maternal &perinatal mortality

8/3/2019 Maternal &Perinatal Mortality

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Maternal &perinatal:mortality

the Confidential EnquiriesBy :Usama El Baz


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Overview :

Worldwide childbearing poses the major risk to the life ofwomen .

In developed countries it is a safe process

Without health care 2% of women will die during their

pregnancyWHO (2001) : complications during pregnancy and childbirthare responsible for 515000 women\year

Sub-Saharan Africa , the area of greatest mortality risk of

dying as a result of childbirth is 1:13for each mother dies , as many as 30 will suffer injury andlong term complications


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World wide causes of maternal mortality :

Together , hemorrhage and infection account for almost 1\2 deaths

Deaths related indirect causes becoming more common , as HIV inc in prevalence

Hemorrhage is the commonest cause of maternal mortality


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Only 53 % of women in developing countries have access toskilled health care in labour , and even fewer have access to

postnatal care .


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As well as poor access to health care , the rapidly evolvingaids is also hampering efforts to improve outcomes for bothmothers and babies

In many areas of sub-Saharan Africa , 30% of women inchildbearing age are infected with HIV.

So any attempt to reduce maternal mortality needs to takeAIDS in to account .


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A global initiative was launched at a conference held inNairobi ,Kenya , in 1987 . The aim was to draw the world'sattention to thousands of deaths and millions of seriousillnesses that afflict women every year .

It was co-sponsored by a group of international agencies thatfounded The Safe Motherhood Interagency Group


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The Safe Mother hood Project aims to provide :

care by skilled health personnel before, during and afterchildbirth

emergency care for lifethreatening obstetric complications

services to prevent and manage the complications of unsafeabortion

family planning

health education and services for adolescent

community education for women, their families and descision

makers


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Maternal and

perinatal mortalityin the UK


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Death of a women in childbirth is now a rare event in the UK

Maternal and perinatal deaths in the uk are subject toconfidential enquiry , conducted mainly by doctors andmidwives.

The confedintial nature of the enquiries encouragesopenness amongst staff and allows investigators to obtain aclearer picture of what happened in a culture of' low blame'.The reporting is anonymized before being seen by regionalassessors.

By this means, recommendations for improvements in carecan be made without direct identification of either the patientor hospital involved .


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The reporting of maternal and infant deaths is fundedthrough the National Institute for Clinical Excellence and ismanaged by a Consortium o Royal Colleges:

-Royal College of OBS&GYN

-R.C of Midwives

-R.C. of Pediatrics and Child Health

-Royal College of Pathologists

-Royal college of Anesthetists

-Faculty of Public HealthAnd is called the Confidential Enquiry into Maternal and Child

Health (CEMACH)


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Maternal mortality


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Defenitions:

Maternal death=death of women while pregnant or within 42days of termination of pregnancy from any cause related topregnancy

Direct deaths=resulting from obstetric complications of thepregnant state (pregnancy, labour and puerperium )

(e.g.death from PPH in a previously well women)

Indirect deaths =resulting from previous existing disease , ordisease that developed during pregnancy and which was notdue to direct obstetric cause( e.g .death from a cardiac lesion)

Late deaths = occur between 42 days and 1 year afterabortion ,miscarriage or delivery .

Coincidental (fortuitous) deaths : unrelated causes (e.g,RTA)


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Maternal mortality rate

Def =number of deaths from obstetric causes per 100000maternities


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Trends in the UK

Maternal mortality rate MMR in UK has been recorded reliablysince 1847 , and history can be divided into 3 phases .

Phase 1 :From 1847 until 1934 , MMR unchanged around 400\100000

or 1\250 births

Ph 2


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Phase 2 :

From 1935 to 1985 , dramatic fall in MMR

This fall is often seen as part of a general improvement in public health ,but the timing suggests the effect of other factors beside improved socialconditions :

1- antibiotics : sulphonamides introduced in 1937 and penicillin appearedduring 2nd world war death rates from puerperal sepsis quickly fell

2- 1936: Midwives Act came into being

limiting role of unqualified birthattendants

3-1940s blood transfusion become safe

4-1940s ergometrine for Tx &prevention of PPH

5-1929OBS become a specialty (Royal college of Obs &Gyn founded)

6-1961OCPreduce Parity7-1967 legalization of abortion


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Phase 3:Since 1985 , little change in MMR


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Methods of enquiry :

women dies during or within year following pregnancy

director of Public Health Medicine sends an enquiry form to (GP , MW , OBS ,Pathologists , Anesthesia and any other staffinvolved In her care

forms are filled with their comments

form sent to the Chief Medical Officer

then made anonymous and then passed to central assessorsof the same disciplines to assess the causes of death .


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C f MM i h UK


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Causes of MM in the UK

in the triennium 1997-99 there were 378 maternal deaths ofwhich:

242direct (106)

In direct(136)

Remainder

coincidental( 29)Late (107)


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#Di t d th


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#Direct deaths :

1- thromboembolism >>>

Death from thromboembolism can occur at any stage ofpregnancy , even in the first trimester "after ectopicpregnancy"

The risk is highest in the early puerperium and continuesuntil about 6 weeks

There has been a dramatic fall in deaths from TE after theprevious enquiry recommended a schedule for TE prophylaxisafter CS , from 2.1 to 1.45 deaths per 100000 maternities

2 h t i di d


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2- hypertensive disorders >>>

The number of deaths from hypertensive disorders has beengradually declining since 1970

Contributors of this improvement

(better Mx of HTN, introduction of magnesium sulphate andbetter anesthetic care )

deaths due to hypertension 15 women the largest singlecause was intracranial hemorrhage (7 deaths)

complication of HTN disease (4 deaths)

(1death) due to pulmonary complications (ARDS)None died of pulmonary edema this is a major improvementfrom previous enquiries = much better understanding of fluidmanagement


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3-hemorrhage >>>

The leading cause of death worldwide but in UK it accountsfor a few deaths each year .

In the last report , 7 direct deaths (3 due to Placentapreviae)(3 abruption)(1 PPH)

4 it l t t i


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4-genital tract sepsis

The other major cause of maternal death worldwide

Account for 14 deaths in 1997 -99 in UK

The rate of death due to sepsis is rising : 4per millionmaternities in 1985 -87 compared to 8.4 in the most recentreport

Major causative agent is Group A streptococcus

5 i ti fl id b li


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5- amniotic fluid embolism >>>

8 cases reported in 1997-99

5\8 were associated with induction or augmentation of labour

It was formerly thought to be associated with high parity butonly one case found to be high parity

The rates of death have declined significantly from 35 casesreported in 1994-1996 although reasons are not clear

6 l d th


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6- early pregnancy deaths

Deaths occurring before 24 weeks "formerly the upper limit was 20 wks"

17 deaths reported

a- ectopic pregnancy :

rate of deaths attributable to ectopic pregnancy has not fallen over the lastfour triennia , 13 women dying in 1997-99

incidence of ectopic pregnancy risen in UK during the last decade toapprox. 1 every 150

the most commonly identified fault contributing to death was failure todiagnose ectopic pregnancy as

b- miscarriage

4 deaths in 1997-992 of which were attributable to infection and were potentially avoidable

c- termination of pregnancy:

1997 -99) 2 legal abortions (one due to TTP and the other suffered anamniotic fluid embolism) no illegal abortions


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7- genital tract trauma:

2 deaths in 1997-99 (one due to ruptured uterus and the otherdue to sustained vaginal wall tear )

8- anesthesia

Rates of death directly attributable to anesthesia fell till 1996.in the last triennium a small rise to 3 cases was seen

I di t d th


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Indirect deaths

1-cardiac disease

Now the joint most common cause of maternal death , with35 recorded deaths

Rheumatic HD is rarely encountered

The major groups comprise congenital HD , ischemic HD andcardiomyopathy

Pulmonary HTN and Eisenmenger's $ carry MMR of 30 -50%

Pulmonary vascular problems accounted for 7of 10 deaths

due to congenital HDPatients with known HD should be managed by a cardiologistin cooperation with an obstetrician .


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2-psychiatric deaths:

As a single category it is the largest cause of death amongstwomen

In 1997-99 report psychiatric disorder contributed to thedeaths of 42 women , 28 due to suicide.

Recommendation : screening at booking for psychiatric ,substance abuse or severe social problems

3- other :

Many diseases are exacerbated by pregnancy , total 75deaths in 1997-99

Epilepsy was a major contributor causing 9 deaths this isa large drop (19 in the previous report )


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maternal &perinatal mortality

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