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Maternal &perinatal mortality

the Confidential Enquiries By :Usama El Baz

Overview :
•Worldwide childbearing poses the major risk to the life of women . •In developed countries it is a safe process •Without health care 2% of women will die during their pregnancy •WHO (2001) : complications during pregnancy and childbirth are responsible for 515000 women\year Sub-Saharan Africa , the area of greatest mortality  risk of dying as a result of childbirth is 1:13 for each mother dies , as many as 30 will suffer injury and long term complications

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

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

•As well as poor access to health care , the rapidly evolving aids is also hampering efforts to improve outcomes for both mothers and babies •In many areas of sub-Saharan Africa , 30% of women in childbearing age are infected with HIV. •So any attempt to reduce maternal mortality needs to take AIDS in to account .

•A global initiative was launched at a conference held in Nairobi ,Kenya , in 1987 . The aim was to draw the world's attention to thousands of deaths and millions of serious illnesses that afflict women every year . •It was co-sponsored by a group of international agencies that founded The Safe Motherhood Interagency Group

The Safe Mother hood Project aims to provide :
•care by skilled health personnel before, during and after childbirth • emergency care for life –threatening obstetric complications • services to prevent and manage the complications of unsafe abortion •family planning • health education and services for adolescent •community education for women, their families and descision makers

Maternal and perinatal mortality in the UK

•Death of a women in childbirth is now a rare event in the UK •Maternal and perinatal deaths in the uk are subject to confidential enquiry , conducted mainly by doctors and midwives. •The confedintial nature of the enquiries encourages openness amongst staff and allows investigators to obtain a clearer picture of what happened in a culture of' low blame'. The reporting is anonymized before being seen by regional assessors. •By this means, recommendations for improvements in care can be made without direct identification of either the patient or hospital involved .

The reporting of maternal and infant deaths is funded through the National Institute for Clinical Excellence and is managed 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 Health And is called the Confidential Enquiry into Maternal and Child Health (CEMACH)

Maternal mortality

•Maternal death=death of women while pregnant or within 42 days of termination of pregnancy from any cause related to pregnancy •Direct deaths=resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium ) (e.g.death from PPH in a previously well women) •Indirect deaths =resulting from previous existing disease , or disease that developed during pregnancy and which was not due to direct obstetric cause( e.g .death from a cardiac lesion) •Late deaths = occur between 42 days and 1 year after abortion ,miscarriage or delivery . •Coincidental (fortuitous) deaths : unrelated causes (e.g,RTA)

Maternal mortality rate
Def =number of deaths from obstetric causes per 100000 maternities

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

Phase 1 :
From 1847 until 1934 , MMR unchanged around 400\100000 or 1\250 births

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 social conditions : 1- antibiotics : sulphonamides introduced in 1937 and penicillin appeared during 2nd world war  death rates from puerperal sepsis quickly fell 2- 1936: Midwives Act came into being  limiting role of unqualified birth attendants 3-1940s  blood transfusion become safe 4-1940s ergometrine for Tx &prevention of PPH 5-1929OBS become a specialty (Royal college of Obs &Gyn founded) 6-1961OCPreduce Parity 7-1967 legalization of abortion

Phase 3:
Since 1985 , little change in MMR

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 staff involved In her care  •forms are filled with their comments  •form sent to the Chief Medical Officer  •then made anonymous and then passed to central assessors of the same disciplines to assess the causes of death .

Causes of MM in the UK
in the triennium 1997-99 there were 378 maternal deaths of which: 242 direct (106) In direct(136) Remainder coincidental( 29) Late (107)

#Direct deaths :
1- thromboembolism >>> •Death from thromboembolism can occur at any stage of pregnancy , even in the first trimester "after ectopic pregnancy" •The risk is highest in the early puerperium and continues until about 6 weeks •There has been a dramatic fall in deaths from TE after the previous enquiry recommended a schedule for TE prophylaxis after CS , from 2.1 to 1.45 deaths per 100000 maternities

2- hypertensive disorders >>>
The number of deaths from hypertensive disorders has been gradually declining since 1970 Contributors of this improvement (better Mx of HTN, introduction of magnesium sulphate and better anesthetic care ) • deaths due to hypertension 15 women the largest single cause 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 improvement from previous enquiries = much better understanding of fluid management

3-hemorrhage >>> The leading cause of death worldwide but in UK it accounts for a few deaths each year . In the last report , 7 direct deaths (3 due to Placenta previae)(3 abruption)(1 PPH)

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 million maternities in 1985 -87 compared to 8.4 in the most recent report •Major causative agent is Group A streptococcus

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 but only one case found to be high parity •The rates of death have declined significantly from 35 cases reported in 1994-1996 although reasons are not clear

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 last four triennia , 13 women dying in 1997-99 incidence of ectopic pregnancy risen in UK during the last decade to approx. 1 every 150 the most commonly identified fault contributing to death was failure to diagnose ectopic pregnancy as b- miscarriage 4 deaths in 1997-99 2 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 an amniotic fluid embolism) no illegal abortions

7- genital tract trauma: 2 deaths in 1997-99 (one due to ruptured uterus and the other due 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

Indirect deaths
1-cardiac disease •Now the joint most common cause of maternal death , with 35 recorded deaths •Rheumatic HD is rarely encountered •The major groups comprise congenital HD , ischemic HD and cardiomyopathy •Pulmonary HTN and Eisenmenger's $ carry MMR of 30 -50% •Pulmonary vascular problems accounted for 7of 10 deaths due to congenital HD •Patients with known HD should be managed by a cardiologist in co –operation with an obstetrician .

2-psychiatric deaths: •As a single category it is the largest cause of death amongst women •In 1997-99 report psychiatric disorder contributed to the deaths 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 75 deaths in 1997-99 •Epilepsy was a major contributor causing 9 deaths  this is a large drop (19 in the previous report )