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)1915194019501960198319972002All 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 18Adequate prenatal care 3Poor prenatal care 5No Prenatal Care 23Leading 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 (IV’s, 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 -slapping 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 > or = 140 mm Hg • or • Diastolic blood pressure > or = 90 mm Hg • Increase of > or = 30 mm Hg in systolic pressure • 4. Increase of > 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 > or = 160 mm Hg (systolic) or • 110 mm Hg (diastolic) on two occasions at least 6 hours apart • Proteinuria > or = 5 g in 24 hours, + 3 • Oliguria > 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 ->34 weeks gestation < 28 weeks 28-32 weeks 33-34 weeks -maternal -steriods, betamethosone -amniocentesis counseling -conservative -intensive management immature or mature management

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

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 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 (>4 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 -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

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. McDonald’s procedure cerclage suture Pursestring sutures

26. Sonograms HCG levels Emotional Support

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 D&C No Pitocin until after deliver What are S&S? 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

32. What are S&S ? Pain Board like abdomen, especially is concealed. Who is high risk population ? History of abruptio Grand parity Povery PIH Advanced 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 1:3000 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 S&S? FIND CAUSE correct DIC is secondary to number of things: hemorrhage septic shock amniotic fluid embolism PIH infection diabetes

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 Willebrand’s 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

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 UTI’s , 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 Vertical 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 S&S 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 S&S 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. 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 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 mom’s 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. Congenital infection: ToRCHS syndrome • T • Toxoplasma • R • Rubella • C • Cytomegalic inclusion disease (CID, CMV) • H • Herpes • S • syphilis • transplacentally acquired • congenital infection • Celery-stalk meaphyses, esp. long bones • Intracranial calcification • Decreased growth • vascular stenosis (aorta, pulm artery)