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Maternal and Perinatal Morbidity and Mortality - Coggle Diagram
Maternal and Perinatal Morbidity and Mortality
Maternal Death Definition
Female death from any cause related to or aggravated by pregnancy or its management (exluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy irrespective of the duration and site of pregnancy (includes ectopic pregnancies, miscarriages, termination of pregnancis)
Classification
Direct Maternal Death
Results from
obstetric complications of the preganacy state
(pregnancy, labour and peurperium) and from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above eg VTE, eclampsia, haemorrhage
Indirect Maternal death
Resulting from previous existing disease(s) that developed duing pregnancy and not due to direct obstetric causes but were
aggravated by the physiological effects of pregnancy
eg cardiac disease, malignancy, neurological condition
Late Maternal Death
Death of a woman from
direct or indirect obstetric causes
more than
42 days
and up to
one year
after termination of a pregnancy
Coincidental
Deaths from unrelated cuases which
happen to occur
in pregnancy or puerperium
eg road accident, trauma
Epidemiology
IRE: 6.3 / 100,000 live births
Maternal Mortality Rates (MMR)
Based on maternal deaths due to direct or indirect causes
Calculated using data of women giving birth to a livebirth or stillbirth with birth weight of 500g or more
Maternal Mortality Rate
No pregnancy related deaths per year / no women of repoductive age alive that year
Maternal Mortality Ration
Compares no pregnancy-related deaths to number of births in a period
Indicates risk once a woman becomes pregnant
Causes of Maternal Death 2019-2021
Direct
Psychiatric - suicide
Thrombosis and thromboembolism
HTN / Eclampsia
Ruptured ectopic
Indirect
Cardiac
Dissection of aorta
Sudden arrhythic death sydndrome
Neurological
Epilepsy
Upper cervical cord injury secondary to fall
Other
Spontaneous intraperitoneal haemorrhage
Thrombotic microangiopathy
Coincidental
RTA
Late
Suicide
Malignancy
VTE
Cerebral haemorrhage
RTA
Overview
Cardiac disease single larges causes
Suicide leading cause of direct and late causes
Thromboembolism leading direct cause
Global Causes
Major complications account for 75%
Severe haemorrhage (PPH)
Sepsis (postpartum)
HTN (PET & eclampsia)
Complications from delivery
Unsafe abortions
Risk Factors
Pre-existing health conditions
CVD, asthma, immune compromise
Advanced maternal age
≥ 2 previous deliveries
Smoking
Anaemia
Multiple pregnancy
Complications
PET, GDM
Racial, ethnic socioeconomic
Confidential Maternal Death Enquiry in Ireland Report (MDE)
Aim
Investigates why some women die during or shortly after pregnancy
To learn how maternal deaths might be avoided in the future
Focus is NOT on attributing blame but on improving future mothers’ care
Provides update on mortality data in IRE
Method
MDE
Analyses and publishes surveillance data on maternal mortality occurring in Ireland independently
MBRACE-UK
(Mothers and Babies: Reducing Risk
through Audits and Confidential Enquiries
Entered into an agreement with MDE Ireland and includes detailed confidential enquiries into the care of the women who died during or after pregnancy in Ireland
Identification
Nationwide reporting to MDE Ireland by:
Maternity unit of woman
General hospitals, coroners, pathologists, GPs, other HCP
Confidential enquiry once reported
MDT in IRE and UK
Assessment of Quality Care
Role of assessors is to identify quality of care given according to criteria set by MBRRACE-UK:
Good care: NO improvements identified
Improvements in care, identified which would have made NO difference to outcome
Improves in care identified which would have made a difference to outcome
Most Recent Enquiry
Non significant increase in overall maternal death rate between 2016-2018 and 2019-2021
Nearly 4x difference in maternal mortality rates for women from Black ethnic background
Nearly 2x difference amongst women of Asian background
When compared to white women
12% of maternal deaths were at severe and multiple disadvantage - mental health diagnosis, substance use, domestic abuse
Deprived areas have highest maternal mortality rates
CVS disorders, thromboembolism, and thrombosis are responsible for same number of deaths in UK followed by psychiatric disorders
Perinatal Morbidity / Mortality definitions
Stillbirth
A child born weighing 500g or more having a gestational age of
24 weeks
or more who shows no signs of live
Early neonatal death
Death of a live born baby occuring
within 7 completed days
of birth
Late neonatal death
Death of a live born baby occuring
after the 7th day within 28 completed days
of birth
Miscarriage
Spontaneous loss of pregnancy
before 24 weeks
gestation
Congenital abnormalities
Physiological or structural abnormalities that develop at or before birth and are present at time of birth
Perinatal Mortality Rate (PMR)
PMR
No. Stillbirths and early neonatal deaths x 1000 / total number of live births and stillbirths
Corrected / Adjusted perinatal mortality rate
No. Stillbirths and early neonatal deaths x 1000 / Total no. of live births and stillbirths
Exluding severe congenital abnormalites & severe prematurity
Perinatal Mortality Epidemiology In Ireland / Globally
Ireland
Relatively high risk
5.5 / 1000
Stillbirths 3.6 / 1000
Early neonatal death 1.9 / 1000
Perinatal mortality rate 5.5 / 1000
Corrected for major congenital anomaly (MCA) perinatal mortality 3.9 / 1000
Globally
40-60% of perinatal mortality occurs within first 7 days of life
Nearly 8 million a year
Risk Factors for Perinatal mortality
<17 or over >40
Asian or afro-caribbean
Medical conditions: HTN disorders, DM, intrahepatic cholestasis of pregnancy
Smoking
Recreational drug use
Alcohol
Lower socioeconomic status
Poor nutrition
Grand multiparity
Obesity
Pregnancy continuing beyond 41 weeks
Causes of Perinatal Mortality
Stillbirths
Unkown
Placental
Cord
Infection
Congenital abnormality
Fetal
Neonatal
Preterm birth
SGA / low birth weight
Neurological
Infections
Congenital abnormality
Stillbirth
Definition
A child born weighing 500g or more ore having a gestational age of 24 weeks or more who shows no signs of life
Detemining Signs of Life
1 or more persistent visble signs
Easily visible heartbeat
Definite movement of arms and legs
Breathing, crying, or sustained gasps
Visble cord pulsation
Causes
No specific cause in 1/2 of stillbirths
If there is a cause - can influence care in a future pregnancy
Management
Conisderations
Individual blifs
Culture / religious beliefs should be respected - should no be pressured into postmortem consent
Foetal karyotyping
Written consent
6% of stillbirths have chromosomal abnormality
Specimens : Skin, cartilage, placenta
Cytogenetic testing
Perform in all cases of stillbirth
Conventional Postmortem
Offer to all
Highest diagnostic yield of all investigations
Exam components
Birth weight
Histology of relevant tissues
Skeletal x-rays
Pathology of cord / membranes / placenta
Should be recommended even if postportem exam is not requested
Placental patholgy should be offered even if postmortem is declines
Lactation suppression
Should be offered
Councelling
Offered to women and partners
Follow up
Hx of stillbirth clearly marked on file
Arrange follow up with named obstetrician
Seen within 3 months to discuss results
Pregnancy after Stillbirth
↑ Risk of stillbirth
Managed by obstetrician
Book early