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Mortality - death.

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Mortality - death. Fetal Death: intrauterine death of a fetus of at least 20 weeks gestation with absence of any signs of life after birth. – PowerPoint PPT presentation

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Title: Mortality - death.


1
Mortality - death.
Fetal Death intrauterine death of a fetus
of at least 20 weeks gestation
with absence of any signs of life after
birth.
Neonatal death death of an infant born with
signs of life up to 28 days
after birth.
Perinatal death sum of fetal neonatal
deaths per 1000 live births.
BEST indicator of
perinatal care
INFANT MORTALITY the number of deaths per
1000 that occur in the first year of
life. This the the statistic used by
most countries. This is what is most
seen in the Literature ALTHOUGH is not the
best indicator of Perinatal care.
Maternal Death death of mothers per
100,000 due to complications of
pregnancy, labor , delivery or postpartum.
2
Maternal Mortality (per 100,000
births) 1915 1940
1950 1960 1983 1997 2002 All Women
608 376 83.3 37 8 7.2 7.6
White Women 61 26
5.9 5.5 6 Nonwhite Women
221.6 97.9 18.3 18-20 18 Adequate
prenatal care 3 Poor
prenatal care 5 No Prenatal Care
23 Leading Causes Pregnancy Related Death
hemorrhage, embolism, hypertension, infection,
anesthesia related complications
3
Maternal Mortality Rate approximately 7.5
per 100,000 in 1998 When compared to white
women Black women have 4 times the risk
for dying from complications of pregnancy and
childbirth. One half of all deaths could be
prevented with early detection. No
significant changes since 1982 - fluctuated
between 7 8 . Hemorrhage, PIH, infection,
and ectopic pregnancies account for most
of the deaths.
Fetal mortality rate in 1998 was 6.7
improved from 6.8 White 5.7 Black
12.3
Perinatal Mortality 7.2 Whites 6.2 ,
Blacks 12.9
Neonatal mortality 4 .8 Whites 4.0 ,
Blacks 9.4 . In 1990 was 5.7
Postneonatal Mortality 2.4 Whites 2.0 ,
Blacks 4.4
Taken from the last CDC statistics 1998
4
Regionalization
Level 1 Level 2 IVCH, CHO Level 3 St.
Francis
Small group of women is high risk with good
prenatal care almost 2/3 of ALL HIGH
risk problems can be identified early and high
possibility of preventing further
complications Only 23-25 of High Risk
delivered are surprises KEY Identification
Prenatal care
5
Obstetrical uterine malformations
Bicornate uterus
Sepate uterus
Didelphys or Complete Double uterus
Double uterus
6
Relationship between maternal and
fetal malnutrition
7
Loss and Grief - outline
Types of losses arising in perinatal period and
their causes
Loss of real vs ideal (pregnancy) -maternal or
fetal demise -need for hospitalization or
transport to distant site -diagnosis of fetal
anomalies -intrauterine fetal demise Loss of
normal labor experience -development of
complications -need for intervention (IVs,
oxytocin, oxygen) -need for FHM -fetal
distress -need to remain in bed or analgesia or
anesthesia Loss of emotional control -screaming,
crying -verbalization of anger, fear,
discouragement -use of expletives
Loss of Physical Control -inability to push or
inability to withstand involuntary urge to push
-involuntary vocalizations, defecation, or
urination during delivery -inability to maintain
breathing or relaxation techniques -vomiting -sla
pping or hitting coach or med staff -throwing
objects Loss of Natural Birth Experience -preterm
birth -need for analgesia or anesthesia -need
for forceps or vacuum extraction -need for
cesarean delivery
8
Types of losses arising in perinatal period and
their causes continued
Loss of shared experiences -absence of father,
partner, or other significant friend Loss of
body image -incompetent cervix -severe edema with
preeclampsia -incision from cesarean birth Loss
of real versus ideal (Neonate -neonatal
anomalies -birth injuries or asphyxia -preterm
infant -need for transport to distant
site -stillbirth/neonate death Loss of
self-image -maternal disease process -postpartum
depression
Loss of real vs. ideal (postpartum
exper.) -maternal trauma or disease -postpartum
depression -neonate unable to breastfeed due to
prematurity illness, or anomalies Loss of Self
Image -maternal disease process -preterm labor or
birth -fetal or neonatal death Loss of
relationships -maternal hospitalization or
transport to distant site -neonatal
transport -fetal or neonatal death -partner
withdrawn during grief process -with fetal or
neonatal death, avoidance behaiors by family or
friends
9
  • DEFINATION OF HYPERTENSION IN PREGNANCY
  • Systolic blood pressure gt or 140 mm Hg
  • or
  • Diastolic blood pressure gt or 90 mm Hg
  • Increase of gt or 30 mm Hg in systolic pressure
  • 4. Increase of gt or 15 mm Hg in diastolic
    pressure

NOTE 3 4, most of our women have lower BP to
start with!
10
PEGNANCY INDUCED HYPERTENSION
  • Preeclampsia Development of hypertension with
    proteinuria, edema or
  • both, induced by pregnancy after the
    20th week of gestation
  • 1. Mild Preeclampsia is considered mild
    unless any criteria for severe
  • is met
  • 2. Severe One or more of the following
    signs defines severe preeclampsia
  • Blood pressure with resting gt or 160 mm Hg
    (systolic) or
  • 110 mm Hg (diastolic) on two occasions at
    least 6 hours apart
  • Proteinuria gt or 5 g in 24
    hours, 3
  • Oliguria gt 400 ml in 24 hours, 30cc/hr
  • Cerebral / vision disturbances (e.g. altered
    consciousness,
  • headache, blurred vision)
  • Pulmonary edema / cyanosis
  • Epigastric / right upper quadrant pain (can
    occasionally
  • precede hepatic rupture
  • Impaired liver function of unknown etilology
  • Thrombocytopenia
  • 3. Eclampsia The occurrence of convulsions in
    a woman who meets criteria
  • for preeclampsia

11
Preeclampsia Most women in Mild preeclampsia
are not immediately hospitalized, but will keep
close monitoring on maternal fetal well being.
ks
agement
oring
tion
ns change
If below 37 weeks, betamethosone IM to mom,
helps surfactant development
12
Checking Reflexes A Biceps B Patellar
reflex with legs hanging freely C
Patellar reflex with client supint D
Checking for ankle clonus
13
Checking for pitting edema
A 1 B 2 C 3 D 4
14
Watch for symptoms even in someone who is
below 140/90
or liver Enzymes Renal function
15
What is MAP ? Talking about blood pressure
Mean arterial pressure
MAP DBP 1/3 of pulse pressure A person with a
BP or 120/60 has a MAP of 80. Often used this
in hyper- tensive crises, more accurate in gaging
medications /or end-organ damage Pulse pressure
the difference between the systolic diastolic
pressure. It is normally about 1/3 of the
systolic pressure. If BP is 120/80, the pulse
pressure is 40. See increased with
arteriosclerosis of the larger arteries or during
exercise. See decreased with hypovolemia.
16
Severe Preeclampsia -Admit
to labor and delivery area -Maternal and fetal
evaluation x 24 hours
No - Maternal Distress Yes
-Severe IUGR -Fetal Distress
----Delivery -Labor
-gt34 weeks gestation
lt 28 weeks 28-32 weeks
33-34 weeks -maternal -steriods,
betamethosone -amniocentesis
counseling -conservative -intensive
management immature or mature management
17
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19
Pathophysiology of PIH
20
Severe Preeclampsia H E L L P H hemolysis E
elevated L liver function tests L low P
platelet count
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22
Postpartum Resolution - brisk diruesis (150
300 ml / hour -IV MgSO4 until diruesis
observed or usually 24 hrs -keep BP lt 140/100 mm
Hg -discharge with weekly follow up until BP is
normal Therapeutic levels of MgSo4 are 4 to 7,
toxic levels 8-10 blood levels will be drawn,
check DTR, resp. rate REMEMBER whenever MgSO4
is in use what drug has to be near by
Calcium gluconate
Uterine relaxation
What should you watch for in mom PP ?
What might happen in newborn ?
Remember MgSO4 is a CNS depressant
respiratory distress, decrease in respiratory
effort
23
Remember 1202
Signs and Symptoms of Shock
  • Hypovolemic Shock SIGNS
  • -tachypnea (deep rapid)
  • -tachycardia
  • -weak, thready pulse
  • -hypotension late sign
  • -narrowed pulse pressure
  • -increased capillary fill time (gt4 sec)
  • -oligura (less than 20-30 mL/ hr)
  • -urine sodium 80 mEq/L
  • -cool, clammy skin
  • -pallor and peripheral cyanosis
  • -hypothermia
  • SYMPTOMS
  • anxiety, restlessness, disorientation
  • -thirst, dry mouth
  • -feeling chilled

Septic Shock -tachycardia -hyperdynami
c pulse -thachypnea, respiratory
alkalosis -hypotension -cerebral
oscje,oa -polyuria, urine sodium 10
mEq/L -hyperthermia (in early septic
shock) SYMPTOMS -palpitations -faintness,
dizziness -anxiety, apprehension,
disorientation, stupor
24
Abortions A Threatened B Inevitable C
Incomplete D Complete E Missed
25
Incompetent cervix A cerclage correction of
recurrent premature dilation of cervix B
cross section of closed cervix Suture
removed around 36-38 wks. McDonalds
procedure cerclage suture Pursestring sutures
26
Sonograms HCG levels Emotional Support
27
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28
Hydatidform mole or a gestataional
trophoblastic neoplasm Rare 1 1000 to 2000 3
times higher in Asian women, 10 develop
Choriocarcinoma
What is treatment?
Often abort spontaneously or DC No Pitocin
until after deliver
What are SS?
Nausea Why? Abnormal uterine growth
What do you have to check? Why? How often?
HCG levels 1-2 wks until norm, then 1-2 mos for a
year. If do not drop may have to be treated
with chemotherapy
Starts as fertilization, trophoblast
Degenerates chorion proliferates
29
Actual Hyditform MOLE
30
Placenta Previa NON PAINFUL BLEEDING
A D Complete B C Partial C B Low
lying or Marginal Lower A Normal
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32
What are SS ?
Pain Board like abdomen, especially is
concealed.
Who is high risk population ?
History of abruptio Grand parity Povery PIH Adva
nced age Supine hypotension Short umbilical cord
during labor Trauma to abdomen Cocaine or other
drug usage Cigarette some say Alcohol abuse
some say
33
CORD INSERTION PLACENTAL VARIATIONS
Rare less than 13000
May lacerate bleed, especially during L D A
Vasa praevia or Velamentous insertion No
wharton jelly B Battledore placenta cord at
end of placenta C Succenturiate placenta
blood vessels maybe supported only by fetal
membranes
34
DIC or Disseminated Intravascular Coagulation
What are SS?
FIND CAUSE correct DIC is secondary to
number of things hemorrhage septic
shock amniotic fluid embolism
PIH infection diabetes
35
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37
During PG, clotting factors normally increase and
thrombolytic activity decreases If a condition
requires some type of anticoagulant heparin is
choice Warfarin crosses the placenta is with
fetal malformations
von Willebrands disease an autosomal dominant
bleeding disorder in abnormality of vW factor
which affects clotting of blood hormones in
pregnancy may improve vW factor but need to
monitor
ATP may improve slightly, but then rebound with
more destruction of the platelets
38
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39
Maternal infections
1 Syphillis may pass through placenta may result
in abortion, a stillborn, preterm labor or
congenital syphillis (enlarged liver, spleen,
skin lesions, rashes, oseteitis, pneumonia,
hepatitis TX penicillin
2 Chlamydial infection (1 STD in US) fetus may
be infected during birth and suffer neonatal
conjunctivitis or pneumonitis, which manifests
at 4-6 wks of age PROM , chorioamnionitis,
preterm labor TX erythromycin or amoxicillin (mom)
3 Gonarrhea fetus may be infected during birth
ophthalmia neonatorium endocervicitis PROM and
preterm labor
4 Condyloma acuminatum or genital warts (human
pailliomavirus) fetus may be infected during
vaginal birth and develop epithelial tumors of
the mucous membranes of the larynx in children.
PG can cause proliferation HPV associated with
cervical dysplasia cancer (see next slide)
5 tichomoniasis basically associated with PROM
and postpartum endometritis
40
Venereal warts or Condylamata acuminata Human
papillomavirus HPV Most common viral STD 3
times greater than herpes Cauliflower like
appearance
41
Maternal vaginal infections
Vaginal candidiasis fetus may be infected during
vaginal birth oral candidiasis (thrush) TX for
infant Mycostatin TX for mom Monistat, Terazole,
Femstat Most say treat for at least 7 days PROM,
preterm labor, low birth weight, postpartum
endometritis
UTIs , cycstitis, acute pyelonephritis PROM,
preterm labor
42
Viral infections remember most virus passes
placental barrier
Cytomegalovirus a member of herpesvirus group.
Infects most humans peak ages 15 to 35 yrs.
Like most herpes after primary infection, lies
latent with periodic reactivation and
shedding of the virus. Fetal neonatal effects
2 of all live births may be infected.
These infants shed the virus from the
nosopharynx and urine for several yrs. Most
severe effects deafness, mental retardation,
seizures, blindness dental bnormalities TX
gancyclovir for TX of congenitally infected
infants No screening yet available
Rubella up to 10 of adults remain
susceptible Fetal neonatal effects greatest
risk is first 3 ms. 1/3 will result
in spontaneous abortion, surviving maybe
seriously compromised deafness, mental
retardaation, cataracts, cardiac defects,
IUGR and mirocephaly. Infants will shed the
virus for many months TX prevention, A titer of
1.8 or greater provides immunity Rubella vaccine
after delivery educate no PG for at least 3
mos. WHY?
43
Varicella Zoster virus ( herpesvirus)
chickenpox Acute infection for mom
r\preterm labor, encephalitis varicella
pneumonia. 5 15 of aduls in US are
susceptible Fetal neonatal effects. Depend
upon time of infection. If in the first 20 wks,
the fetus may have congenital varicella syndrome
(limb hypo- plasia, cutaneous scars,
chorioretinitis, cataracts, microcephal and
symmetric IUGR. In later pregnancy ,
transplacental passage of maternal antibodies
usually protect fetus. However, the infant
who is infected 4-6 days or 2 days after birth
will not have the benefit of maternal
antibodies, leaving the infant at risk for
life-threatening neonatal varicella TX
immune testing, varicella-zoster immune globulin
should be administered to women who have been
exposed TX infants born to mothers infected
with varicella during the perinatal period,
immunization with varicella-zoster immuni
globulin as soon as possible but within 96 hrs
after birth. Live attenuated vaccine after 12
mos through adults, avoid PG for 1 mo after each
of the two injections, which are given 4 to 8 wks
apart.
44
Herpesvirus serotypes 1 2 one of most common
sexually transmissible disease. Most genital
warts are type 2. Lesions form at site, begin
at painful papules that progress to vesicles,
shallow ulcers, pustules, crusts. Virus is shed
until completely healed. lies latent in the
sensory ganglion which can be reactivated Vertica
l transmission from mom to infant generally
occurs 1 after rupture of membranes or 2 during
vaginal birth or with fetal scalp electrode
Fetal neonate effects Primary infection in
first 20 weeks spontaneous abortion,
IUGR and preterm labor. Neonatal herpes
is uncommon but potentially devastating. From
skin lesion to systemic or disseminated. If
systemic death rate or serious sequelae is 50 .
Watch for infection SS temp instability,
lethargy, poor sucking, jaundice, seizure
herpetic lesions. TX no known cure although
antiviral chemotherapy (acyclovir) Category C
May breast feed if no lesions are on breast
45
Parvovirus or erythemia infectiosum or fifth
disease. highly communicable characterized by
slapped cheeks appearance followed by a
generalized maculopapular rash, fever, malaise
and joint pain. Titers can be drawn if exposure
during PG Fetal neonate effects I/4 to
1/3 of fetuses infected will have transient
adverse effects, fetal death rate is less the 5.
Death usually results form failure of fetal
RBC production, fetal anemia, hydrops (edema)
and heart failure
Hepatitis B more likely to occur in person with
STD, IV drug users some population groups,
Asians, Native Americans, Eskimos,
Southeast Asian and subSaharan African
immigrants. Chronic Hepatitis B develops in 1
to 6 of infected adults who are at a greater
risk for chronic liver disease, cirrohosis of
the liver, premary hepatocellular carcinoma
Fetal neonatal effects prematurity, low birth
weight, and neonatal death increases.
Infants born are chronic carriers of hepatitis B.
Chronic hepatitis develops in about 90 of
infected newborns likely to have chronic
liver disease
46
TX for Hepatitis B prevention vaccines of 3 IM
injections given during a 6 12 mos.
period. Screen for HBsAg if at high risk screen
again in 3rd trimester If mom is known GBsAg
positive usually infection of the newborn can be
prevented by administration of hepatitis B
immune globulin followed by hepatitis B
vaccine. Vaccine should be repeated at 1 and 6
mos. Breastfeeding is considered safe as long as
the new born has been vaccinated
HIV human immunodeficiency virus. Fetal
neonatal effects without prophylactic TX
(Zidovudine) has a 20-30 of developing
the disease. Typically are asysmptomatic at birth
but SS during first 12 mos. Enlargement of
liver, spleen, lymphadenopathy, failure to
thrive, persistent thrush, extensive seborrheic
dermatitis or cradle cap. TX prevention
prenatal period intrapartum period (cesarean
birth ? ) postpartum period (no
breastfeeding) With Zidovudine throughout PG and
L D. infant TX with zidovudine syrup may
test positive at birth but only 2 will remain
positive If mom contacts HIV virus during PG
higher change that infant will be HIV
47
Non Viral infections
Toxoplasmosis a protozoan infection. Raw or
undercooked meat, cat feces crosses the
placental barrier. Flu like symptoms in
mom. Can do serologic test Fetal and neonatal
effects spontaneous abortion or live birth with
congenital toxoplasmosis - 50 of infants. May
be asymptomatic at birth or have low birth
weight, enlarged liver and spleen, jaundice and
anemia. Complications chorioretinitis or signs
of neuologic damage may be several years
later. TX prevention and education
Group B Streptococcus (GBS) is a leading cause
of life threatening perinatal infections. 10
30 of women are colonized with GBS in the
vaginal or rectal area. Most are asymptomatic
or may include UTI, chorioamnionitis Fetal
neonatal effects early onset GBS within 7 days
of birth, usually 48 hrs. 1 2 will
develop early onset GBS, sepsis, pneumonia and
meningitis. late onset is after the first
week and meningitis is most common
manifestation. Permanent neurological
consequences may be seen in up to 50 of those
who survive
48
Group B Streptococcus (GBS) is a leading cause
of life threatening perinatal infections. 10
30 of women are colonized with GBS in the
vaginal or rectal area. Most are asymptomatic
or may include UTI, Chorioamnionitis Fetal
neonatal effects early onset GBS within 7 days
of birth, usually 48 hrs. 12 will develop
early onset GBS, sepsis, pneumonia and
meningitis. late onset is after the first week
and meningitis is most common manifestation.
Permanent neurological consequences may be seen
in up to 50 of those who survive
TX prevention, Cultures early and again at 35-37
wks. Intrapartum antibiotics, usually IV
penicillin G 5 million units initially
and 2.5 million units ever 4 hrs after until
birth OR IV ampicillin, 2 g initially
and 1g every 4 hrs until birth
49
Tuberculosis Fetal neonatal effects
perinatal infection is uncommon, may be acquired
as a result of fetus aspirating amniotic
fluid. Signs of congenital TB include TB
failure to thrive, lethargy, respiratory
distress, fever and enlargement of spleen,
liver and lymph nodes. TX for PG woman
isoniazid, pyrazinamide and rifampin every day
for 9 mos. Pyridoxine (vit B 6) should be
given with isoniazid to prevent fetal
nuerotoxicity. Some are using short term therapy
1 to 2 months of therapy, and then
twice weekly therapy TX for neonates. If moms
sputum is free of organisms, infant does not need
to be isolated from mom. Education is
vital. Skin test of newborn may be
started on preventive isonaizid therapy. Skin
testing again at 3-4 mos. If positive,
receive isoniazid for at least 6 mos. If also
have HIV should receive therapy for 12
mos. Breastfed infants of mothers taking
isoniazid should receive pyridoxine with a
multivitamin supplement
50
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51
TORCH T toxoplasmosis O other hepatitis
A hepatitis B R rubella C
cytomegalovirus H herpes genitalis
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