maternal mortality and morbidity in pregnancy

Question 1

what do we mean by indirect maternal mortality?

Answer 1

woman has an underlying pre-existing medical condition and this is exacerbated by pregnancy leading to maternal death

Question 2

what are some causes of direct maternal mortality?

Answer 2

PPH
Sepsis
amniotic fluid embolism

Question 3

what are some common causes of indirect maternal mortality?

Answer 3

underlying cardiac conditions

pre-existing psychiatric causes

Question 4

what do we mean by direct maternal mortality?

Answer 4

maternal mortality related to obstetric complications

Question 5

what are some things we need to consider with maternal resuscitation during pregnancy?

Answer 5

Lateral tilt to prevent aortocaval compression and supine hypotension

pregnant women have increased blood volume (CO increases) meaning that there is increased volume for resuscitation drugs

pregnant women are at increased risk of aspiration due to relaxed LOS

pregnant women have decreased functional reserve capacity but increased basal metabolic requirements and so are more inclined to become hypoxic rapidly–> hence needs adequate ventilation!

alpha and beta agonist drugs e.g. adrenaline and noradrenaline may reduce uteroplacental perfusion

Question 6

why is pre-existing pulmonary hypertension bad in pregnancy?

Answer 6

decreased systemic vascular resistance will increase R to L shunting

Question 7

what are the worst cardiac lesions to have when pregnant and their maternal mortality rates?

Answer 7

pulmonary hypertension- up to 50% mortality
cyanotic heart disease- up to 50% mortality
NYHA 3 and 4- 15% mortality
AS/MR- 15% mortality

Question 8

what are some pre-pregnancy counselling things that we need to consider in a female with CV disease wishing to become pregnant?

Answer 8

• Ix: Echo, ECG, seek cardiac opinion
• Assess functional cardiac status using the NYHA 1-4
• Advise on prognosis for pregnancy
• Consider whether the lesion has genetic basis and can be inherited by offspring
• Consider anticoagulation issues
• Discuss spontaneous bacterial endocarditis prophylaxis
Optimise management of arrhythmia and cardiac failure

Question 9

Describe the New York Heart Association categories?

Answer 9

1= Asymptomatic
2= SOB on exertion; slight limitation of activity
3= SOB on minimal exertion +/- chest pain, palpitations etc
4= SOB on rest

Question 10

what is the risk of women with mitral stenosis who are pregnant and why?

Answer 10

risk of acute APO

MS–> long diastolic filling time

• -> affected by increased HR (tachycardia)
• -> hence aggravated by pain and anxiety during labour/pregnancy

Question 11

what anticoagulation issues do we have with pregnant women?

Answer 11

women who have prosthetic valves and on warfarin need to be considered prior to pregnancy.

Warfarin is teratogenic in pregnancy so they may need to be switched to low molecular weight heparin

Question 12

how might we manage a woman during labour who has a known cardiac condition?

Answer 12

1. Vaginal delivery better overall
2. Ensure haemodynamic stability as best as you can- e.g. IV lines for fluid resuscitation, watching fluids, feet positioned below the heart, slow onset epidural, forceps or suction to reduce maternal pushing
3. Continuous maternal and fetal monitoring
4. Antibiotics for SBE prophylaxis
5. Syntocicin for third stage of labour to augment contractions

Question 13

what are some post labour practice points we need to consider in a woman who has a known cardiac condition?

Answer 13

Monitor closely for APO
Slow oxytocin infusion to prevent postpartum haemorrhage
Early ambulation
Contraception

Question 14

what are the two most common causes of maternal mortality worldwide?

Answer 14

perinatal infection and haemorrhage

Question 15

a woman at 8 weeks gestation is diagnosed with a PE. what is your ongoing management and initial ix for PE?

Answer 15

CTPA for PE diagnosis

1. Perform a thrombophilia screen
2. Commence her on enoxaparin throughout pregnancy and counsel her on the risk of APH and other bleeding
3. Manage as high risk pregnancy under tertiary hospital model of care. Frequent antenatal reviews and fortnightly u/s growth scans to assess fetal growth.
4. Aim for planned induction at 38-39 weeks.
5. At labour withhold LMWH prior to induction and throughout labour. TED stockings, encourage mobilisation. Continuous CTG monitoring throughout labour.
6. Anticipate PPH and active 3rd stage management.
7. Recommence anticoagulation 12 hrs postpartum and refer for ongoing haematological follow up.

May commence warfarin instead during the postpartum period/breastfeeding period if indicated

Question 16

a lady has a history of significant PPH in previous pregnancies. How might we manage her during her current pregnancy?

Answer 16

1. Anticipate PPH
2. Ensure adequate staff present—anaesthetist, obstetrician, midwives
3. Preparation: establish IV access (2 large bore cannulae), give maintenance fluids, test blood group and cross-match blood
4. Give syntometrine IM injection with delivery of anterior shoulder
5. Get equipment ready for PPH management: PPH trolley, oxygen masks, IDC, IV fluids, misoprostol, oxytocic
6. Perform active management of 3rd stage of labour:
   - Administer prophylactic oxytocic (syntocinon/ergometrine/syntometrine)—syntometrine IM injection
   - Cord Mx: clamp cord early, perform controlled cord traction
   - Stimulate uterine contraction—massage (rub up) fundus
   - Empty bladder
7. Ensure complete removal of placenta and membranes
8. Document blood loss and observe for continued bleeding—if >500 ml with vaginal birth (or >1000mL with caesarean birth)- manage as primary PPH