Presentation on theme: "Mortality - death. Fetal Death: intrauterine death of a fetus of at least 20 weeks gestation with absence of any signs of life after."— Presentation transcript:
1 Mortality - death.Fetal Death: intrauterine death of a fetus of at least 20 weeksgestation with absence of any signs of life after birth.Neonatal death: death of an infant born with signs of life up to28 days after birth.Perinatal death : sum of fetal & neonatal deaths per 1000live births ** BEST indicator of perinatal careINFANT MORTALITY: the number of deaths per that occurin the first year of life.*** This the the statistic used by most countries. This is what ismost seen in the Literature ALTHOUGH is not the best indicatorof Perinatal care.Maternal Death: death of mothers per 100,000 due tocomplications of pregnancy, labor , delivery or postpartum.
2 Maternal Mortality (per 100,000 births) All Women White Women Nonwhite Women Adequate prenatal care Poor prenatal care No Prenatal Care 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 fordying from complications of pregnancy and childbirth.One half of all deaths could be prevented with early detection.No significant changes since fluctuated between 7 & 8 %.Hemorrhage, PIH, infection, and ectopic pregnancies account for mostof the deaths.Fetal mortality rate in 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 was 5.7% |Postneonatal Mortality = 2.4% ; Whites = 2.0% , Blacks = 4.4 %Taken from the last CDC statistics 1998
4 RegionalizationLevel 1 :Level 2 : IVCH, CHOLevel 3 : St. FrancisSmall group of women is high riskwith good prenatal care almost 2/3 of ALL HIGH riskproblems can be identified early and high possibility ofpreventing further complicationsOnly 23%-25% of High Risk delivered are surprisesKEY = Identification Prenatal care
6 Relationship betweenmaternal and fetalmalnutrition
7 Loss and Grief - outline Types of losses arising in perinatal period and their causesLoss of “real vs ideal” (pregnancy)-maternal or fetal demise-need for hospitalization or transport to distant site-diagnosis of fetal anomalies-intrauterine fetal demiseLoss of “normal” labor experience-development of complications-need for intervention (IV’s, oxytocin, oxygen)-need for FHM-fetal distress-need to remain in bed or analgesia or anesthesiaLoss of emotional control-screaming, crying-verbalization of anger, fear, discouragement-use of expletivesLoss of Physical Control-inability to push or inability to withstandinvoluntary urge to push-involuntary vocalizations, defecation,or urination during delivery-inability to maintain breathing orrelaxation techniques-vomiting-slapping or hitting coach or med staff-throwing objectsLoss of Natural Birth Experience-preterm birth-need for analgesia or anesthesia-need for forceps or vacuum extraction-need for cesarean delivery
8 Loss of shared experiences Types of losses arising in perinatal period and their causes continued:Loss of shared experiences-absence of father, partner, orother significant friendLoss of body image-incompetent cervix-severe edema with preeclampsia-incision from cesarean birthLoss of “real versus ideal” (Neonate-neonatal anomalies-birth injuries or asphyxia-preterm infant-need for transport to distant site-stillbirth/neonate deathLoss of self-image-maternal disease process-postpartum depressionLoss of “real vs. ideal (postpartum exper.)-maternal trauma or disease-postpartum depression-neonate unable to breastfeed due to prematurityillness, or anomaliesLoss of Self Image-maternal disease process-preterm labor or birth-fetal or neonatal deathLoss of relationships-maternal hospitalization or transport to distantsite-neonatal transport-partner withdrawn during grief process-with fetal or neonatal death, avoidance behaiorsby family or friends
9 DEFINATION OF HYPERTENSION IN PREGNANCY Systolic blood pressure > or = 140 mm HgorDiastolic blood pressure > or = 90 mm HgIncrease of > or = 30 mm Hg in systolic pressure4. Increase of > or = 15 mm Hg in diastolic pressureNOTE # 3 & 4, most of our women have lower BP to start with!
10 PEGNANCY – INDUCED HYPERTENSION Preeclampsia : Development of hypertension with proteinuria, edema orboth, induced by pregnancy after the 20th week of gestation1. Mild: Preeclampsia is considered mild unless any criteria for severeis met2. Severe: One or more of the following signs defines severe preeclampsiaBlood pressure with resting > or = 160 mm Hg (systolic) or110 mm Hg (diastolic) on two occasions at least 6 hours apartProteinuria > or = 5 g in 24 hours, + 3Oliguria > 400 ml in 24 hours, 30cc/hrCerebral / vision disturbances (e.g. altered consciousness,headache, blurred vision)Pulmonary edema / cyanosisEpigastric / right upper quadrant pain (can occasionallyprecede hepatic ruptureImpaired liver function of unknown etilologyThrombocytopenia3. Eclampsia: The occurrence of convulsions in a woman who meets criteriafor preeclampsia
11 PreeclampsiaMost women in Mild preeclampsia are not immediately hospitalized, but will keep close monitoring on maternal & fetal well being.ksagementoringtionns changeIf below 37 weeks, betamethosone – IM to mom, helps surfactant development
13 Checking for pitting edema B = + 2C = + 3D = + 4
14 or liver Watch for symptoms even in someone who is below 140/90 EnzymesRenal function
15 What is MAP ? Talking about blood pressure Mean arterial pressureMAP = DBP + 1/3 of pulse pressureA person with a BP or 120/60 has a MAP of Often used this in hyper-tensive crises, more accurate in gaging medications &/or end-organ damagePulse pressure = the difference between the systolic & diastolic pressure.It is normally about 1/3 of the systolic pressure. If BP is 120/80, the pulsepressure is 40. See increased with arteriosclerosis of the larger arteries orduring exercise. See decreased with hypovolemia.
16 Severe Preeclampsia-Admit to labor and delivery area-Maternal and fetal evaluation x 24 hoursNo Maternal Distress Yes-Severe IUGR-Fetal Distress Delivery-Labor->34 weeks gestation< 28 weeks weeks weeks-maternal -steriods, betamethosone amniocentesiscounseling -conservative-intensive management immature or maturemanagement
22 Postpartum Resolution: - brisk diruesis (150 – 300 ml / hour-IV MgSO4 until diruesis observed or usually 24 hrs-keep BP < 140/100 mm Hg-discharge with weekly follow up until BP is normalTherapeutic levels of MgSo4 are 4 to 7, toxic levels 8-10blood levels will be drawn, check DTR, resp. rateREMEMBER whenever MgSO4 is in use what drug has to benear byCalcium gluconateUterine relaxationWhat should you watch for in mom PP ?What might happen in newborn ?Remember MgSO4 is a CNSdepressant – respiratory distress,decrease in respiratory effort
23 Signs and Symptoms of Shock Remember 1202Signs and Symptoms of ShockHypovolemic Shock SIGNS:-tachypnea (deep & rapid)-tachycardia-weak, thready pulse-hypotension – late sign-narrowed pulse pressure-increased capillary fill time (>4 sec)-oligura (less than mL/ hr)-urine sodium = 80 mEq/L-cool, clammy skin-pallor and peripheral cyanosis-hypothermiaSYMPTOMSanxiety, restlessness, disorientation-thirst, dry mouth-feeling chilledSeptic Shock:-tachycardia-hyperdynamic 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
28 Hydatidform mole or a gestataional trophoblastic neoplasm Rare 1: 1000 to 2000 3 times higher in Asian women, 10% develop ChoriocarcinomaWhat is treatment?Often abort spontaneously or D&CNo Pitocin until after deliverWhat are S&S?Nausea Why?Abnormal uterine growthWhat do you have to check?Why? How often?HCG levels 1-2 wks until norm, then1-2 mos for a year.If do not drop may have to be treatedwith chemotherapyStarts as fertilization, trophoblastDegenerates & chorion proliferates
32 Who is high risk population ? What are S&S ?PainBoard like abdomen, especially isconcealed.Who is high risk population ?History of abruptioGrand parityPoveryPIHAdvanced ageSupine hypotensionShort umbilical cord – during laborTrauma to abdomenCocaine or other drug usageCigarette – some sayAlcohol abuse – some say
33 CORD INSERTION & PLACENTAL VARIATIONS: Rare less than 1:3000 May lacerate & bleed, especiallyduring L& DA = Vasa praevia or Velamentousinsertion : No wharton jellyB = Battledore placenta: cord atend of placentaC = Succenturiate placentablood vessels maybe supportedonly by fetal membranes
34 DIC or Disseminated Intravascular Coagulation What are S&S?FIND CAUSEcorrectDIC is secondaryto number ofthings:hemorrhageseptic shockamniotic fluidembolismPIHinfectiondiabetes
37 During PG, clotting factors normally increase and thrombolytic activity decreases If a condition requires some type of anticoagulant : heparin is choiceWarfarin crosses the placenta & is with fetal malformationsvon Willebrand’s disease : an autosomal dominant bleeding disorder inabnormality of vW factor which affects clotting of blood – hormonesin pregnancy may improve vW factor – but need to monitorATP – may improve slightly, but then rebound with more destructionof the platelets
39 Maternal infections1 Syphillis: may pass through placenta may result in abortion, a stillborn, pretermlabor or congenital syphillis (enlarged liver, spleen, skin lesions,rashes, oseteitis, pneumonia, hepatitisTX penicillin2 Chlamydial infection (#1 STD in US) : fetus may be infected during birthand suffer neonatal conjunctivitis or pneumonitis, which manifestsat 4-6 wks of age PROM , chorioamnionitis, preterm laborTX erythromycin or amoxicillin (mom)3 Gonarrhea: fetus may be infected during birth – ophthalmia neonatoriumendocervicitis = PROM and preterm labor4 Condyloma acuminatum or genital warts (human pailliomavirus): fetus may beinfected during vaginal birth and develop epithelial tumors of themucous membranes of the larynx in children. PG can cause proliferationHPV associated with cervical dysplasia & cancer (see next slide)5 tichomoniasis basically associated with PROM and postpartum endometritis
40 Venereal warts orCondylamata acuminataHuman papillomavirus HPVMost common viral STD3 times greater than herpesCauliflower like appearance
41 Maternal vaginal infections Vaginal candidiasis: fetus may be infected during vaginal birthoral candidiasis (thrush) TX for infant MycostatinTX for mom Monistat, Terazole, FemstatMost say treat for at least 7 daysPROM, preterm labor, low birth weight, postpartum endometritisUTI’s , cycstitis, acute pyelonephritisPROM, preterm labor
42 Viral infections remember most virus passes placental barrier Cytomegalovirus: a member of herpesvirus group. Infects most humanspeak ages 15 to 35 yrs. Like most herpes after primary infection, lies latentwith periodic reactivation and shedding of the virus.Fetal & neonatal effects: 2% of all live births may be infected. Theseinfants shed the virus from the nosopharynx and urine for several yrs.Most severe effects: deafness, mental retardation, seizures, blindness& dental bnormalitiesTX: gancyclovir for TX of congenitally infected infantsNo screening yet availableRubella: up to 10% of adults remain susceptibleFetal & neonatal effects: greatest risk is first 3 ms. 1/3 will result inspontaneous abortion, surviving maybe seriously compromised –deafness, mental retardaation, cataracts, cardiac defects, IUGRand mirocephaly. Infants will shed the virus for many monthsTX: prevention, A titer of 1.8 or greater provides immunityRubella 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 & varicellapneumonia. 5 –15% of aduls in US are susceptibleFetal & 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 whois infected 4-6 days or 2 days after birth will not have the benefitof maternal antibodies, leaving the infant at risk for life-threateningneonatal varicellaTX: immune testing, varicella-zoster immune globulin should be administeredto women who have been exposedTX: 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 aftereach 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 atpainful papules that progress to vesicles, shallow ulcers, pustules, crusts.Virus is shed until completely healed.lies latent in the sensory ganglion which can be reactivatedVertical transmission from mom to infant generally occurs: 1 after rupture ofmembranes or 2 during vaginal birth or with fetal scalp electrodeFetal & neonate effects: Primary infection in first 20 weeks : spontaneousabortion, IUGR and preterm labor.Neonatal herpes is uncommon but potentially devastating. From skinlesion to systemic or disseminated. If systemic death rate or serioussequelae is 50% . Watch for infection S&S temp instability, lethargy,poor sucking, jaundice, seizure & herpetic lesions.TX: no known cure although antiviral chemotherapy (acyclovir) Category CMay breast feed if no lesions are on breast
45 Parvovirus: or erythemia infectiosum or fifth disease. highly communicable characterized by “slapped cheeks” appearancefollowed by a generalized maculopapular rash, fever, malaiseand joint pain.Titers can be drawn if exposure during PGFetal & neonate effects: I/4 to 1/3 of fetuses infected will have transientadverse effects, fetal death rate is less the 5%. Death usually results formfailure of fetal RBC production, fetal anemia, hydrops (edema)and heart failureHepatitis B : more likely to occur in person with STD, IV drug users & somepopulation groups, Asians, Native Americans, Eskimos, SoutheastAsian and subSaharan African immigrants. Chronic Hepatitis Bdevelops in 1 to 6 % of infected adults who are at a greater risk forchronic liver disease, cirrohosis of the liver, premary hepatocellularcarcinomaFetal & neonatal effects: prematurity, low birth weight, and neonataldeath 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 trimesterIf mom is known GBsAg positive usually infection of the newborn can beprevented by administration of hepatitis B immune globulin followedby hepatitis B vaccine. Vaccine should be repeated at 1 and 6 mos.Breastfeeding is considered safe as long as the new born has been vaccinatedHIV – human immunodeficiency virus.Fetal & neonatal effects: without prophylactic TX (Zidovudine) has a 20-30%of developing the disease. Typically are asysmptomatic at birth but S&Sduring first 12 mos. Enlargement of liver, spleen, lymphadenopathy, failureto thrive, persistent thrush, extensive seborrheic dermatitis or cradle cap.TX: prevention prenatal periodintrapartum period (cesarean birth ? )postpartum period (no breastfeeding)With Zidovudine throughout PG and L & D. infant TX with zidovudine syrupmay test positive at birth but only 2% will remain positiveIf 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 fecescrosses the placental barrier. Flu like symptoms in mom.Can do serologic testFetal and neonatal effects: spontaneous abortion or live birth with congenitaltoxoplasmosis - 50% of infants. May be asymptomatic at birth or havelow birth weight, enlarged liver and spleen, jaundice and anemia.Complications chorioretinitis or signs of neuologic damage may beseveral years later.TX: prevention and educationGroup B Streptococcus (GBS): is a leading cause of life threatening perinatalinfections. 10 – 30% of women are colonized with GBS in the vaginalor rectal area. Most are asymptomatic or may include UTI,chorioamnionitisFetal & 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 whosurvive
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, ChorioamnionitisFetal & 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 surviveTX: prevention, Cultures early and again at wks.Intrapartum antibiotics, usually IV penicillin G 5 million units initiallyand 2.5 million units ever 4 hrs after until birth ORIV ampicillin, 2 g initially and 1g every 4 hrs until birth
49 Tuberculosis:Fetal & neonatal effects: perinatal infection is uncommon, may be acquiredas a result of fetus aspirating amniotic fluid. Signs of congenital TB includeTB failure to thrive, lethargy, respiratory distress, fever and enlargement ofspleen, 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 fetalnuerotoxicity. Some are using short term therapy – 1 to 2 months oftherapy, and then twice weekly therapyTX for neonates. If mom’s sputum is free of organisms, infant does not need tobe isolated from mom. Education is vital. Skin test of newborn – maybe 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 shouldreceive therapy for 12 mos. Breastfed infants of mothers taking isoniazidshould receive pyridoxine with a multivitamin supplement