M&M

Question 1

Lifetime risk of maternal death

Answer 1

the probability that a 15y old woman will eventually die from a maternal cause:

• High income countries = 1 in 5400
• Low income countries = 1 in 45

Women in less developed countries have, on average, many more pregnancies
94% of maternal deaths occur in low-resource settings

Question 2

Maternal mortality ratio from three years from 2014 to 2016

also definition

Answer 2

9.4/100,000 births at >20/40 (NZ)

Number of maternal related deaths per 100,000 maternities
Term ‘ratio’ is used to describe ‘incidence’ of maternal mortality because cases included in the numerator may arise from pregnancies that end before 20/40
- Total number of pregnancies ending <20/40 is unknown, therefore is an estimate and cannot be truly called an ‘incidence’

Question 3

Maternal death definition

Answer 3

Death of a woman while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of the pregnancy, from any causes related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes

Question 4

Direct vs. indirect death definition

Answer 4

DIRECT
Death resulting from complications of the pregnant state (pregnancy, labour, puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above
- suicide
- AFE
- Hypertensive disorders
- Obstetric haemorrhage
- Pregnancy-related infection
- VTE

INDIRECT
Death resulting from pre-existing disease, or disease that developed during pregnancy and which was not the result of direct obstetric causes, but was aggravated by the physiological effects of pregnancy
- Cardiac
- Neurological
- Infections not a direct result of pregnanc

Question 5

Coincidental death definition

Answer 5

Death from unrelated causes that happens to occur in pregnancy or the puerperium
E.g. motor vehicle accidents

Question 6

Late death definition

Answer 6

Death occurring between 42 days and one year after the end of pregnancy that is the result of direct or indirect maternal causes

Question 7

Pregnancy-related death

Answer 7

The death of a woman while pregnancy or within 42 days of termination of pregnancy, irrespective of the cause of death
New category to facilitate the identification of maternal deaths in circumstances in which cause of death attribution is inadequate

Question 8

What is the leading cause of maternal death in NZ?

Answer 8

Maternal suicide
- 2006-18 - 44% direct maternal deaths

Maori women over-represented (57%) and those <20y
Most of the women experienced multiple risk factors - therefore area for intervention

Current social situation
Previous / current experience of family violence, sexual abuse and assault
Hx of TOP or miscarriage in previous 12 months
PMHx: mental illness

Reclassified as direct rather than indirect

• Difficult to classify as very mixed group of clinical histories - e.g. postpartum psychosis to those with PMHx of mental illness and multiple stressors
• Reporting as direct will increase the apparent direct maternal mortality ratio, but without any change to the underlying number of deaths
• Consistent with other countries, therefore able to directly compare data
• Raises awareness of suicide

Question 9

PMMRC Recommendations to lower maternal death

Answer 9

Maternal and infant network funded by the MoH
- which includes a review of current mental health services and a national pathway for accessing maternal mental health

Measures to lower risks (not from PMMRC)

• Recognise high risk groups
• Professional interpreters
• MDT
• Dedicated obstetric anaesthetists
• Pre-conception counselling
• EWS

Question 10

Stillbirth rate

• definition
• rate from PMMRC 2018

Answer 10

The number of stillbirths per 1000 livebirths and stillbirths (total births)

5.3 per 1000 total births

Question 11

Perinatal mortality rate

• definition
• rate from PMMRC 2018

Answer 11

fetal deaths (>20/40 or >400g) and early (<7 days) neonatal deaths per 1,000 total babies born alive or born dead at >20 weeks’ gestation or >400g

9.5 per 1000

Question 12

Perinatal related mortality

• definition
• rate from PMMRC 2018

Answer 12

Fetal deaths (including TOP and stillbirths) and neonatal deaths (up to 28 days) per 1,000 total babies born at 20+ weeks, and weighing >400g if gestation was unknown

10.2 per 1000

Question 13

Neonatal mortality / death rate

• definition
• rate from PMMRC 2018

Answer 13

Number of neonatal deaths per 1000 live born babies

2.6 per 1000

Question 14

Causes and risk factors for perinatal mortality

Answer 14

Deaths due to congenital abnormalities remain the leading cause of death overall

Groups at higher risk of serious adverse outcomes:

• Maori mothers
• Pacific mothers
• Indian mothers
• Babies of mothers <20y or >40y
• Babies of mothers living in the most deprived areas (quintile 5)
• Increased maternal BMI
• Babies of mother’s who were smokers at booking visit with LMC

41% of babies who died had optimal investigation into the cause(s) of their death

Question 15

Reducing stillbirth - Safer Baby Bundle

Answer 15

Smoking cessation
FGR
- Risk assessment and surveillance for FGR
Decreased FM
- Raise awareness and improve care for women with RFM
Side sleeping ( from 28/40)
Timing of birth
- Improve decision making about timing of birth in women with risk factors for stillbirth

Question 16

Global interventions to reduce the global burden of stillbirth

Answer 16

1. Periconceptual folic acid supplementation
2. Prevention of malaria
3. Detection and treatment of syphilis
4. Detection and management of hypertensive disorders of pregnancy
5. Detection and management of diabetes in pregnancy
6. Detection and management of FGR
7. Routine IOL to prevent post-term pregnancies
8. Skilled birth attendant
9. Availability of basic emergency obstetric care
10. Availability of comprehensive emergency obstetric care

Question 17

Investigations for stillbirth

Answer 17

Comprehensive maternal history to accompany baby for post-mortem:

• Clinical / obstetric history
• Copies of all USS reports
• Copy of death certificate

Kleihauer-Betke test / Flow cytometry for fetal to maternal haemorrhage
External examination of the baby
Clinical photographs of the baby
Detailed macroscopic examination of the placenta and cord
Placental histopathology
Cytogenetics

Options:

• Full autopsy
• Less invasive autopsies
• Alternatives - x-ray/MRI

Selective investigations based on findings of core investigations:

• congenital infections
• blood group and antibody screen
• thrombophilia screen
• HbA1c

Question 18

Justifications for non-invasive investigations to stillbirth

Answer 18

~25% of stillborn infants were found to have demonstrable abnormalities on external exam
photographs critical in 5% of cases - for later review
X-ray - to detect skeletal abnormalities
MRI - Can be useful for intracranial abnormalities

Question 19

Justifications for placental exam for stillbirth

Answer 19

Offer sampling of cord and placental tissue for chromosomal analysis (if the placenta is not being sent to for pathology)
Send fresh and unfixed for macroscopic and histological examination
Take photos of an entangled cord first, if present
May find contributing cause in 11-65%
Cytogenetics
- to check for chromosomal abnormalities

Question 20

Autopsy justification

Answer 20

PM has the highest diagnostic yield of all investigations
Provides classification of death in 45%
Important information that affected management of next pregnancy elicited in 10% of stillborn infants with no recognisable cause of death from other clinical or laboratory investigations

Identify an accurate cause of death
Exclude some potential causes of death
Provide other information related to the death, including excluding possibilities that may alleviate feelings of guilt
Obtain tissues for genetic test
Assist grieving by helping parents’ understanding of the events surrounding the death
Contribute to research
Inform clinical audit of perinatal deaths
Teach pathologists and medical students
Inform medico-legal processes

Possibility that cause of death may not be determined
The care and respect that will be given to the baby

Question 21

Sonographic findings of IUFD

Answer 21

No blood flow with colour doppler
Overlapping skull bones (Spalding sign)
Fetal skin oedema
Hydrops
Maceration 
Intrafetal gas within the heart, blood vessels, joints

Question 22

Management of IUFD

Answer 22

Vaginal birth can be achieved within 24h of induction of labour with IUFD in ~90% of women
First line - mifepristone and prostaglandin preparation / misoprostol
Risk factors for uterine rupture:
- Previous CS
- Previous uterine surgery
- Parity >5

1 prev CS
- IOL with prostaglandin is safe but not without risk
- Misoprostol can be used
2 prev CS - absolute risk is only slightly higher than those with 1 prev CS
>2 prev CS - safety of IOL is unknown

Suppression of lactation
Follow up

Question 23

Stillbirth

Answer 23

The birth of an infant of at least 20 weeks’ gestation, or if the gestation is unknown, weighing at least 400g at birth, with no signs of life after birth

Note that the period of gestation when the fetus is delivered and not when the fetus ceases to live is the gestation of the stillborn

Question 24

Preterm birth

Answer 24

Babies born alive before 37 weeks of pregnancy are completed

- <28 weeks = extremely preterm
- 28-32 weeks = very preterm
- 32-37 weeks = moderate to late preterm

Question 25

Infant death

Answer 25

Death of an infant before his / her first birthday

Question 26

In 2000, a United Nations initiative involved the development of eight international goals, known as The Millennium Development Goals (MDG). The aim is to achieve these goals by 2015.

• what are the 2 targets,
• what are nominated measureable indicator for each target.

Answer 26

Reduce by 3/4 , between 1990 and 2015, the maternal mortality ratio

• Maternal mortality ratio
• Proportion of deliveries attended by skilled health personnel

Achieve, by 2015, universal access to reproductive health
- Contraceptive prevalence rates

Question 27

) major avoidable causes of maternal death in developing countries and discuss solutions for each cause.

Answer 27

PPH

• Births attended by skilled health professionals
• Active management of third stage

Pregnancy related infection / sepsis

• Births attended by skilled health professionals
• Good hygiene practiced
• Sterile equipment
• Early infection treated
• Access to antibiotics, IVF, vaccinations

Hypertensive disorders / eclampsia

• Structured antenatal care which incorporates screening for hypertensive disorders and education to women
• Access to MgSO4 IV and anti-hypertensive medications

Obstructed labour / complications from delivery

• Births attended by skilled health professionals
• Early recognition of labour dystocia
• Access to oxytocin for augmentation
• Facilitate transfers to hospital
• Access to safe CS
• Education and training for midwives

Unsafe abortion

• Readily available contraception to prevent unwanted pregnancies
• Education about abortion providers and the risks of unsafe abortion
• Provision of safe abortion services to the full extent of the law
• Quality post-abortion care