys and provide health information to citizens.
- Barriers to implementing mHealth included lack of infrastructure, guidelines and standards, security and privacy issues, and financial constraints.
- Evaluation of mHealth initiatives found they can effectively promote health, improve access to care and
The document summarizes the key findings of the WHO's second global survey on eHealth, which focused on mobile health (mHealth). The survey found that 83% of responding countries have at least one mHealth initiative, with the most common being health call centers, emergency services, and mobile telemedicine. However, many programs are still pilots. Higher-income countries have more mHealth activity than lower-income countries. Competing health priorities and a lack of evaluation were cited as major barriers. The survey highlights the need for more strategic planning, development, evaluation and integration of mHealth with broader health systems.
Gestational trophoblastic disease (GTD) forms a spectrum of tumors arising from placental tissue. Most GTDs are benign, but some can become malignant. The tumors include molar pregnancies, invasive moles, and choriocarcinoma. Molar pregnancies are categorized as complete or partial based on morphology and karyotype. Complete moles lack fetal tissue and have paternal chromosomes only. Partial moles contain fetal tissue and are usually triploid. Invasive moles and choriocarcinoma can metastasize and secrete hCG. Treatment involves surgery and multi-agent chemotherapy, with cure rates near 100% even in metastatic cases. Prognosis depends on factors like hCG
A serious pregnancy complication in which the placenta detaches from the womb (uterus).
Placental abruption occurs when the placenta detaches from the inner wall of the womb before delivery. The condition can deprive the baby of oxygen and nutrients.
Symptoms include vaginal bleeding, stomach pain and back pain in the last 12 weeks of pregnancy.
Depending on the degree of placental separation and how close the baby is to full-term, treatment may include bed rest or a Caesarean (C-section).
Placenta previa is a condition where the placenta covers part or all of the cervical opening. It presents a high risk for both mother and fetus due to the potential for bleeding during pregnancy or delivery. The bleeding can range from light to profuse and be caused by internal exams, intercourse, or external versions of the baby. Risk factors include advanced maternal age, prior C-sections, and multiple pregnancies. Management may involve bed rest, monitoring, induction of labor, or surgical delivery depending on the severity of the placenta previa and stability of the mother and fetus.
Nutritional supplement on multiple pregnancymothersafe
Nutritional supplement recommendations for multiple pregnancies include:
1) Women with twin or triplet pregnancies should receive the same dietary, lifestyle, and supplement advice as women with singletons.
2) Women with multiples have a higher risk of anemia and should have their iron and folate levels checked at 20-24 weeks and 28 weeks.
3) A balanced diet with adequate calories is important, along with supplements of folic acid, iron, vitamin D, and DHA omega-3 fatty acids.
4) The optimal diet for multiples is uncertain due to lack of research evidence, but general guidelines are provided.
ADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANIDR SHASHWAT JANI
1. Adherent placenta occurs when there is a defect in the decidua basalis, resulting in abnormal invasion of the placenta directly into the uterus.
2. Diagnosis is usually made using ultrasound and MRI to detect irregularities in the placenta and loss of tissue planes between the placenta and uterus.
3. Treatment depends on the extent of invasion and patient desires, ranging from conservative surgeries like resection to hysterectomy, with the goal of managing blood loss and preserving the uterus if possible.
This presentation is all about the epidemiology of stillbirths, in India. It talks about the different challenges in controlling the stillbirths and the strategies of controlling it. The INAP guideline of Government of India, which is a stepping stone for controlling stillbirths in India, is also discussed here.
This document discusses antepartum hemorrhage (APH), specifically placenta previa and placental abruption. It defines APH as bleeding from or into the genital tract after 28 weeks of pregnancy but before birth. Placenta previa is when the placenta implants over the lower uterine segment or cervical os, while placental abruption is the premature separation of a normally implanted placenta. Both can cause painless vaginal bleeding and are medical emergencies. The document outlines risk factors, clinical features, diagnosis, potential complications, and management approaches for each condition.
Multiple pregnancies, especially twins, present special challenges in obstetric practice. The rate of multiple pregnancies varies widely around the world, from under 6 per 1,000 pregnancies in Japan to over 66 per 1,000 in parts of Nigeria. The increasing use of fertility treatments has led to higher rates of triplets and more. Twins can be either monozygotic (from one fertilized egg) or dizygotic (from two eggs) and determining zygosity helps manage risks. Complications of multiple pregnancies include preterm birth, anemia, preeclampsia, and growth problems for one or both babies. Careful monitoring and management of labor and delivery aims to deliver both babies safely.
Intrauterine growth restriction (IUGR), also known as small for gestational age (SGA), refers to a fetus whose weight is below the 10th percentile for gestational age. It can be caused by placental insufficiency, genetic factors, maternal medical conditions, infections, or other uteroplacental problems. Diagnosis involves serial ultrasounds to measure fetal growth curves, biophysical profile, and Doppler studies of umbilical and uterine blood flow. Management may include bed rest, corticosteroids to promote lung maturity, c-section delivery, and neonatal intensive care. Complications can include fetal distress, low birth weight, and long term issues with growth, development and learning.
This document discusses placental insufficiency, fetal hypoxia, and newborn asphyxia. It defines placental insufficiency as disorders of the placenta's trophic, endocrine, and metabolic functions that impair the exchange between the mother and fetus. Fetal hypoxia is a leading complication of pregnancy and cause of antenatal and intranatal death, referring to insufficient oxygen supply or utilization by tissues. Asphyxia in newborns is characterized by an absence of breathing but presence of heartbeat, and can be classified as mild, moderate or severe based on the Apgar score. The document outlines methods for diagnosing and treating placental insufficiency, fetal hypoxia and newborn asphyxia
This document provides information on menorrhagia (heavy menstrual bleeding), its pathological causes, associated symptoms, and investigations and treatments for abnormal uterine bleeding and menstrual disorders. It defines menorrhagia, dysfunctional uterine bleeding, and discusses pathological causes such as fibroids, endometriosis, and cancers. It also lists investigations that may be performed and a hierarchy of medical and surgical treatments available for different conditions.
Primary Maternal Care addresses the needs of healthcare workers in level 1 district hospitals and clinics who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book complements the national protocol of antenatal care in South Africa. It covers: booking for antenatal care, assesing fetal growth and wellbeing, hypertensive disorders of pregnancy, antepartum haemorrhage, preterm labour, important medical conditions
Hi, myself Dipanwita Maity ,' Clinical Instructor ' of 'Shova Rani Nursing College ' (A unit of KPC Medical College & Hospital , Jadavpur , Kolkata ) , am sharing my PPT on "Cord Prolapse"( Subject: Midwifery & Obstetrical Nursing ) with all of you .
Robson classification Dr. Iqra Malik.pptJawad Awan
Cesarean section (CS) was introduced to obstetrical practice as a lifesaving procedure both for mother and her child. It gives an opportunity to evaluate the prevalence of CSs among various groups of women, to compare data between institutions, learn from each other and to create strategies for better results.
Based on the available knowledge, the Robson classification (the Ten-group classification system) meets the current needs the best.
Caesarean section (CS) rates have been increasing worldwide and have caused concerns. For meaningful comparisons to be made World Health Organization recommends the use of the Ten-Group Robson classification as the global standard for assessing CS rates.
The document provides details about the panel moderator Dr. Kiran Pandey and her qualifications and experience in the field of obstetrics and gynecology. It lists her positions held including as head of the department of obstetrics and gynecology at GSVM Medical College in Kanpur, and her contributions to several national conferences and publications. It also outlines her areas of interest and awards received for her work.
This document discusses hemorrhage in early pregnancy, miscarriage, ectopic pregnancy, and hydatidiform mole. It provides definitions, risk factors, clinical features, management, and pathogenesis for each condition. Key points include:
- Miscarriage (spontaneous abortion) occurs in 10-20% of pregnancies and is often due to fetal chromosomal abnormalities or maternal factors like age. Management depends on severity from expectant to surgical evacuation.
- Recurrent miscarriage is defined as 2 or more losses and can be caused by genetic, endocrine, immune, or inherited factors.
- Ectopic pregnancies implant outside the uterus, most commonly in the fallopian tubes. Risk factors
This document discusses decreased fetal movements (DFM) and provides guidance on evaluating and managing cases of reported DFM. Key points include:
- DFM can be an early sign of fetal compromise and is associated with 16.4% of stillbirths.
- There is no agreed upon definition of reduced fetal movements. Guidelines recommend focusing on qualitative maternal perception.
- Evaluation of DFM includes history, exam, NST, ultrasound to check growth, amniotic fluid and anatomy, and may include BPP, Doppler, biophysical profile if indicated.
- For persistent unexplained DFM, monitoring with NST and ultrasound twice weekly is suggested under 37 weeks, induction after 37 weeks if cervix is
The document discusses preterm labor and birth. It defines preterm birth as babies born alive before 37 weeks of pregnancy. It notes the main complications of preterm birth include neonatal death, respiratory distress syndrome, and other issues. Risk factors for preterm birth include multiple pregnancies, smoking, cervical insufficiency, and infection. The prevention and treatment of preterm labor focuses on identifying women at risk and using interventions like progesterone supplementation, cervical cerclage, and tocolytic drugs to delay birth.
This document is a report from the World Health Organization on the results of their second global survey on electronic health (eHealth) and mobile health (mHealth) initiatives. Some key findings include:
- Over 800 experts from 114 countries provided information on over 1,000 mHealth initiatives in low and middle income countries.
- The most common types of mHealth initiatives were using mobile phones to raise health awareness, manage treatment compliance, conduct health surveys and provide health information to citizens.
- Barriers to implementing mHealth included lack of infrastructure, guidelines and standards, security and privacy issues, and financial constraints.
- Evaluation of mHealth initiatives found they can effectively promote health, improve access to care and
The document summarizes the key findings of the WHO's second global survey on eHealth, which focused on mobile health (mHealth). The survey found that 83% of responding countries have at least one mHealth initiative, with the most common being health call centers, emergency services, and mobile telemedicine. However, many programs are still pilots. Higher-income countries have more mHealth activity than lower-income countries. Competing health priorities and a lack of evaluation were cited as major barriers. The survey highlights the need for more strategic planning, development, evaluation and integration of mHealth with broader health systems.
The document discusses a workshop on measuring maternal mortality. The objectives of the workshop were to discuss maternal mortality trends in Asia, compare estimates from WHO and IHME, define methods to improve estimates, and discuss next steps. It provides background on definitions of maternal deaths, metrics for measurement like maternal mortality ratio, and obstacles to accurate measurement like misclassification of causes of death in places without proper death certification.
This document summarizes an update published in 2007 on HIV transmission through breastfeeding. It reviews scientific evidence from 2001 to 2007 on the risk of HIV transmission through breastfeeding, the impact of different infant feeding options on child health outcomes, and strategies to reduce transmission through breastfeeding in developing countries. The update aims to inform public health recommendations around infant feeding by HIV-infected mothers.
This document provides guidance on monitoring and evaluating programs that implement lifelong antiretroviral treatment (ART) for pregnant and breastfeeding women living with HIV and their infants. It recommends adapting current monitoring and evaluation systems to integrate prevention of mother-to-child transmission and ART monitoring. This will allow programs to better measure maternal retention on ART, health outcomes for HIV-exposed infants, and identify implementation challenges. The document distinguishes between routine monitoring, which provides essential reporting data, and enhanced monitoring for early implementation of new approaches like Option B+. Enhanced monitoring involves additional data collection to promptly recognize and address problems.
This document discusses normal and abnormal modes of delivery. It begins by looking at worldwide and Lebanese cesarean section (C-section) rates, noting the WHO recommended rate of 15% and Lebanon's current rate of 44-45%. Several factors that may be contributing to high C-section rates are then examined, including financial incentives for doctors and hospitals, a lack of preparation for natural birth, and defensiveness due to malpractice fears. The short and long-term risks of C-sections for both mothers and babies are also reviewed. The document advocates for reducing unnecessary C-sections through measures such as implementing national guidelines and increasing access to natural birthing options and education.
The World Health Report: 2005 – make every mother and child countAndy Dabydeen
This report from the World Health Organization focuses on improving maternal and child health. It finds that while some progress has been made, gains have been uneven and millions of mothers and children are still dying each year from preventable causes. Barriers to care like poverty, conflict and a lack of health resources contribute to many being excluded from life-saving services. The report calls for strategies to expand access, such as increasing skilled birth attendance and integrating maternal, newborn and child health services. With greater political will and financial investment, the WHO believes universal coverage can be achieved.
The document summarizes guidance from various medical societies on fertility treatments during the COVID-19 pandemic. It discusses two Chinese studies on potential effects of COVID-19 on male fertility. The societies recommend suspending new fertility treatments and elective surgeries to avoid complications, support social distancing, and allocate health resources. While the virus may temporarily reduce male fertility through fever, long-term effects are unclear due to limited research.
This document provides an overview of patient safety initiatives and issues in hospitals. It discusses that 10% of hospital patients suffer adverse events, with medical errors causing around 100,000 deaths per year in the US. Common types of errors include overdoses and performing procedures on the wrong patient. The document then outlines the Patient Safety Friendly Hospital Initiative, which develops standards to assess patient safety in hospitals and has piloted the approach in 7 countries. It describes the five domains used to measure hospital performance on patient safety and provides examples of critical and core standards. The document concludes by offering recommendations on how hospitals can develop their own patient safety programs.
This guidance from the WHO provides recommendations for preventing viral hepatitis B and C among people who inject drugs. Key recommendations include:
1) Offering people who inject drugs either a standard or rapid hepatitis B vaccination schedule, as both help increase uptake and completion rates.
2) Providing incentives to increase completion of the hepatitis B vaccine schedule.
3) Distributing low dead-space syringes through needle and syringe programs, as they reduce the amount of blood and virus remaining after injection compared to standard syringes.
4) Not suggesting psychosocial interventions alone but suggesting offering peer interventions to reduce viral hepatitis incidence.
The guidance emphasizes fully implementing existing recommendations for a comprehensive prevention package, including
PHÒNG NGỪA VÀ ĐIỀU TRỊ BĂNG HUYẾT SAU SINH THEO WHOSoM
The document provides recommendations from the WHO for the prevention and treatment of postpartum haemorrhage (PPH). It details the guideline development process, which included reviewing evidence from 22 systematic reviews using the GRADE methodology. The WHO Technical Consultation adopted 32 recommendations, which are presented in Boxes A, B and C. The recommendations cover the prevention of PPH during vaginal and caesarean births, the treatment of PPH, and the organization of PPH care. Key recommendations include the use of uterotonics (preferably oxytocin) for PPH prevention and treatment, and misoprostol administration by community health workers when skilled attendants are unavailable.
The document provides recommendations from the WHO for the prevention and treatment of postpartum haemorrhage (PPH). It details the guideline development process, which included reviewing evidence from 22 systematic reviews using the GRADE methodology. The WHO Technical Consultation adopted 32 recommendations, which are presented in Boxes A, B and C. The recommendations cover the prevention of PPH, treatment of PPH, and organization of PPH care. Key recommendations include the use of uterotonics (preferably oxytocin) during the third stage of labour to prevent PPH, and the use of uterotonics (preferably oxytocin), uterine massage, fluid resuscitation and other conservative interventions for PPH treatment. The
Foundation module the midwife in the communityPaul Mark Pilar
This document provides an introduction to a set of midwifery education modules developed by the World Health Organization (WHO) to help upgrade midwifery skills and strengthen maternal and newborn health services. The modules aim to help midwives and others develop skills to respond appropriately to major causes of maternal mortality such as hemorrhage, abortion complications, obstructed labor, puerperal sepsis, and eclampsia. The modules cover topics like managing complications in pregnancy and childbirth, the midwife's role in the community, and include skills for both prevention and management of complications as well as general midwifery skills. They are intended to be used for in-service training of midwives but can also
The World Health Organization's annual World Health Statistics report presents data on over 50 health indicators related to the Sustainable Development Goals and WHO's Triple Billion targets. The 2022 edition focuses on monitoring health in the context of the COVID-19 pandemic. It finds that as of April 2022, over 50 million COVID cases and 6 million COVID deaths had been reported, though excess mortality estimates suggest the actual death toll is around 15 million. The pandemic has disrupted essential health services. While life expectancy and healthy life expectancy have increased globally since 2000, inequalities persist and the pandemic may slow or reverse progress on some health measures. Risk factors like obesity, hypertension and air pollution also remain challenges.
introduction to ICD 10 course ,presented according to the health offices computerization under the supervision of the national information center -Ministry of health and population.
This document describes the International Statistical Classification of Diseases and Related Health Problems (ICD), which provides a system to classify diseases and health conditions. The ICD aims to allow standardized recording, analysis, and comparison of mortality and morbidity data internationally. It consists of three volumes covering the classification list, instruction manual, and alphabetical index. The ICD is part of a "family" of disease classifications that can be condensed or expanded depending on need, and includes specialty-specific adaptations as well as classifications for other health-related topics like procedures and disability.
This report analyzes the worldwide markets for HIV/AIDS Testing in US$ Million by the following product segments: HIV/AIDS Screening Tests, HIV/AIDS Confirmatory Tests, and HIV/AIDS Monitoring Tests. The report provides separate comprehensive analytics for the US, Canada, Japan, Europe, Asia-Pacific, Latin America, and Rest of World. Annual estimates and forecasts are provided for the period 2007 through 2015. A seven-year historic analysis is also provided for these markets.The report profiles 63 companies including many key and niche players such as Abbott Laboratories Inc., Abbott Molecular Inc., Adaltis S.r.l., Biom
This document provides guidance for healthcare providers on safe abortion care. It discusses the importance of providing women with information and counseling to allow for informed decision making about abortion. A medical history should be taken and physical exam conducted to determine pregnancy duration and check for any conditions that could impact the abortion procedure. Contraceptive options should also be discussed to help prevent future unintended pregnancies.
Este documento presenta las siete etapas clave para elaborar un póster científico efectivo: 1) Planificar, 2) Componer, 3) Elaborar, 4) Revisar, 5) Imprimir, 6) Trasladar, y 7) Presentar. Explica cada etapa en detalle, incluyendo aspectos como estructura, colores, imágenes y texto. Además, ofrece consejos sobre creatividad, equilibrio y proporción para lograr un diseño atractivo y de calidad.
Este documento describe el sistema extrapiramidal, los síndromes extrapiramidales y sus manifestaciones clínicas. Explica que el sistema extrapiramidal controla los movimientos voluntarios y el tono muscular, y participa en los movimientos automáticos. Los síndromes extrapiramidales se deben a la disfunción de los ganglios basales y sus conexiones, y se manifiestan a través de trastornos del movimiento, el tono y la postura. Describe en detalle diferentes trastornos como temblor, corea, distonía
Recomendaciones para el tratamiento de la HTA - JNC8 2014Jaime dehais
Este documento resume las recomendaciones actuales del panel de expertos JNC 8 (2014) para el tratamiento de la hipertensión arterial. Proporciona 5 recomendaciones principales sobre cuándo iniciar el tratamiento farmacológico y los objetivos de presión arterial, basadas en la evidencia de estudios aleatorios controlados. Las recomendaciones varían según la edad, la presencia de otras afecciones como diabetes o enfermedad renal, y los niveles basales de presión arterial sistólica y diastólica.
Mitos, presunciones y hechos acerca de la obesidadJaime dehais
El documento analiza siete mitos, seis presunciones y nueve hechos sobre la obesidad. Los mitos carecen de evidencia científica o tienen evidencia contradictoria. Las presunciones no tienen evidencia concluyente que las confirme o desmientan. Los hechos están respaldados por evidencia de estudios aleatorizados. El documento concluye que muchas creencias sobre la obesidad persisten debido a sesgos cognitivos y falta de consideración de la compensación fisiológica en los cambios de consumo y gasto calórico
Nejm journal watch practice changing articles 2014Jaime dehais
This document provides a compilation of summaries of the latest practice-changing articles from NEJM Journal Watch. It includes summaries of articles on topics such as delayed or no antibiotic prescriptions for respiratory infections, physical therapy being beneficial for knee osteoarthritis, low-dose steroids being better than high-dose for COPD exacerbations, a diagnostic algorithm for upper-extremity deep vein thrombosis, evidence that meniscal tears may not require surgery, improvements in mental health with smoking cessation, doubts cast on flu drugs by meta-analyses, the 2014 recommended childhood immunization schedule, sentinel lymph node biopsies for thin melanomas, age-specific d-dimer cutoffs for pulmonary embolism, evidence that FOD
El documento describe la exploración del cuello realizada por el Dr. Jaime Dehais, que incluye la inspección visual del área y la palpación de los ganglios linfáticos, la tráquea y la glándula tiroides para detectar cualquier anomalía.
El documento describe la exploración de los oídos, la nariz y la boca de un paciente. Incluye inspecciones de los pabellones auriculares, tímpanos, senos paranasales, narinas, vestíbulos, lengua, paladar y orofaringe, así como pruebas de agudeza auditiva, diapasón, Weber y Rinne. El doctor examina las estructuras y sistemas de cada área y anota cualquier anormalidad encontrada.
Este documento proporciona orientación sobre la preparación y respuesta ante la eventual introducción del virus chikungunya en las Américas. Describe la epidemiología, clínica, diagnóstico de laboratorio, manejo de casos, vigilancia y respuesta a brotes, control de vectores y comunicación de riesgos relacionados con el virus chikungunya. El objetivo es mejorar los conocimientos sobre esta amenaza y brindar herramientas para prevenir la introducción o controlar brotes si el virus se introduce en la región.
Este documento describe los procedimientos para examinar la pupila, incluyendo su tamaño, forma y reflejos pupilares. Explica cómo probar el reflejo fotomotor directo e indirecto, así como una prueba de iluminación alternante para detectar cualquier defecto en la conducción nerviosa del nervio óptico. Además, cubre cómo examinar el reflejo de acercamiento y determinar si las pupilas son normorreactivas.
NEJM Clinical Guidelines Watch Update. Abril 2014Jaime dehais
This document provides guidelines for the assessment and management of overweight and obesity in adults. It recommends:
1) All overweight and obese patients should receive counseling on modest weight loss through dietary changes, increased physical activity, and behavioral therapy to improve health outcomes.
2) If lifestyle changes alone do not achieve sufficient weight loss, anti-obesity medications may be considered for some patients.
3) Bariatric surgery should be considered for some patients with a BMI of 40 or greater, or between 35-40 with obesity-related conditions, when lifestyle changes and medications have failed.
Este documento discute los efectos de la marihuana en el cerebro y el cuerpo. Explica que la marihuana contiene THC, que se adhiere a receptores en el cerebro para producir efectos como euforia y relajación, pero también puede causar ansiedad, problemas de memoria y coordinación, y en dosis altas, psicosis. Además, detalla que el consumo de marihuana es común entre adolescentes y jóvenes adultos en los EE. UU., a pesar de que puede afectar negativamente el desarrollo del cerebro
Guideline on Use Antiretroviral in Pregnancy. Marzo, 2014Jaime dehais
This document provides recommendations for using antiretroviral drugs in pregnant women with HIV-1 to benefit maternal health and reduce perinatal HIV transmission in the United States. It summarizes key changes made to the guidelines, including expanding preferred antiretroviral regimen options and strengthening language around nevirapine use. The guidelines discuss antepartum, intrapartum, and postpartum care for HIV-infected pregnant women and their infants, including antiretroviral treatment, monitoring, delivery considerations, and infant prophylaxis.
CDC. Recommendations for the Laboratory Based Detections of STDs. March 2014Jaime dehais
This document provides updated recommendations from the CDC regarding laboratory testing for Chlamydia trachomatis and Neisseria gonorrhoeae infections. It recommends using nucleic acid amplification tests (NAATs) cleared by the FDA as the preferred method of screening and diagnosis due to their increased sensitivity compared to other tests. It provides guidance on appropriate specimen types for detecting genital and extragenital infections, and notes that culture testing may still be needed in some cases such as evaluating treatment failure or infections in children. The recommendations are based on a review of literature by a panel of experts convened by CDC and APHL to evaluate available data and develop evidence-based guidelines.
Report. the comparative safety diabetes medications. april 2014Jaime dehais
1) This document analyzes the comparative safety profiles of medications used to treat type 2 diabetes, including GLP-1 agonists, DPP-4 inhibitors, and SGLT2 inhibitors, using the FDA Adverse Event Reporting System.
2) Key findings from the analysis suggest that GLP-1 and DPP-4 inhibitors may be linked to pancreatitis and pancreatic cancer, while SGLT2 inhibitors are associated with urinary tract infections but possibly other serious events as well.
3) Within drug classes, Bydureon is identified as potentially safer than other GLP-1 agonists, and Nesina is flagged as a potential concern among DPP-4 inhibitors.
El documento narra la historia de Juanito, un niño de 7 años que asiste a su primera corrida de toros. Al principio se muestra emocionado por el espectáculo, pero luego queda horrorizado al presenciar cómo matan brutalmente a varios toros uno tras otro. Finalmente, cuando un toro hiere a un torero, Juanito grita apoyándolo. Este evento lo hace darse cuenta de que el sufrimiento de los toros no debería ser motivo de celebración.
Sentinel Lymph Node Biopsy for Patients with Early Stage Breast Cancer. Updat...Jaime dehais
This guideline from ASCO updates recommendations for the use of sentinel lymph node biopsy (SNB) in patients with early-stage breast cancer based on new evidence. The main recommendations are:
1) Women without sentinel lymph node metastases should not receive axillary lymph node dissection (ALND).
2) Women with one to two metastatic sentinel nodes planning breast-conserving surgery plus radiation should not undergo ALND in most cases.
3) Women with sentinel node metastases who will undergo mastectomy should be offered ALND.
The guideline also makes recommendations regarding the use of SNB in special circumstances like multicentric tumors or prior surgery, and circumstances where SNB is not recommended, based on randomized trials
La Misión de Observación Electoral de la OEA en El Salvador expresó su satisfacción por la tranquilidad y espíritu cívico durante la segunda vuelta de las elecciones presidenciales. La participación ciudadana aumentó con respecto a la primera vuelta. El Tribunal Supremo Electoral realizó un trabajo técnico y logístico adecuado a pesar de que se necesitan ajustes. La MOE/OEA observó algunas discrepancias entre poderes e instituciones del Estado sobre las normas electorales que podrían causar dificultades en el futuro
Skin infections as targets for antibiotic stewardship 2007 2010Jaime dehais
This study analyzed national emergency department data from 2007-2010 to evaluate antibiotic prescribing practices for skin infections. The key findings were:
1) The percentage of ED visits for skin infections remained stable around 3%, while incision and drainage procedures for abscesses increased slightly.
2) The use of antibiotics targeting community-associated MRSA (CA-MRSA) increased significantly from 61% to 74% of antibiotic regimens for skin infections.
3) Potential quality measures identified were high rates of antibiotic prescribing for discharged abscess patients (87%, indicating overuse) and low rates of CA-MRSA antibiotic inclusion for abscess patients given antibiotics (84%, indicating underuse).
European clinical practice guideline on diagnosis hiponatremiaJaime dehais
1. Hyponatraemia, defined as a serum sodium concentration less than 135 mmol/l, is common in clinical practice and associated with increased mortality, morbidity, and length of hospital stay.
2. Despite this, management of patients with hyponatraemia remains problematic due to diverse approaches across institutions and specialties.
3. The European Society of Intensive Care Medicine, European Society of Endocrinology, and European Renal Association developed this joint clinical practice guideline to provide a standardized approach to diagnosis and treatment of hyponatraemia.
El documento describe los patrones de onda de diferentes sonidos pulmonares, incluidos los sonidos normales, estridor, sibilancias, roncus, crepitaciones y roce pleural. Muestra formas de onda no expandidas y ampliadas de cada sonido, identificando características clave como frecuencia, duración y presencia de oscilaciones sinusoidales. Esto ayuda a diferenciar los diferentes tipos de sonidos a través de la auscultación pulmonar.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
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- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Hiranandani Hospital in Powai, Mumbai, is a premier healthcare institution that has been serving the community with exceptional medical care since its establishment. As a part of the renowned Hiranandani Group, the hospital is committed to delivering world-class healthcare services across a wide range of specialties, including kidney transplantation. With its state-of-the-art facilities, advanced medical technology, and a team of highly skilled healthcare professionals, Hiranandani Hospital has earned a reputation as a trusted name in the healthcare industry. The hospital's patient-centric approach, coupled with its focus on innovation and excellence, ensures that patients receive the highest standard of care in a compassionate and supportive environment.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
5. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Acknowledgements
The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium was
developed by the WHO Working Group on Maternal Mortality and Morbidity Classification. The
following individuals (listed in alphabetical order) participated in the activities of the WHO Working
Group on Maternal Mortality and Morbidity Classification: Linda Bartlett, Jon Barrett, Alma Virginia
Camacho, José Guilherme Cecatti, Veronique Filippi, Rogelio Gonzalez, Ahmet Metin Gülmezoglu,
Anoma Jayathilaka, Affette McCaw-Binns, Robert C Pattinson, Mohamed Cherine Ramadan, Cleone
Rooney, Lale Say, João Paulo Souza, Mary Ellen Stanton, Buyanjargal Yadamsuren and Nynke van
den Broek, and Zelka Zupan. We thank numerous reviewers for critically reviewing the earlier drafts.
Robert Pattinson and Lale Say prepared the alpha and beta drafts of this work, based on the
guidance provided by the working group. Lale Say, Robert Pattinson, Affette McCaw-Binns, João
Paulo Souza and Cleo Rooney revised the beta draft, which was approved by the working group.
The final version of the document was prepared by Doris Chou, Robert Pattinson, Cynthia Pileggi,
Cleone Rooney and Lale Say.
We thank the Child Health Epidemiology Reference Group (CHERG), Robert Jakob, Patricia Wood,
and the Mortality Reference Group of the ICD, and Maria Rodriguez for their technical review and
comments of this work.
This work was funded by USAID, the UNDP/UNFPA/WHO/World Bank Special Programme of
Research, Development and Research Training in Human Reproduction (HRP), and by a grant from
the Bill and Melinda Gates Foundation to the US Fund for UNICEF for the work of the Child Health
Epidemiology Reference Group.
iii
6. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
iv
7. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Contents
Acknowledgements iii
Abbreviations and acronyms vi
Executive summary vii
Introduction 1
Development of the WHO Application of ICD-10 to deaths during pregnancy,
childbirth, and the puerperium 3
The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium 7
Specific explanations and motivations 17
Implications for practice and research 21
Conclusion 21
References 22
Appendix 1: Reviewers of draft versions of the Classification of maternal mortality and morbidity 23
Annex A: List of codes and ICD-MM groups 24
Annex B1: Tabular List of ICD-10 codes that describe conditions which may be causes
of death (underlying cause) 24
Group 1: Pregnancy with abortive outcome 25
Group 2: Hypertensive disorders in pregnancy, childbirth and the puerperium 28
Group 3: Obstetric Haemorrhage 29
Group 4: Pregnancy-related infection 32
Group 5: Other obstetric complications 34
Direct deaths without an Obstetric code in ICD-10 37
Group 6 : Unanticipated complications of management 40
Group 7: Non-obstetric complications 42
Group 8: Unknown/undetermined 47
Group 9: Coincidental causes 47
Annex B2: Tabular List of Chapter 15 codes that describe conditions which are unlikely
to cause death but may have contributed to the death (contributory condition) 48
Annex B3: Tabular List of Other codes of interest 65
Annex C: Suggestions of tools and examples to facilitate the implementation
of the guide and its groupings 66
v
8. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Abbreviations and acronyms
AFLP acute fatty liver of pregnancy
AIDS acquired immunodeficiency syndrome
APH antepartum haemorrhage
CHERG Child Health Epidemiology Reference Group
FIGO Federation of Gynecology and Obstetrics
HELLP haemolysis, elevated liver enzymes, low platelet count
HIV human immunodeficiency virus
HRP UNDP/UNFPA/WHO/World Bank Special Programme of Research Development
and Research Training in Human Reproduction
ICD International Statistical Classification of Diseases and Related Health Problems
MDG Millennium Development Goal
NEC not elsewhere classified
NOS not otherwise specified
PPH postpartum haemorrhage
PV per vaginam
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VR vital registration
WHO World Health Organization
vi
9. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Executive summary
Reducing maternal mortality by 75% is the Millennium Development Goal 5a. To reach this
goal, countries need an accurate picture of the causes and levels of maternal deaths. However,
efforts to document the progress in decreasing maternal mortality must make adjustments
for inconsistencies in country-reported maternal mortality. Completeness of maternal death
reporting and accuracy of statements of causes of death need to be improved and may
compromise the output resulting from subsequent standardized coding and classification
according to the rules of the International Statistical Classification of Diseases (ICD).
The WHO Application of ICD-10 to deaths during pregnancy, childbirth, and the puerperium:
ICD-Maternal Mortality (ICD-MM) is based upon the 10th revision of the ICD (ICD-10) and its
coding rules. It is intended to facilitate the consistent collection, analysis and interpretation of
information on maternal deaths. Improved reporting will also facilitate the coding of conditions.
This document is primarily intended to assist health-care providers, those who complete death
certification by clarifying the application of the ICD-10 and standardizing the identification of
direct and indirect maternal deaths. Its principles should be applicable for categorizing deaths
data collected through civil registration, surveys, hospital information systems, verbal autopsies,
confidential enquiries and other special studies.
The accompanying appendices and tables
• facilitate consistent reporting of the clinical conditions,
• identify conditions and codes which are unlikely causes of death but may have contributed to
death,
• indicate which causes of death are counted as direct or indirect maternal deaths.
Ultimately, standardization of the cause of death attribution will improve:
• interpretation of data on maternal mortality,
• analysis on the causes of maternal death,
• allocation of resources and programmes intended to address maternal mortality.
Applying ICD-MM will decrease errors in coding and improve cause of maternal death attribution.
This will enhance usability and comparability of maternal mortality statistics generated from ICD
data. It is recommended that countries adopt the ICD-MM, and statistical offices and academicians
collect data according to the ICD-MM.
The guide should always be used in conjunction with the three volumes of ICD-10. The
suggested code should be verified and possible additional information should be coded
using the full ICD-10, Volumes 1 and 3; rules for selection of underlying cause of death and
certification of death apply in the way they are described in ICD-10 Volume 2.
vii
10. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
viii
11. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Introduction
Reducing maternal mortality is one of the key of this bias on programmatic work and public
targets within the Millennium Development health policies then becomes readily apparent.
Goals (MDGs). To reach this target, countries need Recognizing the particular difficulty in identifying
an accurate picture of the levels and causes of maternal deaths, the 43rd World Health Assembly
maternal deaths (1). A majority of countries use the in 1990 approved the addition of a “checkbox” to
International statistical classification of diseases and ICD death certificates to indicate whether a woman
related health problems, Tenth revision (ICD-10) as was pregnant, or had recently terminated/delivered
the standard tool to guide their collection, coding, a pregnancy at the time (14). This was incorporated
tabulation and reporting of mortality statistics into ICD-10 Volume 2 (2) and implemented in more
based on civil registration(2). than 30 countries (15).
In the ICD-10, deaths with a causal and/or temporal In response to the ongoing need for a better
relationship to pregnancy are characterized and understanding of the underlying causes of death,
defined as maternal deaths due to direct or indirect WHO initiated an activity aiming to develop, test
causes, deaths during pregnancy, childbirth and and promote standardization of reporting and new
puerperium, or late maternal deaths (see Box 3). ways of tabulating maternal causes of death, in line
Despite guidance within the ICD and definitions with ICD-10. The Application of ICD-10 to deaths in
that describe discrete entities, in practice, childbirth, pregnancy, and the puerperium is based
the identification, reporting and consequent upon the 10th revision of the ICD (ICD-10) and
classification of maternal death are inconsistent follows all rules for mortality coding as described
(3). There remains apparent confusion between in Volume 2 of the ICD. The application clarifies
symptoms, signs and diseases, and which conditions relevance of existing ICD-10 codes and related
should be reported and accordingly tabulated conditions and provides guidance to meaningful
as cause of death. The reporting also impacts on grouping of ICD categories to enable consistent
the ability of coding to either indirect maternal or application of ICD coding and rules to improve data
incidentally maternal deaths. An analysis of cause collection and analysis.
of maternal death data found variation in the way
deaths are reported in different countries (3). This document presents:
• a brief summary of the development of this
A range of conditions that are frequently reported
guide;
have different public health impact in view of
• a grouping system for identification of maternal
progress in measures to improve pregnancy
deaths using existing ICD-10 codes, which coun-
outcomes and reducing the maternal mortality
tries can immediately implement.
such as obstructed labour, anaemia, or HIV. Specific
rationale and explanations and motivation for their This document is intended to be used by those
revised handling are given later in this document charged with death certification. It is intended
(page 21). to guide their ability to document the pertinent
information by clarifying which conditions should
An immediate consequence of the inconsistency in be considered underlying causes of death; thus,
death attribution, reporting, and resulting coding, improving accurate death attribution. As a result,
is misclassification and underreporting of maternal the information available to coders, programme
deaths extracted from vital registration (VR), which managers, statistical offices, and academicians/
in turn may bias understanding of the magnitude researchers will be improved.
and causes of maternal death (4–13). The implication
1
12. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
2
13. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Development of the WHO Application of ICD-10 to deaths
during pregnancy, childbirth, and the puerperium
The guide and groupings described here, based An alpha-draft of this guide, groupings, and the
on ICD-10, were developed through a consultative recommendations for classification was peer
process. WHO established a technical working reviewed by more than 40 individuals, professional
group of obstetricians, midwives, epidemiologists societies (e.g. the International Federation of
and public health professionals from developing Gynecology and Obstetrics (FIGO), the Royal College
and developed countries to prepare this standard of Obstetricians and Gynaecologists, the American
guide for capturing information relating to deaths College of Obstetricians and Gynecologists,
during pregnancy, childbirth and the puerperium. and the Canadian College of Obstetricians and
The group adopted three principles for its work. Gynaecologists) and relevant international agencies.
First, the new guide and groupings should be Following this feedback, a second version was
practical and understood by its users (clinicians, tested on nine databases of maternal deaths:
coders, epidemiologists, programme managers, national registration and surveillance databases
and researchers). Second, in line with ICD rules, from Colombia, Jamaica, Mongolia and South Africa;
detailed underlying cause categories should be other health facility based databases from Kenya,
mutually exclusive and should identify all of the Malawi and Zimbabwe; and verbal autopsy data
conditions that are epidemiologically and/or from Afghanistan and Nigeria. This was performed
clinically important. The clinically related conditions following the steps described in Box 1 .
are aggregated in new groups that facilitate
epidemiological analysis and health service planning Based on the experiences accumulated during the
and evaluation. Third, the way of grouping that test with databases, and the input received from
results form this work does contribute to and will be experts, a revised, beta-draft recommendation
compatible with the 11th revision of the ICD. for groupings was prepared. This was reviewed
Box 1
Steps taken for testing the guide
1. Identification and description of the denominator population.
2. Verification and description of data-collection procedures and methods (for the original set).
3. Assignation of causes of deaths by using the new groupings with respect to underlying causes and
contributory conditions.
4. Determination of the proportion (%) of deaths that could not be classified with the new system, and
determination of the reasons for nonclassification (e.g. category does not exist, category now within
contributory factors and the real cause cannot be identified).
5. Comparison of differences on the distribution of causes as compared to previous attribution.
6. Assessment of the difficulty/ease of using the proposed system.
7. Identification of specific issues that would require prospective study.
3
14. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
by a wide range of stakeholders for further inputs ICD-11. Also the proposed groupings of categories
and revision, and finalized by WHO. Interactions shade a new light on needs of public health in
with the ICD Secretariat and the ICD-11 revision maternal mortality and needs for future changes
team were held in order to ensure consistency and to ICD. As the revision towards ICD-11 is ongoing,
compatibility between the proposed guide and the the reader is referred to the web page available at
ICD. http://www.who.int/classifications/icd/revision/
en/index.html for further details on the process of
This document is based upon ICD-10 codes and revisions and suggested changes to the ICD. Once
coding principles. However, in the course of this ICD-11 is released, any new codes pertinent to cause
work, needs for additional and different detail of death attribution in pregnancy, childbirth or the
not reflected in ICD-10 were identified, resulting puerperium, will be added to future updates of this
in proposals for new codes to be included in the guide.
4
15. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
5
16. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
6
17. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
The WHO Application of ICD-10 to deaths during pregnancy,
childbirth and the puerperium
Understanding death certification, ICD terms and relationship to maternal deaths
Cause of death: documentation and analysis
Certification of cause of death
Cause of death is first determined by the certifier Based on the ICD recommendations, countries
who reports the morbid conditions and events produce their own forms for use in civil registration
leading to the woman’s death on a medical and provide accompanying instructions to certifiers/
certificate of cause of death. It is essential that at doctors on how to complete them. Based upon
this stage all relevant information is reported in a resolution approved by the 43rd World Health
a complete fashion. ICD-10 lays out the format of Assembly (WHA 43.24), ICD-10 recommends that
the medical certificate of cause of death, which countries should consider inclusion on death
is designed to help the certifier record the whole certificates questions about current pregnancy and
sequence of events leading to death in Part 1, in pregnancy within one year preceding death (ICD-10
steps starting from the immediate cause on line 1a VOL 2 para 5.8.1). This has been shown to reduce
and going back to each earlier step on subsequent underreporting of maternal deaths (16). It reminds
lines (top to bottom) until they get to the earliest the certifier to consider whether the death was
event, usually the underlying cause. Part 1 should due to a complication of pregnancy. Figure 1 gives
always include clear information about whether an example of the medical certification of cause of
mutual aggravation between a disease and death (MCCD).
pregnancy lead to death (indirect maternal deaths).
Figure 1. Example of the medical certification of cause of death (MCCD).
Cause of death the disease or condition thought to be the underlying cause should Approximate interval
appear in the lowest completed line of part I between onset and death
Part I
Disease or condition leading directly to death
a)
Antecedent causes:
Due to or as a consequence of
b)
Due to or as a consequence of
c)
Due to or as a consequence of
d)
Part II Other significant conditions Contributing
to death but not related to the disease or
condition causing it
The woman was:
pregnant at the time of death
not pregnant at the time of death (but pregnant within 42 days)
pregnant within the past year
Countries may add tick boxes to the form of medical certificate of cause of death (MCCD) to indicate pregnancy.
7
18. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Coding cause of death In multiple cause coding, all of the conditions on
the death certificate are assigned ICD codes and
A trained coder then codes the conditions
retained for statistical analysis. These include other
mentioned on the death certificate and after
contributory conditions in the sequence in Part 1
applying the ICD-10 rules for coding and selection
and conditions in Part 2. Contributory cause is used
assigns a single ICD-10 code for the single
here to include conditions that may exist prior to
underlying cause of death. The pregnancy tick box
development of the underlying cause of death or
informs the coder to consider whether the death
develop during the chain of events leading to death
might be coded to a maternal death. For indirect
and which, by its nature, contributed to the death.
maternal deaths, it is essential that in Part 1 of the
In this document however, contributory conditions
certificate there is a clear statement about mutual
also refers to conditions that might be reported in
aggravation between the pregnancy and the disease
Part 1 of the certificate.1
leading to death.
Interested readers are also referred to detailed
Analysing cause of death
training on ICD which can be found online apps.
Statisticians or analysts then aggregate these who.int/classifications/apps/icd/icd10training/
ICD codes into epidemiologically and clinically or downloaded for offline use: apps.who.int/
meaningful groups and publish mortality statistics. classifications/apps/icd/ClassificationDownload/
This statistical information is used by multiple DLArea/OfflineTrainingPackage.zip
stakeholders, whose objectives may differ, but
all users rely heavily on the quality, accuracy and This WHO guide and its revised groupings of
consistency of the data. maternal deaths were developed in relation to
mortality data derived from civil registration with
Box 2 medical certification of cause of death. However, it
can be used in other settings, e.g. where the cause
ICD-10 terminology of death is determined by verbal autopsy, survey or
confidential enquiry.
Underlying cause of death is defined as the
disease or condition that initiated the morbid
Using existing ICD-10 codes, this document
chain of events leading to death or the
identifies those conditions that may be a potential
circumstances of the accident or violence that
produced a fatal injury. The single identified cause of death and are of high public health and
cause of death should be as specific as possible. distinguishes them from those that are unlikely to
cause death but may have contributed to or been
part of the course of events leading to death.
If the death certificate has been completed correctly,
Irrespective of setting, the guide and its groupings
the underlying cause of death should normally be
have been devised to capture at least the most
the single condition which the certifier has written
important basic information on cause of death,
on the lowest used line of Part 1. The mortality
while allowing for refinement with more specific
selection and modification rules in Volume 2 of
details. At the most basic level, ‘Deaths during
ICD-10 have been developed to enable coders
pregnancy, childbirth or the puerperium’ may be
to select the most useful information on cause
enumerated even in countries or areas where no
of death for public health purposes as the single
information on cause of death is available. Mortality
underlying cause, even when the certificate is not
rates can then be compared with those based on
completed correctly or where it is important to
data aggregated across all causes in areas where
consider/combine information from other parts of
cause is available.
the certificate.
1
In this document contributory causes refers to conditions that
may be reported in Part 1 of the death certificate. These are also
referred to as “intervening causes” within ICD terminology,
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19. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Box 3
Definition of deaths in pregnancy, childbirth and the puerperium: ICD-10
Death occurring during pregnancy, childbirth and the puerperium is the death of a woman while
pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death (obstetric
and non-obstetric).
Maternal death
A maternal death is the death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management, but not from accidental or incidental causes.
Maternal deaths are subdivided into two groups:
• direct obstetric deaths: direct obstetric deaths are those resulting from obstetric complications
of the pregnancy state (pregnancy, labour and the puerperium), from interventions, omissions,
incorrect treatment, or from a chain of events resulting from any of the above.
• indirect obstetric deaths: indirect obstetric deaths are those 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 physiologic effects of pregnancy.
Late maternal death
A late maternal death is the death of a woman from direct or indirect causes more than 42 days but
less than one year after termination of pregnancy.
Application of ICD-10 to deaths In settings where the cause of death is identified
during pregnancy, childbirth and the by verbal autopsy or similar data gathering from
puerperium reporters who have not been trained in clinical
diagnosis or certification of cause of death, it may
This document standardizes identifying relevant only be possible to classify causes of death to
causes of death and ensures their accurate relatively broad groups. It has often been necessary
reporting. In such way conditions can be coded in for clinicians to reformulate the histories from lay
a more detailed way and the quality of information reporters into sequences in the ICD death certificate
related to maternal death (see Box 3) will improve. format to identify the underlying cause even at this
With training on the rationale of death certification broad group level.
and how the derivative data are used, certifiers will Annex A provides an electronic link to an excel sheet
be better able to complete death certificates with indicating the group for each existing ICD-10 code
meaningful data. ICD coding rules are not affected in Chapter XV. Additionally, tools to assist in the
by the re-grouping of ICD codes, and in fact the implementation of this guide and its groupings and
standardization of maternal underlying causes to synergize with maternal death review and audit
of death codes ensures that ICD coding rules are processes are also in development.
followed. In countries that collect VR data based on
medical certification, trained coders code the cause
of death to the highest level of detail per ICD-10
coding convention.
9
20. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Analysis of underlying causes of death use. Note that any local modifications of the nine
groups into categories and subcategories will not
In order to foster a common framework for
affect the overall standardization of attribution of
international comparisons, categories of underlying
cause of death or its classification and definition
causes of death were aggregated in nine groups
as a “maternal death”, or “death during pregnancy,
of causes of death during pregnancy, childbirth
childbirth and the puerperium”.
and the puerperium. These groups are clinically
and epidemiologically relevant, mutually exclusive
and totally inclusive and descriptive of all causes
of maternal and pregnancy-related deaths.
Furthermore, they simplify the characterization of
maternal deaths, whether due to direct and indirect
causes.2
Table 1 presents the nine groups of causes during
pregnancy, childbirth and the puerperium, with
examples of corresponding conditions to be
included in each group. Clinically, conditions that
may result in mortality may also cause morbidity
and these specified as conditions that should
be identified as underlying cause of maternal
deaths. A complete listing of conditions that may
be underlying causes of either death or maternal
morbidity is detailed in Annexes B1, B2, and B3.
In some settings, the underlying cause of death
may only be identified at the broad level of the
group, whereas in other areas, the cause of death
may be attributed with more detail, at category or
subcategory level. In practice, consistent allocation
of deaths to broad groups may be more difficult
than actual consistent coding to detailed ICD
codes and subsequent aggregation into larger
groups. In either case, it is essential to have a good
understanding of the meaning of terms used in
that setting to describe cause of death and accurate
and consistent indexing of all such terms to the
correct category at whatever level of detail is in
2
An important rationale for creating these groupings is to
clarify and standardize the reporting of conditions considered
to have high public health impact. The coding of the identified
conditions, correctly filled in on death certificates, follows coding
procedures described in ICD-10 Volume 2. From the perspective
of analysis, these are labelled single underlying cause of death as
consistent with the ICD.
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21. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Table 1
Groups of underlying causes of death during pregnancy, childbirth and the puerperium in mutually exclusive, totally
inclusive groups 3
Type Group name/number EXAMPLES of potential causes of death
Maternal death: direct 1. Pregnancies with abortive Abortion, miscarriage, ectopic pregnancy and
outcome other conditions leading to maternal death and a
pregnancy with abortive outcome
Maternal death: direct 2. Hypertensive disorders in Oedema, proteinuria and hypertensive disorders in
pregnancy, childbirth, and the pregnancy, childbirth and the puerperium
puerperium
Maternal death: direct 3. Obstetric haemorrhage Obstetric diseases or conditions directly associated
with haemorrhage
Maternal death: direct 4. Pregnancy-related infection Pregnancy-related, infection-based diseases or
conditions
Maternal death: direct 5. Other obstetric complications All other direct obstetric conditions not included in
groups to 1–4
Maternal death: direct 6. Unanticipated complications of Severe adverse effects and other unanticipated
management complications of medical and surgical care during
pregnancy, childbirth or the puerperium
Maternal death: indirect 7. Non-obstetric complications Non-obstetric conditions
• Cardiac disease (including pre-existing hyper-
tension)
• Endocrine conditions
• Gastrointestinal tract conditions
• Central nervous system conditions
• Respiratory conditions
• Genitourinary conditions
• Autoimmune disorders
• Skeletal diseases
• Psychiatric disorders
• Neoplasms
• Infections that are not a direct result of
pregnancy
Maternal death: unspecified 8. Unknown/undetermined Maternal death during pregnancy, childbirth and
the puerperium where the underlying cause is
unknown or was not determined
Death during pregnancy, 9. Coincidental causes Death during pregnancy, childbirth and the
childbirth and the puerperium due to external causes
puerperium
3
See Annex A and B1 for complete enumeration and details
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22. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Conditions unlikely to cause death but a pattern can be detected that may help in the
may have contributed to the events management of similar women in the future.
leading to death Complications encompass significant morbidities
(Contributory conditions) such as organ system dysfunction, and the codes for
these conditions are found in the morbidity list.
The section describes conditions that may have
contributed to or may be associated with, but
Annexes B1 and B2 presents clinically and
should not to be reported as sole condition on
epidemiologically relevant conditions to be
the death certificate or selected as the underlying
considered as possible morbidities.
cause of death. Contributing causes may predispose
women to death, as either a pre-existing condition
Applicability: The following examples are intended
or a risk factor. For example, in a woman with twin
illustrate the format of death certificate completion,
gestation, whose delivery is complicated by uterine
documenting the sequence of events from the
atony and postpartum bleeding, hypovolaemic
underlying cause to the immediate cause of death
shock, disseminated intravascular coagulopathy
and the feasibility of applying the groupings in
and renal failure. In this case, using multiple cause
practice.
coding, the contributory conditions include twin
gestation (ICD code O30.0), shock, DIC, and renal
failure whereas the underlying cause of death is
postpartum haemorrhage resulting from uterine
atony (ICD-10 code O72.1). If only single cause
coding is used, only the underlying cause of death,
postpartum haemorrhage (uterine atony), O72.1
would be recorded.
Annex B2 presents a separate tabular list of
the conditions unlikely to cause death, these
‘contributory’ codes that may be used in multiple
cause of death coding to describe maternal
morbidities associated with pregnancy, childbirth
or the puerperium. It is possible that more than
one contributory condition may exist, and in this
circumstance, multiple coding for these conditions
is recommended. These codes are not to be selected
as underlying cause of death, because they do not
capture the most useful information needed for
health service and public health interventions to
prevent further deaths.
In the example above, the other diagnoses of
hypovolaemic shock, disseminated intravascular
coagulopathy and renal failure are complications,
and these are indicated in Part 1 of the death
certificate. It is necessary to document the
complications that resulted in the death, as this
might help in developing treatment protocols to
prevent such complications in the future. Further,
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23. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
EXAMPLE 1
A woman who had anaemia during pregnancy and after delivery had a postpartum haemorrhage due
to uterine atony, and died as a result of hypovolaemic shock.
Medical certificate of cause of death
Cause of death the disease or condition thought to be the underlying cause Approximate interval
should appear in the lowest completed line of Part I between onset and death
1. Disease or condition leading directly (a) hypovolaemic shock 10 minutes
to death
A contributory cause indicated in Part 1. This is assigned a
code when multiple cause coding is undertaken
Antecedent causes: (b) postpartum haemorrhage 30 minutes
Due to or as a consequence of
Due to or as a consequence of (c) uterine atony 45 minutes
The underlying cause. This is the last condition noted in
Part 1 and is a condition found in Annex B1
Due to or as a consequence of (d)
2. Other significant conditions Anaemia pre-existing
Contributing to death but not related
to the disease or condition causing it
The woman was:
x
pregnant at the time of death
not pregnant at the time of death (but pregnant within 42 days)
pregnant within the past year
If deceased was a woman, was she pregnant when she died or within 42 days before she died ? Yes
(Part I shaded for purposes of the example)
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24. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
EXAMPLE 2
A woman infected with HIV who has a spontaneous abortion that becomes infected, and dies due to
septic shock and renal failure.
Medical certificate of cause of death
Cause of death the disease or condition thought to be the underlying cause Approximate interval
should appear in the lowest completed line of Part I between onset and death
1. Disease or condition leading directly (a) renal failure 2 hours
to death
A contributory condition, indicated in Part 1
Antecedent causes: (b) septic shock 24 hours
Due to or as a consequence of
Due to or as a consequence of (c) septic miscarriage 36 hours
The underlying cause. This is the last condition noted in
Part 1 and is a condition found in Annex B
Due to or as a consequence of (d)
2 . Other significant conditions HIV pre-existing
Contributing to death but not related
to the disease or condition causing it
A contributory condition, indicated in Part IIB
The woman was:
x
pregnant at the time of death
not pregnant at the time of death (but pregnant within 42 days)
pregnant within the past year
If deceased was a woman, was she pregnant when she died or within 42 days before she died ? Yes
(Part I shaded for purposes of the example)
Verbal autopsy
In some settings, maternal deaths are ascertained by verbal autopsy. Once the relevant details
are extracted from the verbal autopsy, the maternal death guide and its groupings may also be
used to standardize the information regarding cause of death, see Example 3 (17).
EXAMPLE 3
This was the woman’s third pregnancy and she had not had any complications during the first two
deliveries. She did not have any tetanus toxoid vaccination or antenatal consultation by a doctor or nurse
in any of her pregnancies because of her religious beliefs. She ate normally and her health was good,
although she sometimes suffered from headaches at which time she liked to lie down on her bed. After six
months of pregnancy she became unable to see at night but no consultation with a doctor was arranged
for this problem. She did not develop any bodily swelling.
When she was nine months pregnant, it was one day before her death, she went into labour at about
7 o’clock in the evening and she called her mother (who was a Dai) to the house. After she had finished
her “esha” prayer at 9 o’clock in the evening, her labour pain increased a little. Her mother examined her
14
25. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
and felt that the baby’s head was not yet close to the birth passage. At 11 o’clock at night her mother
examined her again and found slight vaginal bleeding. She examined her a total of three times.
Around midnight, her labour pain increased again and after another hour her waters broke. After fifteen
minutes of watery discharge, she had a normal delivery at 1 o’clock at night. After five minutes, her
placenta was also normally delivered. During the delivery she had normal blood and water discharge.
Shortly after the delivery, she said that she felt dizzy and wanted to lie down. Her mother-in-law and
sister-in-law (husband’s brother’s wife) were washing her baby. Suddenly she said she felt sick, she
developed a headache and wanted to sit down. As soon as her sister–in-law helped her to sit on the bed
she developed excessive vaginal bleeding. She then stood up on a jute mat, which became soaked with
blood. After that, she was made to lie down but she still had excessive bleeding, which continued for
another hour.
Her husband tried to fetch a doctor but he said he would not come until the morning. After an hour of
excessive PV [per vaginam] bleeding, the woman’s whole body had become cold and pale. The bleeding
then began to slow down and she was given hot compresses. However, some time after the bleeding had
reduced, she began to tremble and started to clench her teeth. After 30 minutes in that condition she
became exhausted and remained on the bed with her eyes closed. At 5 o’clock in the early morning she
had three hiccups and died.
Medical certificate of cause of death
Cause of death the disease or condition thought to be the underlying cause Approximate interval
should appear in the lowest completed line of Part I between onset and death
1. Disease or condition leading directly (a) postpartum haemorrhage 3 hours
to death
The underlying cause. This is the last condition noted in
Part 1 and is a condition found in Annex B
Antecedent causes: (b)
Due to or as a consequence of
Due to or as a consequence of (c)
Due to or as a consequence of (d)
2. Other significant conditions Lack of access to medical care to
Contributing to death but not related prevent or treat haemorrhage
to the disease or condition causing it following normal vaginal delivery
A contributory condition, indicated in Part II. No code is
assigned because only single cause coding of deaths
The woman was:
x
pregnant at the time of death
not pregnant at the time of death (but pregnant within 42 days)
pregnant within the past year
If deceased was a woman, was she pregnant when she died or within 42 days before she died ? Yes
(Part I shaded for purposes of the example)
15
26. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
16
27. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Specific explanations and motivations
Prolonged/obstructed labour In this clinical scenario, there are two conditions
but only the ruptured uterus can be considered the
The ICD-10 aims to capture the initiating step most
single underlying cause whereas obstructed labour
relevant to public health in the sequence leading
may have multiple clinical outcomes as it not only
to death, because preventing this condition would
contributes to the ruptured uterus but also other
prevent not just the death, but all of the illness,
conditions such as puerperal sepsis.
complications and disability that preceded it.
Obstructed labour may be the start of a sequence
At present, some countries report obstructed labour
leading to death, or may itself be due to some
as a contributing condition while other countries
preceding condition such as contracted maternal
report obstructed labour and ruptured uterus as
pelvis or transverse fetal lie. In these cases, death
causes of death. It is important to standardize this
might be prevented by access to operative delivery.
in order to permit informed analysis of comparable
However, there is evidence that many deaths may
data on causes of death. Programmatically, the
be mis-attributed to obstructed labour, leading
objective is to prevent obstructed labour, and, when
to over-estimation of the proportion that could
not possible or once obstructed labour is diagnosed,
be prevented through operative delivery and
the need is to identify the access to emergency
underestimating the need for other services. In
obstetric care and the allocation of services (e.g.
areas where deliveries are not attended by trained
access to safe blood transfusion, antibiotics and
professionals and maternal mortality is high, very
postpartum care in the event of fistulas).
little information may be available about the
sequence of events that lead to death, or about the
In practice, in settings where mortality is covered by
progress of labour. The only information from lay
vital registration, individual countries will be able
reporters may be that the woman appeared to be
to disaggregate national data by both underlying
in labour, or in pain, for a considerable time before
cause and contributory causes, where multiple
death, and/ or that she died undelivered. These
cause reporting and analysis is feasible, ensuring
deaths may then be attributed to obstructed labour,
that no loss of information occurs. In setting where
without any good evidence that the condition really
information on maternal mortality is collected by
existed.
other mechanisms such as maternal death audit,
maternal death review or verbal autopsy, certifiers
The WHO working group decided that it would be
of death are informed by this guide that obstructed
preferable only to accept the diagnosis if further
labour alone is insufficient as a cause of death, it
evidence, for example the fatal complication of
is envisaged that they will be prompted to supply
obstructed labour (e.g. ruptured uterus, uterine
more information about the circumstances of death.
atony/haemorrhage or sepsis) was specified. In
As a result, programmes should be able to identify
other words, certifiers should report more detail on
additional health interventions, such as access to
the death certificate, than just obstructed labour. It
safe blood transfusion and antibiotics, needed to
should also be noted that this decision reflects the
prevent these deaths.
principles used to develop the groupings and the
recommendations of the ICD, e.g., that the identified
This additional level of detail is feasible and will
underlying cause must be mutually exclusive. The
increase the robustness of information available to
use of obstructed labour as an underlying cause
programme managers and policy makers who are in
alone is not sufficient, as exemplified by the case of
the position to influence the quality and availability
uterine rupture associated with obstructed labour.
of care to avoid preventable maternal deaths.
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28. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
This recommendation is predicated on the need for is considered a direct maternal death, counting
training of certifiers of death (health-care providers) each case of obstructed labour, but only Example 4
to understand that a diagnosis of obstructed labour provides details on potential gaps in intrapartum care
alone is usually insufficient . Where multiple cause provision.
coding is undertaken, the specification of this
detail will be easily incorporated. However, in the It is important to note that this description of
circumstance that single cause of death coding is reconciling data regarding obstructed labour is
performed, if details surrounding the death of a particular to ICD-10. With future revisions of ICD, it
woman who was diagnosed with obstructed labour is anticipated that coding for obstructed labour and
are provided, these deaths will be coded as seen in its associated conditions (e.g., haemorrhage, sepsis)
Example 4. If no other information is provided (see will be simplified with the proposal of new linked
Example 5), then coders would be obligated to use codes that identify both concepts in one code and
the codes for obstructed labour as the underlying streamline single cause of death coding.
cause of death. In both circumstances, the death
EXAMPLE 4
This was the woman’s third pregnancy and she had not had any complications during the first
two deliveries. She did not have any tetanus toxoid vaccination or antenatal consultation by a
doctor or nurse in any of her pregnancies because of her religious beliefs. She ate normally and
her health was good, although she sometimes suffered from headaches at which time she liked
to lie down on her bed. After six months of pregnancy she became unable to see at night but
no consultation with a doctor was arranged for this problem. She did not develop any bodily
swelling.
A woman with a baby in breech position who experiences obstructed labour and dies of
puerperal sepsis
• Underlying cause: Group 4, pregnancy-related infection
• Category: puerperal sepsis
• Contributing condition: obstructed labour due to fetal malpresentation
EXAMPLE 5
A woman who dies very soon after arriving at a health facility. She died undelivered, but
health personnel at the facility are able to feel fetal parts on vaginal examination. The person
accompanying her to the health facility is only able to indicate that she had “pains” for more
than a day and a half.
• Underlying cause: Group 5, other obstetric complications
• Category: obstructed labour NOS (not otherwise specified)
• Contributing condition: no details
This change will indicate:
• the number of deaths that follow the development of obstructed labour,
• the number of women who die of conditions amenable to treatment such as blood transfu-
sions or antibiotics,
which will inform programmes on areas of need in the antenatal and intrapartum period.
18
29. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
HIV and AIDS and appropriate B codes to describe deaths of
women when HIV or AIDS is the underlying cause
There is a tendency in many parts of the world to
and where pregnancy is incidental will reduce
attribute all deaths in people known to have HIV
confusion and standardize statistical tabulation.
or AIDS to AIDS. However, such patients may die
“from AIDS”, or “with HIV”. Temporal to pregnancy, it
Anaemia
is useful to distinguish those deaths of HIV-infected
women that should be considered maternal deaths. With the exception of pre-existing disease such
as sickle cell disease, or thalassaemia, anaemia
In terms of dying “with HIV” or “from AIDS”, women may be secondary to infections, malnutrition,
may die from obstetric causes, e.g. incomplete bleeding, etc. Anaemia rarely causes death on its
abortion, complicated by haemorrhage or own. In this guide and its groupings, anaemia is a
tetanus, or an ectopic pregnancy. These deaths are factor contributing to maternal death. Even where
considered direct maternal deaths. In these cases, anaemia complicates postpartum haemorrhage, it is
their HIV infection or AIDS might have coexisted at still almost always the haemorrhage that caused the
time of death but it is not the underlying cause of death.
death.
Tetanus
In contrast, “AIDS related indirect maternal deaths”
OB tetanus ( ICD 10 code A34) is a rare cause of
are deaths of HIV-infected women who die because
maternal death. For the purposes of classification,
of the aggravating effect of pregnancy on HIV.
in the absence of detailed information regarding
This interaction between pregnancy and HIV is
the clinical course of infection, it is considered an
the underlying cause of death. These are coded as
DIRECT maternal cause of death within the group
O98.7 and categorized in Group 7 (non-obstetric
“pregnancy related infection” . Where there is
complications). Proper reporting of the mutual
evidence that tetanus exposure and infection is the
influence of HIV or AIDS and pregnancy in Part 1 of
result of an obstetric event, eg abortion or puerperal
the certificate will guide the coders.
sepsis, the death is classified to the respective
DIRECT cause of death.
On the other hand, a woman with HIV may die
of one of the fatal complications of HIV or AIDS
Malnutrition
while pregnant, though this is probably a rare
event since such severe illness makes pregnancy This is not a disease entity causing death, but may
unlikely. An example may be when an HIV-positive have contributed to the death.
woman who is in early pregnancy dies due to HIV
wasting syndrome. Here the pregnancy is incidental Female genital mutilation
to her underlying cause of death, which is HIV This is common in some areas of the world and may
wasting syndrome. In these rare cases, HIV or AIDS contribute the death of a woman due to the scarring
is selected as the underlying cause of death and causing prolonged labour and predisposing the
the appropriate code in block B20-B24 of ICD-10 women to uterine atony, puerperal sepsis or severe
selected. These are termed “HIV-related deaths to lower genital tract trauma due to tearing of the scar
women during pregnancy, delivery or puerperium” tissue.
and are not considered maternal deaths.
Previous caesarean section
Classifying each and every case in terms of HIV
This may have contributed to the death by
status will give a clearer picture of the role of HIV
promoting placenta accreta, uterine rupture or
and AIDS in maternal deaths. The convention of
placenta praevia.
using O98.7 to describe indirect maternal deaths
19
30. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Obesity, depression and domestic violence depression. ICD-10 categorizes suicides in the
code range X60-X84 in the Chapter XX. Hence,
Obesity is becoming an increasing problem, and
maternal deaths due to suicide are identified when
by facilitating collection of these data on maternal
information about the pregnancy was indicated on
deaths the impact of obesity on maternal deaths
the death certificate, either in Part 1, 2, or by the
might be better understood. The same is true for
“tick box”.
depression and domestic violence as contributory
conditions but it may be more difficult to collect the
Specific to late postpartum suicide occurring
information on every case.
between 42 days and one year postpartum, these
may receive an additional code O96.0 (late maternal
Suicide
death from direct obstetric cause) or if greater than
The ICD-10 and ICD-MM recommend collecting one year postpartum. If the event occurs greater
all pertinent information describing the events than one year postpartum and an established
leading to death. Within ICD-10 coding convention, diagnosis of puerperal psychosis and/or postpartum
maternal deaths due to suicide and coded depression exists, these may receive an additional
appropriately to the Chapter XX within vital code as death from sequelae of direct obstetric
registration data alone would not be considered cause (O97.0). 5
within international maternal mortality estimation
per current methodology. 4 However, when
maternal deaths due to suicide are included within 4
The Maternal Mortality estimation Interagency Group publishes updates
surveillance reporting, these would be included in on global maternal mortality. The methodology describing how maternal
deaths are identified within vital registration data can be found in the
the maternal mortality estimation studies dataset. full report, Trends in maternal mortality: 1990 to 2010 WHO, UNICEF, UNFPA
and The World Bank estimates (http://www.who.int/reproductivehealth/
publications/monitoring/9789241503631/en/index.html) and ICD-10
Antenatal and postpartum suicide are grouped in Volume 2.
this guide under direct causes of death under the 5
For single condition coding and tabulation of the cause of death, the
“Other” category. This is recommended even if it external cause describing the suicide should be used as the primary code.
For multiple coding, the additional information on pregnancy related
may not be possible to definitively establish the depression and the differentiation between late maternal and sequelae
diagnosis of puerperal psychosis and/or postpartum will be useful in the analysis of maternal causes of death.
Figure 2. All deaths (death during pregnancy, childbirth or puerperium)
ALL DEATHS
(death during pregnancy, childbirth or puerperium)
MATERNAL DEATH OTHER DEATHS
Direct maternal death: In-direct maternal death: Unknown Coincidental
• non-obstetric complications Undetermined
• abortive outcome
• hypertensive disorders
• obstetric haemorrhage
• pregnancy related
infection
• other obstetric
complications
• unanticipated
complications
20
31. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Implications for practice and research
The guide and its groupings are expected to render a better assessment of conditions leading
to death during pregnancy, childbirth and the puerperium. Applying this guide and its
groupings should help to identify the real clinical causes and health-system shortfalls that
countries need to address in order to reduce complications and fatal outcomes of pregnancy.
Annex C provides additional suggestions of tools to facilitate implementation. The use of this
guide and its groupings are recommended as part of the efforts to estimate and address the
burden of maternal mortality around the world.
Conclusion
The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium
builds upon the ICD-10 to create a useful framework for programme officers, health-care
workers certifying deaths, and statistical offices and researchers. It has the potential to improve
the quality of data derived from all sources of information on the cause of maternal death. This
will improve comparability of data and inform the development of programmes to decrease
maternal mortality.
Since the guide and its groupings build upon the ICD, end users will be familiar with the clinical
concepts organized within the groupings of this guide. The advantage of this guide lies in that
simplicity. Future research on the application of the guide and its groupings is necessary.
Achieving MDG5 will require an understanding of not only the magnitude but also the
contribution of causes of death. Currently, about one third of WHO Member States/territories
are able to provide high-quality VR data. Even so, it is recognized that misclassification of deaths
that are temporal to pregnancy occurs in these data. The use of the guide, in addition to a
pregnancy check box on death certificates, is intended to improve the accurate capture of data
and its attribution.
For Member States and territories with some facility to capture VR events, the guide is poised
to improve their quality of VR data on attribution of cause. Where data are collected by
means of special surveys, the Application of ICD-10 to Maternal Mortality: ICDMM will improve
comparability of data.
21
32. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
References
1. Trends in maternal mortality: 1990 to 2008. 11. Horon IL.Underreporting of maternal deaths
Estimates developed by WHO, UNICEF, UNFPA, on death certificates and the magnitude of
and The World Bank. Geneva, World Health the problem of maternal mortality. American
Organization, 2010. Journal of Public Health, 2005, 95(3):478–482.
2. World Health Organization: International 12. Salanave B et al. Classification differences
statistical classification of diseases and related and maternal mortality: a European study.
health problems, 10th revision. Geneva, World MOMS Group. Mothers’ Mortality and
Health Organization, 1992. Severe morbidity. International Journal of
Epidemiology, 1999, 28(1):64–69.
3. Daniels J, et al. The WHO analysis of causes of
maternal death, in preparation, 2011. 13. Atrash HK, Alexander S, Berg CJ. Maternal
mortality in developed countries: not
4. Karimian-Teherani D et al. Under-reporting just a concern of the past. Obstetrics and
of direct and indirect obstetrical deaths Gynecology, 1995, 86(4 Pt 2):700–705.
in Austria, 1980–98. Acta Obstetrica et
Gynecologica Scandinavica, 2002; 81:323– 14. Resolution WHA 43.24. Report of the
327. International Conference for the Tenth
Revision of the International Classification
5. Bouvier-Colle MH et al. Reasons for the of Diseases. In Forty-third World Health
underreporting of maternal mortality Assembly, Geneva. (Fourteenth plenary
in France, as indicated by a survey of all meeting, 17 May 1990 ,Committee B, third
deaths among women of childbearing age. report.
International Journal of Epidemiology, 1991,
20(3):717–721. 15. Reported information on mortality statistics.
Geneva, World Health Organization,
6. Deneux-Tharaux C et al. Underreporting of 2005. (http://www.who.int/healthinfo/
pregnancy-related mortality in the United mort2005survey/en/index.html, accessed
States and Europe. Obstetrics and Gynecology, 8 March 2012)
2005, 106(4):684–692. Erratum in: Obstetrics
and Gynecology, 2006, 107(1):209. 16. Horon IL, Cheng D. Effectiveness of
pregnancy check boxes on death certificates
7. Gissler M et al. Pregnancy-related deaths in in identifying pregnancy-associated
four regions of Europe and the United States mortality. Public Health Report, 2011,
in 1999–2000: characterisation of unreported 126(2):195–200.
deaths. European Journal of Obstetrics
Gynecology and Reproductive Biology, 2007, 17. Why mothers die in Matlab. Dhaka, ICDDRB,
133(2):179–185. Centre for Health and Population Research,
2005. (http://centre.icddrb.org/images/
8. Schuitemaker N et al. Underreporting of Why_mothers_die_in_Matlab2.pdf, accessed
maternal mortality in The Netherlands. 8 March 2012).
Obstetrics and Gynecology, 1997, 90(1):78–82.
9. Kao S et al. Underreporting and
misclassification of maternal mortality in
Taiwan. Acta Obstetrica et Gynecologica
Scandinavica, 1997, 76(7):629–636.
10. Department of Health. Report on confidential
enquiries into maternal deaths in the United
Kingdom 1988–1990. London, HMSO, 1994.
22
33. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Appendix 1: Reviewers of draft versions of the
Classification of maternal mortality and morbidity
Dorothy Shaw, FIGO Regional Advisers
Margaret Wash, FIGO
WHO Regional Office for Africa
Barbara de Zalduondo, UNAIDS
Seipati Mothebesoane Anoh
Francisco Songane, Partnership for Maternal, Djamila Cabral
Newborn and Child Health
Gwyneth Lewis, Department of Health, WHO Regional Office for the Americas
United Kingdom Ricardo Fescina
Bremen de Mucio
Luc de Bernis, UNFPA
Vincent Fauveau, UNFPA
WHO Regional Office for South-East Asia
Wendy Graham, Initiative for Maternal Mortality Ardi Kaptiningsih
Programme Assessment
Zoe Matthews, Department for International WHO Regional Office for Europe
Development, United Kingdom Gunta Lazdana
Julia Hossein, Initiative for Maternal Mortality Alberta Bacci
Programme Assessment
Kathy Herschderfer, International Confederation WHO Regional Office for the Eastern Mediterranean
of Midwives Ramez Mahaini,
Hossam Mahmoud
Country reviewers
Guillermo Carroli, Argentina WHO Regional Office for the Western Pacific
Jose Guilherme Cecatti, Brazil Narimah Awin
Anibal Faundes, Brazil
Zhao-Gengli, China
Edgar Kestler, Guatemala
Sunita Mittal, India
Manorama-Balkisan Purwar, India
Horace Fletcher, Jamaica
Cherry Than-Than-Tin, Myanmar
Prasanna-Gunasekera, Nepal
Saramma T. Mathai, Nepal
Mario Festin, Philippines
Thilina Palihawadana, Sri Lanka
Prof. H.R. Seneviratne, Sri Lanka
Pisake Lumbiganon, Thailand
Sompop Limpongsanurak, Thailand
Tippawan Tippawan-Liabsuetrakul, Thailand
Jose Villar, United Kingdom
Alain Prual, United States
Tran Son Thach, Viet Nam
23
34. Annex A: List of codes and ICD-MM groups
A complete listing of ICD-10 codes and corresponding ICD-MM groups can be found online
www.who.int/reproductivehealth/publications/monitoring/9789241548458/en/
This list should always be used in conjunction with the three volumes of ICD-10. The
suggested code should be verified and possible additional information should be coded
using the full ICD-10, looking up the terms in Volume 3 and verifying the code with Volume 1;
rules for certification and selection of the underlying cause of death apply in the way they are
described in ICD-10 Volume 2.
Annex B1: Tabular List of ICD-10 codes that
describe conditions which may causes of death
(underlying cause)
Codes in this section may be used in mortality or morbidity coding (unless the code is
specifically specified as a mortality code)
Codes are grouped into the nine groups of obstetric causes of death, rather than the order of
the tabular list in Volume 1 of the ICD-10, or its special tabulation lists and may not contain all
codes within a block.
For the purposes of this guide, only conditions and associated codes in this section should be
selected as underlying causes of deaths.
The annex should always be used in conjunction with the three volumes of ICD-10. The
suggested code should be verified and possible additional information should be coded
using the full ICD-10, Volumes 3 and 1; rules for certification of death apply in the way they are
described in ICD-10 Volume 2. Further modifications as published in the 11th revision of the
ICD may result in changes.
24
35. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Group 1: Pregnancy with abortive outcome
Excl.: continuing pregnancy in multiple gestation after abortion of one fetus or more (O31.1)
The following fourth-character subdivisions are for use with categories O03-O06:
Note: Incomplete abortion includes retained products of conception following abortion.
.0 Incomplete, complicated by genital tract and pelvic infection
With conditions in O08.0
.1 Incomplete, complicated by delayed or excessive haemorrhage
With conditions in O08.1
.2 Incomplete, complicated by embolism
With conditions in O08.2
.3 Incomplete, with other and unspecified complications
With conditions in O08.3-O08.9
.4 Incomplete, without complication
.5 Complete or unspecified, complicated by genital tract and pelvic infection
With conditions in O08.0
.6 Complete or unspecified, complicated by delayed or excessive haemorrhage
With conditions in O08.1
.7 Complete or unspecified, complicated by embolism
With conditions in O08.2
.8 Complete or unspecified, with other and unspecified complications
With conditions in O08.3-O08.9
.9 Complete or unspecified, without complication
O00 Ectopic pregnancy
Incl.: ruptured ectopic pregnancy
Use additional code from category O08.-, if desired, to identify any associated complication.
O00.0 Abdominal pregnancy
Excl.: delivery of viable fetus in abdominal pregnancy (O83.3)
maternal care for viable fetus in abdominal pregnancy (O36.7)
O00.1 Tubal pregnancy
Fallopian pregnancy
Rupture of (fallopian) tube due to pregnancy
Tubal abortion
O00.2 Ovarian pregnancy
O00.8 Other ectopic pregnancy
Pregnancy:
• cervical
• cornual
• intraligamentous
• mural
O00.9 Ectopic pregnancy, unspecified
25
36. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
O01 Hydatidiform mole
Use additional code from category O08.-, if desired, to identify any associated complication.
Excl.: malignant hydatidiform mole (D39.2)
O01.0 Classical hydatidiform mole
Complete hydatidiform mole
O01.1 Incomplete and partial hydatidiform mole
O01.9 Hydatidiform mole, unspecified
Trophoblastic disease NOS
Vesicular mole NOS
O02 Other abnormal products of conception
Use additional code from category O08.-, if desired, to identify any associated complication.
Excl.: papyraceous fetus (O31.0)
O02.0 Blighted ovum and nonhydatidiform mole
Mole:
• carneous
• fleshy
• intrauterine NOS
Pathological ovum
O02.1 Missed abortion
Early fetal death with retention of dead fetus
Excl.: missed abortion with:
• blighted ovum (O02.0)
• mole:
• hydatidiform (O01.-)
• nonhydatidiform (O02.0)
O02.8 Other specified abnormal products of conception
Excl.: those with:
• blighted ovum (O02.0)
• mole:
• hydatidiform (O01.-)
• nonhydatidiform (O02.0)
O02.9 Abnormal product of conception, unspecified
O03 Spontaneous abortion
[See before O03 for subdivisions]
Incl.: miscarriage
26
37. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
O04 Medical abortion
[See before O03 for subdivisions]
Incl.: termination of pregnancy:
• legal
• therapeutic
therapeutic abortion
O05 Other abortion
[See before O03 for subdivisions]
O06 Unspecified abortion
[See before O03 for subdivisions]
Incl.: induced abortion NOS
O07 Failed attempted abortion
Incl.: failure of attempted induction of abortion
Excl.: incomplete abortion (O03-O06)
O07.0 Failed medical abortion, complicated by genital tract and pelvic infection
With conditions in O08.0
O07.1 Failed medical abortion, complicated by delayed or excessive haemorrhage
With conditions in O08.1
O07.2 Failed medical abortion, complicated by embolism
With conditions in O08.2
O07.3 Failed medical abortion, with other and unspecified complications
With conditions in O08.3-O08.9
O07.4 Failed medical abortion, without complication
Failed medical abortion NOS
O07.5 Other and unspecified failed attempted abortion, complicated by genital tract and
pelvic infection
With conditions in O08.0
O07.6 Other and unspecified failed attempted abortion, complicated by delayed or excessive
haemorrhage
With conditions in O08.1
O07.7 Other and unspecified failed attempted abortion, complicated by embolism
With conditions in O08.2
O07.8 Other and unspecified failed attempted abortion, with other and unspecified
complications
With conditions in O08.3-O08.9
O07.9 Other and unspecified failed attempted abortion, without complication
Failed attempted abortion NOS
27
38. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Group 2: Hypertensive disorders in pregnancy, childbirth
and the puerperium
(note that O10, pre-existing hypertension is in Group 7)
O11 Pre-existing hypertensive disorder with superimposed proteinuria
Incl.: Conditions in O10.- complicated by increased proteinuria
Superimposed pre-eclampsia
O12 Gestational [pregnancy-induced] oedema and proteinuria
without hypertension
O12.0 Gestational oedema
O12.1 Gestational proteinuria
O12.2 Gestational oedema with proteinuria
O13 Gestational [pregnancy-induced] hypertension without significant proteinuria
Incl.: Gestational hypertension NOS
Mild pre-eclampsia
O14 Gestational [pregnancy-induced] hypertension with significant proteinuria
Excl.: superimposed pre-eclampsia (O11)
O14.0 Moderate pre-eclampsia
O14.1 Severe pre-eclampsia
O14.2 HELLP syndrome
Combination of hemolysis, elevated liver enzymes and low platelet count
O14.9 Pre-eclampsia, unspecified
O15 Eclampsia
Incl.: convulsions following conditions in O10-O14 and O16
eclampsia with pregnancy-induced or pre-existing hypertension
O15.0 Eclampsia in pregnancy
O15.1 Eclampsia in labour
O15.2 Eclampsia in the puerperium
O15.9 Eclampsia, unspecified as to time period
Eclampsia NOS
O16 Unspecified maternal hypertension
28
39. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
Group 3: Obstetric Haemorrhage
O20 Haemorrhage in early pregnancy
Excl.: pregnancy with abortive outcome (O00-O08)
O20.0 Threatened abortion
Haemorrhage specified as due to threatened abortion
O20.8 Other haemorrhage in early pregnancy
O20.9 Haemorrhage in early pregnancy, unspecified
O43 Placental disorders
Excl.: maternal care for poor fetal growth due to placental insufficiency (O36.5)
placenta praevia (O44.-)
premature separation of placenta [abruptio placentae] (O45.-)
O43.2 Morbidly adherent placenta
O44 Placenta praevia
O44.1 Placenta praevia with haemorrhage
Low implantation of placenta, NOS or with haemorrhage
Placenta praevia:
• marginal
• partial
• total
NOS or with haemorrhage
Excl.: labour and delivery complicated by haemorrhage from vasa praevia (O69.4)
O45 Premature separation of placenta [abruptio placentae]
O45.0 Premature separation of placenta with coagulation defect
Abruptio placentae with (excessive) haemorrhage associated with:
• afibrinogenaemia
• disseminated intravascular coagulation
• hyperfibrinolysis
• hypofibrinogenaemia
O45.8 Other premature separation of placenta
O45.9 Premature separation of placenta, unspecified
Abruptio placentae NOS
O46 Antepartum haemorrhage, not elsewhere classified
Excl.: haemorrhage in early pregnancy (O20.-)
intrapartum haemorrhage NEC (O67.-)
placenta praevia (O44.-)
premature separation of placenta [abruptio placentae] (O45.-)
29
40. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
O46.0 Antepartum haemorrhage with coagulation defect
Antepartum haemorrhage (excessive) associated with:
• afibrinogenaemia
• disseminated intravascular coagulation
• hyperfibrinolysis
• hypofibrinogenaemia
O46.8 Other antepartum haemorrhage
O46.9 Antepartum haemorrhage, unspecified
O67 Labour and delivery complicated by intrapartum haemorrhage, not
elsewhere classified
Excl.: antepartum haemorrhage NEC (O46.-)
placenta praevia (O44.-)
postpartum haemorrhage (O72.-)
premature separation of placenta [abruptio placentae] (O45.-)
O67.0 Intrapartum haemorrhage with coagulation defect
Intrapartum haemorrhage (excessive) associated with:
• afibrinogenaemia
• disseminated intravascular coagulation
• hyperfibrinolysis
• hypofibrinogenaemia
O67.8 Other intrapartum haemorrhage
Excessive intrapartum haemorrhage
O67.9 Intrapartum haemorrhage, unspecified
Rupture of uterus not stated
O71 Other obstetric trauma
Incl.: damage from instruments
O71.0 Rupture of uterus before onset of labour
O71.1 Rupture of uterus during labour
as occurring before onset of labour
O71.3 Obstetric laceration of cervix
Annular detachment of cervix
O71.4 Obstetric high vaginal laceration alone
Laceration of vaginal wall without mention of perineal laceration
Excl.: with perineal laceration (O70.-)
O71.7 Obstetric haematoma of pelvis
Obstetric haematoma of:
• perineum
• vagina
• vulva
30
41. The WHO Application of ICD-10 to deaths during pregnancy, childbirth and the puerperium: ICD MM
O72 Postpartum haemorrhage
Incl.: haemorrhage after delivery of fetus or infant
O72.0 Third-stage haemorrhage
Haemorrhage associated with retained, trapped or adherent placenta
Retained placenta NOS
Use additional code, if desired, to identify any morbidly adherent placenta (O43-O45)
O72.1 Other immediate postpartum haemorrhage
Haemorrhage following delivery of placenta
Postpartum haemorrhage (atonic) NOS
O72.2 Delayed and secondary postpartum haemorrhage
Haemorrhage associated with retained portions of placenta or membranes
Retained products of conception NOS, following delivery
O72.3 Postpartum coagulation defects
Postpartum:
• afibrinogenaemia
• fibrinolysis
31