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 careINFANT 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.

Maternal Mortality (per 100,000 births) 1915 1940 1950 1960 1983 1997 2002 All 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 23

Leading Causes Pregnancy Related Death: hemorrhage, embolism, hypertension, infection, anesthesia related complications

Maternal Mortality Rate : approximately 7.5 per 100,000 in 1998 When compared to white women ; Black women have 4 times the risk fordying 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

RegionalizationLevel 1 :

Level 2 : IVCH, CHO

Level 3 : St. FrancisSmall group of women is high riskwith good prenatal care almost 2/3 of ALL HIGH riskproblems can be identified early and high possibility ofpreventing further complications

Only 23%-25% of High Risk delivered are surprises

KEY = Identification Prenatal care

Sepate uterusBicornate uterusDouble uterusDidelphys orComplete Double uterusObstetrical uterine malformations

Relationship betweenmaternal and fetalmalnutrition

Loss and Grief - outlineLoss 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 (IVs, 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

Types of losses arising in perinatal period and their causesLoss of Physical Control-inability to push or inability to withstandinvoluntary urge to push -involuntary vocalizations, defecation,or urination during delivery-inability to maintain breathing orrelaxation 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

Types of losses arising in perinatal period and their causes continued:Loss of shared experiences-absence of father, partner, orother 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 prematurityillness, 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 behaiorsby family or friends

DEFINATION OF HYPERTENSION IN PREGNANCY

Systolic blood pressure > or = 140 mm HgorDiastolic blood pressure > or = 90 mm Hg

Increase of > or = 30 mm Hg in systolic pressure

4. Increase of > or = 15 mm Hg in diastolic pressureNOTE # 3 & 4, most of our women have lower BP to start with!

PEGNANCY INDUCED HYPERTENSIONPreeclampsia : 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 preeclampsiaBlood 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, + 3Oliguria > 400 ml in 24 hours, 30cc/hrCerebral / vision disturbances (e.g. altered consciousness, headache, blurred vision)Pulmonary edema / cyanosisEpigastric / right upper quadrant pain (can occasionally precede hepatic ruptureImpaired liver function of unknown etilologyThrombocytopenia 3. Eclampsia: The occurrence of convulsions in a woman who meets criteria for preeclampsia

PreeclampsiaMost women in Mild preeclampsia are not immediately hospitalized, but will keep close monitoring on maternal & fetal well being.ks agementoringtionns changeIf below 37 weeks, betamethosone IM to mom, helps surfactant development

Checking Reflexes

A = Biceps

B = Patellar reflex with legs hanging freely

C = Patellar reflex with client supint

D = Checking for ankle clonus

Checking for pitting edemaA = + 1B = + 2C = + 3D = + 4

Watch for symptoms even in someone who is below 140/90 or liverEnzymesRenal function

What is MAP ? Talking about blood pressureMean arterial pressureMAP = DBP + 1/3 of pulse pressureA 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 orduring exercise. See decreased with hypovolemia.

Severe Preeclampsia

-Admit to labor and delivery area -Maternal and fetal evaluation x 24 hoursNo - 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

Pathophysiology of PIH

Severe Preeclampsia

H E L L P

H = hemolysisE = elevated L = liver function testsL = lowP = platelet count

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 8-10blood levels will be drawn, check DTR, resp. rate

REMEMBER whenever MgSO4 is in use what drug has to be near byCalcium gluconateWhat should you watch for in mom PP ?Uterine relaxationWhat might happen in newborn ? Remember MgSO4 is a CNSdepressant respiratory distress, decrease in respiratory effort

Remember 1202Hypovolemic 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

SYMPTOMSanxiety, restlessness, disorientation-thirst, dry mouth-feeling chilledSigns and Symptoms of Shock 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

Abortions

A = Threatened

B = Inevitable

C = Incomplete

D = Complete

E = Missed

Incompetent cervix

A = cerclage correctionof recurrent prematuredilation of cervix

B = cross section of closed cervix

Suture removed around36-38 wks.

McDonalds procedure cerclage suture Pursestring sutures

SonogramsHCG levelsEmotional Support

Hydatidform mole or a gestataional trophoblastic neoplasm Rare 1: 1000 to 2000 3 times higher in Asian women, 10% develop ChoriocarcinomaWhat are S&S?Nausea Why?Abnormal uterine growthWhat do you have to check?Why? How often?HCG levels 1-2 wks until norm, then1-2 mos for a year.If do not drop may have to be treated with chemotherapyStarts as fertilization, trophoblast Degenerates & chorion proliferatesWhat is treatment?Often abort spontaneously or D&CNo Pitocin until after deliver

Actual HyditformMOLE

A & D =Complete

B & C =Partial

C & B =Low lying or Marginal

Lower A=NormalPlacenta Previa NON PAINFUL BLEEDING

Pain Board like abdomen, especially is concealed.What are S&S ?Who is high risk population ?History of abruptioGrand parityPoveryPIHAdvanced ageSupine hypotensionShort umbilical cord during laborTrauma to abdomenCocaine or other drug usageCigarette some sayAlcohol abuse some say

CORD INSERTION & PLACENTAL VARIATIONS: Rare less than 1:3000May lacerate & bleed, especiallyduring 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

DIC or Disseminated Intravascular CoagulationWhat are S&S? FIND CAUSE correctDIC is secondary to number of things: hemorrhage septic shock amniotic fluid embolism PIH infection diabetes

During PG, clotting factors normally increase and thrombolytic activity decreases

If a condition requires some type of anticoagulant : heparin is choiceWarfarin crosses the placenta & is with fetal malformationsvon Willebrands disease : an autosomal dominant bleeding disorder inabnormality of vW factor which affects clotting of blood hormonesin pregnancy may improve vW factor but need to monitorATP may improve slightly, but then rebound with more destructionof the platelets

Maternal infections2 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 laborTX erythromycin or amoxicillin (mom)3 Gonarrhea: fetus may be infected during birth ophthalmia neonatoriumendocervicitis = PROM and preterm labor1 Syphillis: may pass through placenta may result in abortion, a stillborn, preterm labor or congenital syphillis (enlarged liver, spleen, skin lesions,rashes, oseteitis, pneumonia, hepatitisTX penicillin 4 Condyloma acuminatum or genital warts (human pailliomavirus): fetus may beinfected during vaginal birth and develop epithelial tumors of themucous membranes of the larynx in children. PG can cause proliferationHPV associated with cervical dysplasia & cancer (see next slide) 5 tichomoniasis basically associated with PROM and postpartum endometritis

Venereal warts orCondylamata acuminataHuman papillomavirus HPV

Most common viral STD 3 times greater than herpesCauliflower like appearance

Maternal vaginal infectionsVaginal candidiasis: fetus may be infected during vaginal birthoral candidiasis (thrush) TX for infant MycostatinTX for mom Monistat, Terazole, FemstatMost say treat for at least 7 daysPROM, preterm labor, low birth weight, postpartum endometritisUTIs , cycstitis, acute pyelonephritisPROM, preterm labor

Viral infections remember most virus passes placental barrierCytomegalovirus: 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. Theseinfants shed the virus from the nosopharynx and urine for several yrs.Most severe effects: deafness, mental retardation, seizures, blindness & dental bnormalitiesTX: gancyclovir for TX of congenitally infected infantsNo screening yet available

Rubella: up to 10% of adults remain susceptibleFetal & neonatal effects: greatest risk is first 3 ms. 1/3 will result inspontaneous abortion, surviving maybe seriously compromised deafness, mental retardaation, cataracts, cardiac defects, IUGRand mirocephaly. Infants will shed the virus for many monthsTX: prevention, A titer of 1.8 or greater provides immunityRubella vaccine after delivery educate no PG for at least 3 mos. WHY?

Varicella Zoster virus ( herpesvirus) = chickenpox: Acute infection for mom: r\preterm labor, encephalitis & varicella pneumonia. 5 15% of aduls in US are susceptibleFetal & 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 whois infected 4-6 days or 2 days after birth will not have the benefitof maternal antibodies, leaving the infant at risk for life-threateningneonatal 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 aftereach of the two injections, which are given 4 to 8 wks apart.

Herpesvirus serotypes 1 & 2: one of most common sexually transmissibledisease. Most genital warts are type 2. Lesions form at site, begin atpainful 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 ofmembranes 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 skinlesion to systemic or disseminated. If systemic death rate or serioussequelae 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

Parvovirus: or erythemia infectiosum or fifth disease.highly communicable characterized by slapped cheeks appearancefollowed 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 failureHepatitis B : more likely to occur in person with STD, IV drug users & some population groups, Asians, Native Americans, Eskimos, SoutheastAsian and subSaharan African immigrants. Chronic Hepatitis B develops in 1 to 6 % of infected adults who are at a greater risk forchronic liver disease, cirrohosis of the liver, premary hepatocellularcarcinoma 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

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 trimesterIf 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 periodintrapartum 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 positiveIf mom contacts HIV virus during PG higher change that infant will be HIV *

Non Viral infections:Toxoplasmosis: a protozoan infection. Raw or undercooked meat, cat fecescrosses the placental barrier. Flu like symptoms in mom.Can do serologic test

Fetal and neonatal effects: spontaneous abortion or live birth with congenitaltoxoplasmosis - 50% of infants. May be asymptomatic at birth or havelow birth weight, enlarged liver and spleen, jaundice and anemia. Complications chorioretinitis or signs of neuologic damage may beseveral 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

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. 12 % 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

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 therapyTX for neonates. If moms 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

TORCH T = toxoplasmosis O = otherhepatitis Ahepatitis B R = rubella C = cytomegalovirus H = herpes genitalis