Maternal Health problems by mikeholy

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									     Maternal Health problems



Maternal health problems are the leading
  cause of maternal mortality among
    women in the reproductive age.
• The main health problems affecting the
  health of the mother and the child, in the
  developing countries, are due to:

        –   Malnutrition,
        –   Infection,
        –   Unregulated reproduction
        –   Medical conditions (aggravated by pregnancy) e.g.

                      * Diabetes Mellitus
                      * Heart Diseases
                      * Renal disease
A-   Malnutrition
• The intrauterine period is a very important
  one, as infants born with adequate birth
  weight had relatively low mortality even
  under poor environmental conditions.

• The adverse effects of maternal
  malnutrition:
        Anemia.
        Maternal depletion syndrome.
        Toxemias of pregnancy.
        Post-partum hemorrhage.
        Low birth weight.
   1- Anemia
during pregnancy
• It is the condition in which there is a
  reduction of the concentration of
  hemoglobin (Hb) in the blood to a level
  below 11 gm/100 ml (Hb less than 70%)
  for women living at sea level.
• For those living at greater altitudes the
  values are higher.



                            Anemia
Severity of Anemia during pregnancy:



• Degrees of anemia (severity)

   Moderate       7 – 10.9 gm /100 ml

   Severe        4 – 6.9 gm / 100 ml

   Very severe   < 4 gm / 100 ml
             Predisposing factors:
1- Iron deficiency:
 The occurrence of anemia is affected by the iron reserves and
  the dietary intake.

 Iron is lost through normal menstruation and repeated pregnancy.

 Dietary intake is deficient if there is

          decreased intake of food rich in iron or food that
          enhance absorption like fruits or vitamin C

          or there is intake of substances which inhibit iron
           absorption like tea.
• The incidence of anemia during pregnancy is increased
  due to
      • increased daily requirements of iron during
        pregnancy
      • and inadequacy of dietary intake.


• 2- Infections:

  Also high prevalence of parasitic infections in certain
  areas leads to chronic loss of iron aggravating anemia
  during pregnancy e.g.
              ** Malaria,
              ** Bilharzia,
              ** Hook worms.
Complications of anemia during pregnancy:


a) Maternal complication:

1 – Preexisting anemia can render an:
               - ante partum or
               - post partum hemorrhage more fatal.
2 – Reduction of a woman’s resistance to infection, hence
   they suffer more frequent and dangerous infections of:
                - the respiratory tract,
                - genital tract
                - and puerperal sepsis.
3 – Uncorrected severe anemia is associated
  with increased incidence of :

           - acute heart failure
           - and maternal deaths.

4 – Increased incidence of complications due
  to:

           - anesthesia or
           - operative interference.
b) Fetal and newborn complications :

 1 - Low birth weight due to intrauterine
     growth retardation especially among infants
     whose mother either were not treated or failed
     to respond to treatment.

 2 – Abortion   (Fetal loss)

 3- Asphyxia

 4- Still birth
Prevention of anemia and its
       complications
1- Early detection of anemic pregnant woman during antenatal
   visits by:

  a. Clinical examination (Pallor and general weakness) and

   b. laboratory investigation (hemoglobin concentration.)

2- Nutrition education

  a. Motivate women to select foods which:
       i. contain iron ( liver-dark green leafy vegetables)
       ii. foods which enhance iron absorption (foods of animal
            origin, fruits and vegetables rich in vitamin C )

  b. Convince mothers to avoid substances that inhibit iron
     absorption (such as tea or coffee and calcium supplements
     two hours after meals ).
3- Treatment of parasitic infections, e.g.
  Malaria as well as bacterial and viral
  infections is recommended.

4- Prevention at population basis is possible by
  fortification with iron of
             salts
             bread, and
             sugar
    (depending on the consumption pattern )
• 5- Start folic acid at preconception visit
• In areas of high prevalence of iron deficiency anemia
      • give 400 mg ferrous sulphate (2 tablets) per day or
        once a week with 250ug folate for 4 months to pregnant
        and lactating women.


      Iron supplementation should not be offered routinely to all
         pregnant women. It does not benefit the mother’s or the
         baby’s health and may have unpleasant maternal side effects.
• 6- For anemic pregnant ladies:

   – If moderate anemia, give standard dose of iron / foliate

   – If severely anemic, treat for a month with higher dose.

   – In the third trimester if
           –   easily fatigued,
           –   breathlessness on mild exertion,
           –   weakness, and
           –   dizziness,
            give IM iron.

   – If Hb level not raised after treatment, refer to hospital
     (to avoid complications)

   – If very anemic or symptomatic refer to hospital (to avoid
     complications)
          Iron deficiency anemia
Iron deficiency anemia is characterized by
• Pallor (reduced amount of oxyhemoglobin in skin or
   mucous membrane),
• Fatigue and weakness. Because it tends to develop slowly,
   adaptation occurs and the disease often goes unrecognized
   for some time.
• In severe cases, dyspnea (trouble breathing) can occur.
• Unusual obsessive food cravings, known as pica, may
   develop. Pagophagia or pica for ice is a very specific
   symptom and may disappear with correction of iron
   deficiency anemia.
• Hair loss and
• Lightheadedness can also be associated with iron
   deficiency anemia.
    Other symptoms patients with iron deficiency anemia have
                        reported are:


•   Constipation
•   Sleepiness
•   Tinnitus
•   Palpitations
•   Hair loss
•   Fainting or feeling faint
•   Depression
•   Breathlessness
•   Twitching muscles
• Tingling, numbness, or burning sensations
• Sleep apnea
• Missed menstrual cycle
• Heavy menstrual period
• Glossitis
• Angular chelitis
• Koilonychia (spoon-shaped nails) or nails that are
  weak or brittle
• Poor appetite
• Pruritus
Finger-like projections papillae are lost,
 causing the tongue to appear smooth




         Glossitis
2- Obstetric Hemorrhage:
        Identification

• Antepartum hemorrhage is:
  “hemorrhage from the genital tract
   occurring after 22 weeks of gestation till
   before delivery of the baby”

• Postpartum hemorrhage is:
 “ the loss of 500 ml or more of blood from
  the genital tract after delivery of the
  baby.”

  Post partum hemorrhage was the first
   leading cause of maternal deaths in
   developing countries
Complications


• 1- Maternal complications include:
     • shock,
     • cardiac failure,
     • infection


• 2- fetus / newborn:
     • low birth weight,
     • asphyxia,
     • and still birth
Early detection and management:
1- Heavy antepartum
 hemorrhage:

  “ is assessed if clean pad is
   soaked in 5 minutes or if
   there is shock”

  – No vaginal examination should
    be carried out at the health
    center in case of antepartum
    hemorrhage.


  – Give IV fluids if mother is
    shocked and refer to hospital
2- Excessive postpartum hemorrhage:
 “is suspected if there is soaking of more than one pad
 per hour or bright red bleeding with or without clots
 after delivery”

  – Give IV fluid if the mother is shocked.

  – Do massage and bimanual compression of the uterus
    and

  – Give oxytocin, and catheterize to pass urine.

  – If bleeding is not reduced in 15 minutes refer to hospital
• If placenta is still retained refer the
  patient to the hospital

• All women with severe bleeding should
  receive iron therapy in the post partum
  period.
B . Maternal infection:
• Can lead to the following complications:

        Abortion.

        Retarded fetal growth and low birth
         weight.

        Congenital anomalies :e.g.
              Congenital Toxoplasmosis
              Rubella syndrome



        Puerperal sepsis.
1. Puerperal sepsis
             Definition

• It is an acute bacterial infection of
  the genital tract at any time after
  rupture of membrane till the 42nd
  day after delivery or abortion.

• Second direct cause of maternal
  mortality
Identification

 Usually   there is fever ( 38.5 oc or more ),

 Offensive   profuse vaginal discharge,

 Local   pelvic pain and

 Slowing   of the involution of uterus
   – (slow in the reduction of size of uterus)
   – (<2 cm / day in the first 8 days).
       Predisposing factors:

1- Low general resistance:

         Malnutrition.

         Infections (respiratory, genital or urinary).

         Hemorrhage.

         Toxemia.
2- Low resistance of the genital tract :

     •   Premature rupture of the membrane.

     •   Manual or operative interference,

     •   septic techniques and

     •   the presence of tears.

     •   Prolonged labor, or infection
       Complications:


1- Maternal complication:
    • septicemia shock


2- Neonatal sepsis
    • Ophthalmia neonatorum
Prevention of puerperal sepsis:
      a) During pregnancy:

1- Health education e.g.
       - Personal Hygiene &
       - abstinence from inter course late in
          pregnancy).

2 – Nutritional education and correction of anemia.

3 – Treatment of any septic focus of infection

4- Referral of severe infection
    b) During labor & puerperium:

1 -Training of provider of care on:
               strict aseptic technique,

              avoid transmission of infection from attendants or
               visitors,

              avoid repeated manipulation and personal hygiene
               sitting position.

              Training should also cover proper recognition and
               management of the puerperal sepsis; to give antibiotics
               and refer to hospital if there is no improvement in 2
               days.
2 - Prophylactic use of antibiotic.

3 - Early detection, treatment and referral.

4- Women should be made aware of:

   ** the early signs and symptoms of
      infection
   ** and be encouraged to seek treatment.
2- Congenital Toxoplasmosis
• Toxoplasmosis is a parasitic disease caused by a
  protozoan, Toxoplasma gondii

• Infections of humans are common,
  and are usually asymptomatic

• In two cases infection may be serious:

       • If the infection is transmitted to the fetus during
         pregnancy (Congenital Toxoplasmosis)

       • Infection or reactivation of a Toxoplasmosis in patients
         with immuno-deficiancy disease(AIDS)

• Measures of prophylaxis, early detection of the infection
  and treatment can avoid Congenital Toxoplasmosis and
  many long term effects.
Cycle of infection

                     A fresh maternal
                     infection during
                      pregnancy can lead
                      to an infection of the
                      placenta.
                     Congenital Toxoplasmosis
                     results from
                     transplacental
                     infection of the fetus
                     during pregnancy
                   LIFE CYCLE
  The T. gondii life cycle has three stages:
  tachyzoite, bradyzoite, and sporozoite.
• During the acute stage of T. gondii infection,
  tachyzoites invade and replicate within cells and
  are responsible for congenital infection.
• The tachyzoites invade all organs, especially the
  muscles (including the heart), liver, spleen, lymph
  nodes, and central nervous system (CNS).
• During latent infection, bradyzoites are present in
  tissue cysts. Sporozoites are found in
  environmentally resistant oocysts formed after
  the sexual stage of the life cycle.
The source of infection:
• The source of infection is uncooked meat
  containing the tissue cyst and any other raw
  food contaminated by infected cat’s faeces.
Symptoms

• The consequences of the infection of the fetus can be very
  different: between subclinical and very serious.
        • Abortion
        • Overt disease: the symptoms vary widely, the classical
          triad of Congenital Toxoplasmosis is
        • Hydrocephalus
        • Intracranial calcification
        • Chorioretinitis

• Subclinical infection: no symptoms at birth

        • late onset symptoms (most common in the eyes:
          Chorioretinitis)
        • no symptoms at all
  Prognosis of infection

• The earlier in pregnancy the mother is
  infected,
        – the lower is the risk of an infection of the fetus,
        – but the severer is the disease.



• The later in pregnancy the mother is
  infected,
        – the higher is the possibility of fetal infection,
        – and the disease is less severe (often subclinical
          infection)
• Adults and children can get infected:

     • asymptomatic (90%) or

     • with symptoms like flu: fever, typically swollen
       lymphatic glands .

     • symptoms which need treatment are very rare


• In case of immunodeficiency the
  symptoms can be serious!
               Diagnosis
• It can be performed by (a combination of several
  approaches:
    serological tests :measure "antibodies" (the
      reaction of the body) to the parasites
    For diagnosis of Toxoplasmosis usually IgG
      and IgM are measured (some times Ig A)
    That means, if You find (stable) IgG and no
      IgM :there had been the infection longer
      time ago, and there is protection now (and in
      the future). ("latent infection(”
    If there are IgG and IgM :the infection
      happened short time ago.
   Diagnosis of Toxoplasmosis: pregnant
                  women



• Serological screening :
        - to detect asymptomatic infections
              Treatment

• Any maternal infection should be treated
  with antibiotic drugs until delivery,
• Referal
 Prevention

• The aim of all medical
   intervention is the
   prevention of Congenital
  Toxoplasmosis.

• Primary prevention
   is an information about the ways of infection (cats, raw meet) to
   avoid ingestion or inhalation. This is important for all pregnant
   women who are "seronegative "
• Secondary prevention
  is the detection of infected women during pregnancy to start
   treatment before the fetus gets infected .
• Tertiary Prevention
    is the treatment of infected children to reduce or avoid symptoms
    Prevention of Exposure to Toxoplasmosis

• The following guidelines can reduce or even
  eliminate the risk of contracting
  Toxoplasmosis

     • Change cat litter daily (it takes 24-48hrs after passage of
       faeces for oocysts to become infective(

     • Cats are generally infected with the organism by eating
       rodents or birds or eating raw meat infected by
       Toxoplasma, so keeping cats inside and feeding only
       cooked or processed meat with reduce the risk of cats
       becoming infected .
• Wash vegetables (especially home-grown ones)
  thoroughly before consumption

• Boil water from ponds and streams prior to consumption
  when camping

• Cover backyard sandpits to prevent cats soiling in them

• Wash hands with soap after handling raw meat,
  gardening or working with soil (ideally you should wear
  gloves when gardening (

• Wash all utensils used when preparing raw meat before
  using to prepare other food

• Cook meat thoroughly (until internal temperature
  exceeds 66ºC(
Toxemia of pregnancy
        Hypertensive disorders,
     pre-eclampsia and eclampsia.
• A diagnosis of hypertension in a pregnant
  woman is made when:
        the blood pressure is 140 / 90 or greater,

      or there has been   a rise 30 mm Hg systolic

      or 15 mm Hg diastolic over baseline values


• On at least two occasions, six or more
  hours apart.
     Identification:

 Pre-eclampsia is a syndrome characterized by :

       hypertension,
       generalized edema
       and proteinuria.

 With the development of
  convulsion and coma the disorder is termed:

                     Eclampsia
  Pre-Eclampsia: Severity

• Woman over 20 weeks
  gestation with:

  – Diastolic blood pressure
   > 90 mm Hg
  – and Proteinuria

• Predisposes woman to
  develop eclampsia
  Mild Pre-eclampsia

• Two readings of diastolic
  blood pressure 90-110
  mm Hg 6 hours apart
  after 20 weeks gestation

• Proteinuria up to 2+

• No other signs/symptoms
  of severe pre-eclampsia
Severe Pre-eclampsia
• Diastolic blood    Other signs and
  pressure           symptoms sometimes
  > 110 mm Hg        present:
                       Epigastric
• Proteinuria > 3+      tenderness
                       Headache
                       Visual changes
                       Pulmonary edema
                       Oliguria
               Eclampsia


• Convulsions occurring after 20 weeks
  gestation in a woman without a previously
  known seizure disorder

• (A small proportion of women with
  eclampsia have normal blood pressure)
    Who are at risk to Develop Pre-eclampsia


• Women with chronic hypertension
  (high blood pressure before becoming pregnant)

• Women who developed high blood pressure or pre-
  eclampsia during a previous pregnancy, especially if
  these conditions occurred early in the pregnancy .

• Women who are obese prior to pregnancy .
   Who are at risk to Develop Pre-eclampsia


• Pregnant women under the age of 20 or over
  the age of 40 .



• Women with chronic diseases e.g.
    diabetes, kidney disease, rheumatoid
    arthritis, lupus, or scleroderma
    Complications:

1- Maternal death due to:

        - circulatory collapse,
        - pulmonary edema,
        - shock,
        - cerebral hemorrhage
        - or renal failure.

2. Fetal death due to hypoxia or acidosis.

3. Recurrence with subsequent pregnancy.
Prevention
1-   Raise the community awareness of signs and symptoms of
     hypertensive disorders of pregnancy. Seek for care, if pregnant
     woman experiences:

           severe headache,
           and generalized edema,
           blurring of vision
           and or convulsion.

2-   During antenatal care ask about :
        - edema,
        - or convulsions,

     frequent measurement of
         - blood pressure
         - and weight and
         - urine analysis for proteinuria.
3- Management of pre-eclampsia at the health
   center if:
       - BP (diastolic) is 90 – 100 mm Hg
        - no proteinuria

  This is done through:
        - bed rest and
        - check B/P twice weekly

4- Refer to hospital if:
       - B/P rises and /or
       - edema or proteinuria develops
Erythroblastosis fetalis
         Definition
• Erythroblastosis fetalis refers to two
  potentially disabling or fatal blood disorders
  in infants:

     • Rh incompatibility disease and

     • ABO incompatibility disease.


• Either disease may be apparent before birth
  and can cause fetal death in some cases.
• The disorder is caused by incompatibility between a
  mother's blood and her unborn baby's blood.

• Because of the incompatibility, the mother's immune
  system may launch an immune response against the
  baby's red blood cells.

• As a result, the baby's blood cells are destroyed, and the
  baby may suffer
       • severe anemia (deficiency in red blood cells),
       • brain damage,
       • or death.
     Prevention


• With any pregnancy, whether it results in a
  live birth, miscarriage, stillbirth, or abortion,
  blood typing is a universal precaution
  against blood compatibility disease.

• Blood types cannot be changed, but
  adequate forewarning allows precautions
  and treatments that limit the danger to
  unborn babies.
• If an Rh-negative woman gives birth to an
  Rh-positive baby, she is given an injection of
  immunoglobulin G, a type of antibody
  protein, within 72 hours of the birth.

• The immunoglobulin destroys any fetal
  blood cells in her bloodstream before her
  immune system can react to them.

• In cases where this precaution is not taken,
  antibodies are created and future
  pregnancies may be complicated.
• administer a series of two Rh immune-
  globulin shots during her first pregnancy. The
  first shot is given around the 28th week of
  pregnancy and the second within 72 hours
  after giving birth. Rh immune-globulin acts
  like a vaccine, preventing the mother's body
  from producing any potentially dangerous Rh
  antibodies that can cause serious
  complications in the newborn or complicate
  any future pregnancies

								
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