Maternal Mortality and Morbidity

Question 1

What is maternal mortality?

Answer 1

Women who died during or within 42 days of the end of pregnancy

Question 2

Top causes of maternal deaths

Answer 2

-Psychiatric
-Cardiac disease
-Covid-19
-Thrombosis and thromboembolism (direct)
-Neurological (seizures)
-Sepsis
-Indirect causes
-Haemorrhage (direct/ indirect)
-Amniotic fluid embolism
-Pre-eclampsia
-Malignancy
-Anaesthesia

-Massive racial disparity: more black women deaths

Question 3

Risk factors for pre-eclampsia

Answer 3

-First pregnancy
-Age 40+
-Multiple pregnancy
-Pregnancy interval of more than 10 years
-BMI of 35+
-FHx

Question 4

Management of pre-eclampsia

Answer 4

-Antihypertensives if sustained systolic BP of 140+/ sustained diastolic BP 90+
-Target: 135/85
-Aspirin (75-100mg)

Question 5

Risk factors for heart disease

Answer 5

-Older age
-Smoking
-Obesity
-Diabetes
-Hypertension/ pregnancy hypertensive disorders
-FHx premature coronary disease
-Hypercholesterolaemia

Question 6

Neurological investigations in pregnancy

Answer 6

-Neurological examination including fundoscopy mandatory in women with new onset headaches/ headache with atypical symptoms

-Red flags:
=Sudden-onset/ thunderclap
=Takes longer than usual to resolve or persists more than 48 hrs
=Associated symptoms: fever, seizures, focal neurology, photophobia, diplopia
=Excessive use of opioids

Question 7

Red flags in mental health

Answer 7

-New thoughts feelings that make you feel disturbed or anxious
-Suicidal thoughts
-Sleep struggles
-Feeling estranged/ cannot cope/ incompetent
-Getting worse?

Question 8

Direct causes of maternal death

Answer 8

-VTE
-Psychiatric
-Sepsis (Covid)
-Eclampsia
-Amniotic Fluid Embolism
-Early pregnancy problems
-Haemorrhage
-Anaesthesia

Question 9

Indirect causes of maternal death

Answer 9

-Cardiac
-Neurological
-Psychiatric
-Cancer
-Sepsis

Question 10

VTE physiology

Answer 10

-Hypercoagulable state (1st trimester until 6 weeks PP)
-Increase factors 8,9,10, fibrinogen, prothrombin
-Decreased fibrinolytic activity, endogenous anticoagulants (antithrombin and protein S)
-Venous stasis in lower limbs associated with vasodilatation and decreased flow

Question 11

Epidemiology of VTE in pregnancy

Answer 11

-Leading direct cause
=1 per month of PE
-85% DVT (left sided)
-72% iliofemoral (vs 9% non-pregnant): compression of vein by gravid uterus
-Long term morbidity from post thrombotic syndrome in up to 23% reduced to 11% if compression stockings worn for 2 years

Question 12

Risk factors for VTE

Answer 12

-Obesity
-Age>35
-FHx
-High parity
-Previous VTE
-Immobility
-Pre-eclampsia
-Psychiatric illness and learning disabilities
-Gynae: fibroids
-Varicose veins
-Thrombophilia
-Infection
-C section (emergency especially)

Question 13

Long term sequelae in VTE

Answer 13

-Recurrent DVT x4
-Post thrombotic syndrome
-Pulmonary hypertension

Question 14

Symptoms of VTE in pregnancy

Answer 14

-Asymptomatic
-Classical features unreliable: leg oedema asymmetrical and calf pain common without DVT
-Lower abdominal pain
-Breathlessness, pleuritic pain, cough, haemoptysis
-Collapse

Question 15

Diagnosis and management of VTE in pregnancy

Answer 15

-Predictive tools for VTE not validated in pregnancy
-VTE risk assessment in all stages
-D-dimers are not valid

=Chest X ray

Question 16

Investigations for chest pain in pregnancy

Answer 16

-ECG
-CXR
-blood gases
-Troponin level
-CTPA
-ECHO