Maternal Morbidity and Mortality

Question 1

What % of maternal deaths are direct and what % are indirect?

Answer 1

32% direct, 68% indirect

Question 2

What are direct (pregnancy induced condition) causes of maternal mortality?

Answer 2

1) Thrombosis - PE
2) Sepsis (genital tract)
3) Haemorrhage
4) Pre-eclampsia (hypertensive disorders of pregnancy)
5) Amniotic fluid embolism
6) Early pregnancy deaths
7) Anaesthesia

Question 3

What are indirect causes (pregnancy may have exacerbated a condition not caused by pregnancy) of maternal mortality?

Answer 3

1) Cardiac disease
2) Sepsis (influenza, pneumonia)
3) Neurological (epilepsy, stroke) - 11%
4) Psychiatric causes (⅔ die from a mental health condition)
5) Cancer

Question 4

What percentage of maternal deaths are from a cardiac cause?

Answer 4

23% - never make the assumptions that symptoms are just caused by pregnancy

Question 5

What are cardiac causes of persistent breathlessness or chest pain that can just be put down to pregnancy?

Answer 5

1) MI
2) Cardiomyopathy
3) Aortic dissection
4) Valvular heart disease
5) Sudden arrhythmic death syndrome

Question 6

What is an urgent neurological situation in pregnancy?

Answer 6

• Worsening epilepsy

- First seizure in pregnancy

Question 7

Should you stop neurological medication in pregnancy?

Answer 7

No

Question 8

How can mental health problems in pregnancy be handled?

Answer 8

1) Pay special attention to women with complex social backgrounds, a history of substance abuse or pre-existing mental health problems
2) If communication is difficult, enlist the help of an interpreter

Question 9

What investigations/treatments for PE are safe in pregnancy?

Answer 9

• CXR

- LMWH, thrombolysis

Question 10

What investigation to exclude a PE is not safe or useful in pregnancy?

Answer 10

D-dimer
- Pregnancy is known to increase the D-dimer concentration above the conventional normal threshold of 0.50 mg/L, leading to an increased false-positive D-dimer test when VTE is clinically suspected in a pregnant patient

Question 11

What extra letter is added onto the ABCDE approach and why?

Answer 11

F - fetus, aortocaval compression

Question 12

What happens to airways in pregnancy?

Answer 12

They vasodilate - oedematous

Question 13

How is blood glucose level in pregnancy different?

Answer 13

> 5.3 glucose not normal, but baby needs more sugar

Question 14

What should you do if a pregnant woman faints?

Answer 14

Sit them up and move the uterus (aortic compression)

Question 15

What should you do if a pregnant woman has a heart attack?

Answer 15

Remove the baby after a certain amount of time

Question 16

What type of X ray should you not to in pregnancy?

Answer 16

Abdominal

Question 17

What is the maximum recommended radiation exposure in pregnancy?

Answer 17

50,000 mGy

Question 18

What investigations give low fetal radiation doses in pregnancy?

Answer 18

1) CXR - < 10 mGy
2) Perfusion scan - 60-120 mGy
3) Ventilating lung (technetium 99m) - 10-350 mGy
4) CTPA - < 500 mGy

Question 19

What can pregnancy symptoms mask?

Answer 19

Pathology

Question 20

What is the three delay model?

Answer 20

1) First delay is related to the recognition by women and families of the need to seek care
2) Second delay is related to accessing care - referral chain between facilities, barriers in the community (physical, cultural or financial), thinking it’s not important
3) Third delay is related to receiving appropriate care in the facility

Question 21

What is a maternal death?

Answer 21

Death during or up to 6 weeks after the end of the pregnancy

Question 22

What is a ‘late’ maternal death?

Answer 22

Covers the period from 6 weeks postpartum until 12 months after the end of the pregnancy

Question 23

When may women present with a pre-existing disease?

Answer 23

In pregnancy

Question 24

What are risk factors for direct maternal death?

Answer 24

1) Medical comorbidites
2) Previous pregnancy problems
3) Hypertensive disorders of pregnancy
4) Inadequate use of antenatal care
5) Indian ethnicity
6) Substance misuse

Question 25

What makes a women at a higher risk of dying in pregnancy?

Answer 25

1) Afro-Caribbean origin

2) Older

Question 26

What is a risk factor for blood clots incl. in early pregnancy?

Answer 26

Overweight or obesity

Question 27

What symptom is not normal in pregnancy and may mean there are heart problems?

Answer 27

Persistent breathlessness when lying down (orthopnoea)

Question 28

What type of chest pain may be cardiac?

Answer 28

Severe chest pain spreading to the left arm or back

Question 29

How do you detect pre-eclampsia?

Answer 29

• Check BP and urine at every antenatal visit
• Pre-eclampsia can be asymptomatic even when BP is high and there is heavy proteinuria with low platelets and high liver enzymes

Question 30

When do most pregnancy related deaths occur?

Answer 30

After delivery (not before or during)

Question 31

Where do most pregnant women die?

Answer 31

In hospital (bc most women give birth in hospital)

Question 32

Can you give the flu vaccine in pregnancy?

Answer 32

Yes bc it is not live

Question 33

What type of vaccines can you not give in pregnancy?

Answer 33

Live vaccines

Question 34

What is a maternal near miss?

Answer 34

A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy (either bc of good care or good luck)

Question 35

Why are women seen more frequently near the end of pregnancy?

Answer 35

Events are more likely to happen near and at term so see women more frequently to prevent them from happening

Question 36

What do you do if a mother is Rh negative?

Answer 36

If Rh negative then get RhoGAM injection which is Rho(D) immunoglobulin at 28 weeks and within 72h of birth

Question 37

Should a women be encouraged if she wants to measure her own BP during pregnancy?

Answer 37

Yes

Question 38

What is the test for gestational diabetes offered to at risk women?

Answer 38

• 75g 2hr oral glucose tolerance test at 24-28 weeks
• Do NOT use fasting plasma glucose, random blood glucose, HbA1c, glucose challenge test or urinalysis for glucose to assess risk of developing gestational diabetes