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- 1. Maternal Mortality BY SHANNON LARATONDA, MHS
- 2. Definition and statistics Maternal mortality: deaths due to complications from pregnancy or childbirth (UNICEF) Death of a woman during pregnancy or within 1 yr. of pregnancy termination (CDC) From 1990 to 2013, rate declined 45% 1990 – 377,000 deaths 2013 – 293,000 deaths Average annual rate of reduction 2.6% 5.5% annual decline rate needed to achieve United Nations’ Millenium Development Goal 5 To ↓ rate by 75% by 2015
- 3. Maternal mortality ratio Maternal mortality ratio: maternal deaths per 100,000 live births in women aged 15-49, by region, 1990, 2005, and 2013 Remains unacceptably high in sub-Saharan Africa Huge disparities found between richest and poorest countries serve as evidence that almost all maternal deaths can be prevented
- 4. Facts from World Health Organization Every day approx. 800 women die from preventable causes related to pregnancy and childbirth (worldwide) 650 per year in U.S. 99% of all mortality deaths occur in developing countries More than half occur in sub-Saharan Africa Almost 1/3 occur in South Asia Maternal mortality is higher in women living in rural areas and among poor communities Females <15yo. & >35yo. face highest risk of complications and death from pregnancy Leading cause of death among adolescent girls in developing countries 1/160 lifetime risk of maternal death in developing countries; 1/3700 developed Skilled care BEFORE, DURING, and AFTER childbirth can save the lives of women and newborns
- 5. Causes of Maternal Mortalities Worldwide in 2014
- 6. Causes of Maternal Mortalities in the U.S. in 2011
- 7. Infection → Sepsis (14% U.S.) Mother should practice good hygiene Helps if early signs of infection are recognized and treated in a timely manner Chills, pus draining from uterus, fever, lower abdominal pain, malaise, uterine tenderness, uterus does not return to normal size Puerperal sepsis: infection related to giving birth Chlamydia, C. tetani, C. welchii, E. coli, gonococci, staph, strep Endometritis Breast infections ie. mastitis – 1 in 20 nursing mothers Wounds from childbirth Urinary tract infections Unsafe abortions
- 8. Postpartum Hemorrhage (11.3% U.S.) Severe bleeding after birth can kill a healthy woman within hours if unattended Approx. 4% of women More likely with a C-section #1 cause is uterine atony Other causes: Retained products of conception (RPOC) Uterine tear Poor clotting Maternal hemorrhage is the third most likely cause of death for women in low income countries; behind HIV/AIDS and TB (WHO, 2008) Oxytocin immediately after childbirth effectively reduces the risk of bleeding
- 9. Postpartum Hemorrhage Symptoms Uncontrolled bleeding Decreased BP Increased HR Low Hct Swelling and pain in tissues in the vaginal and perineal areas Diagnosis Medical hx, PE, and labs Estimation of blood loss PR and BP Hct Clotting factors in blood
- 10. Postpartum Hemorrhage Treatment IV fluids Blood transfusion to prevent shock Oxytocin, Misoprostol, Ergotamine Oxygen mask Stop the cause Manual massage of the uterus to stimulate contractions Removal of placental pieces Pack the uterus with sponges or other sterile materials Tie-off bleeding blood vessels Laparotomy to ID source of bleeding hysterectomy
- 11. Postpartum Hemorrhage Risk factors Placental abruption Placenta previa Overdistended uterus from excess amniotic fluid, large fetus or multiple pregnancy Gestational hypertension or preeclampsia More than 5 previous births General anesthesia Prolonged labor Infection Obesity Medications to induce labor Medications to stop contractions for preterm labor Use of forceps or vacuum- assisted delivery
- 12. Peripartum Cardiomyopathy (10.1% U.S.) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2612110/ Increased blood volume → increases CO
- 13. Thrombotic PE (9.8% U.S.) Hypercoagulability Main reason - pregnancy is a hypercoagulable state 4-5 fold increase risk of thromboembolism during pregnancy and post partum Highest risk in 3rd trimester 80% are venous thromboembolism (VTE) Incidence 0.49-1.72 per 1,000 pregnancies Risk factors Hx of thrombosis Inherited or acquired thrombophilia Increased maternal age Complications of pregnancy and childbirth
- 14. Hypertensive Disorder of Pregnancy (8.4% U.S.) Preeclampsia Hypertension after 20 weeks, edema, proteinuria, thrombocytopenia Should be detected and managed before seizure onset (eclampsia) HELLP syndrome Hemolysis, Elevated Liver enzymes, Low Platelets 0.2-0.6% of all pregnancies Abnormal periph. smear, LD >600U/L, bilirubin >1.2mg/dl, elevated AST/ALT, low platelets DELIVER BABY!!! Rx magnesium sulfate to prevent seizures, blood transfusion To prolong pregnancy: bed rest, fetal monitor, antihypertensive and corticosteroids Treatment
- 15. Amniotic Fluid Embolism (5.6% U.S.) http://en.wikipedia.org/wiki/Amniotic_fluid_embolism
- 16. Avoid Maternal Deaths Prevent unwanted pregnancies and young adolescent pregnancies Access to contraception Safe abortion services and post-abortion care Education and awareness
- 17. References Centers for Disease Control and Prevention (2015). Pregnancy Mortality Surveillance System. Retrieved April 20, 2015 from http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html. UNICEF (2015). Maternal Mortality. Retrieved April 20, 2015 from http://data.unicef.org/maternal-health/maternal-mortality. World Health Organization (WHO), (May 2014). Maternal Mortality. Retrieved April 20, 2015 from http://www.who.int/mediacentre/factsheets/fs348/en/.
Editor's Notes
- Factors that prevent women from receiving or seeking care during pregnancy and childbirth: poverty, distance, lack of information, inadequate services (resources and low numbers of skilled health workers), cultural practices
- Disparities between countries, between women with high and low income, between women living in rural and urban areas
- The remainder are caused by or assoc. w/ diseases like malaria and AIDS during pregnancy Pre-existing conditions: DM, cardiac disf(x), SLE, HTN
- Uterine atony: uterus does not contract strong enough to compress bleeding vessels after placenta detaches
- Hypercoagulability evolved to protect mother from hemorrhage when tissue detaches Normal pregnancy: increased concentrations of factors 7, 10, 13 & VW, fibrinogen, plasminogen activator inhibitor increases most in 3rd trimester; placenta produces most solutes in third trimester.
- Corticosteroids temporarily improve liver and platelet f(x)