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1
Civil Society Legislative Advocacy Centre (CISLAC). Policy brief on MDGs 4 & 5 on reduction of under five and maternal mortality rate. Abuja, Nigeria: CISLAC, 2007.
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2
Children's Defense Fund (U.S.). Health Division. Maternal and child health in America's cities. Washington, D.C: Health Division, Children's Defense Fund, 1991.
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3
Halder, Suni, and Steve Yentis. Maternal mortality and morbidity. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0031.
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The risk to women’s health is increased during pregnancy, and maternal mortality is used as an indicator of general healthcare provision as well as a target for improving women’s health worldwide. Morbidity is more difficult to define than mortality but may also be used to monitor and improve women’s care during and after pregnancy. Despite international efforts to reduce maternal mortality, there remains a wide disparity between the rate of deaths in developed (maternal mortality ratio less than 10–20 per 100,000 live births) and developing (maternal mortality ratio as high as 1000 or more per 100,000 live births in some countries) areas of the world. Similarly, treatable conditions that cause considerable morbidity in developed countries but uncommonly result in maternal death (e.g. pre-eclampsia (pre-eclamptic toxaemia), haemorrhage, and sepsis) continue to be major causes of mortality in developing countries, where appropriate care is hampered by a lack of resources, skilled staff, education, and infrastructure. Surveillance systems that identify and analyse maternal deaths aim to monitor and improve maternal healthcare through education of staff and politicians; the longest-running and most comprehensive of these, the Confidential Enquiries into Maternal Deaths in the United Kingdom, was halted temporarily after the 2006–2008 report but is now active again. Surveillance of maternal morbidity is more difficult but systems also exist for this. The lessons learnt from such programmes are thought to be important drivers for improved maternal outcomes across the world.
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Van Calsteren, Kristel. Chronic maternal infections. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0050.
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Pregnant women diagnosed with chronic infections are a worldwide problem. In developed countries, the most frequently encountered are hepatitis B and C, toxoplasmosis, syphilis, herpes simplex, and Cytomegalovirus infections. In developing countries, human immunodeficiency virus and malaria are also seen commonly in pregnant women. Maternal infections are associated with various complications in pregnant women, but also with congenital infections with or without structural anomalies and long-term sequelae, fetal growth restriction, preterm delivery, and perinatal mortality. Moreover, increasing evidence suggests that maternal infection during pregnancy affects the developing immune system of the fetus independently of the vertical transmission of pathogens. This chapter discusses the pathogen characteristics, ways of transmission, clinical presentation, diagnostic options, treatment, and, if relevant, prophylaxis for the most common infections in pregnant women (excluding hepatitis which is discussed elsewhere).
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Anderson, John A., Pierre-Antoine Laloë, and Derek J. Tuffnell. Hypertension in pregnancy. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0036.
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The hypertensive disorders of pregnancy encompass a spectrum of disease, including gestational hypertension, haemolysis, elevated liver enzymes, and low platelets (HELLP syndrome), and acute fatty liver of pregnancy through to pre-eclampsia and eclampsia. These conditions can pose significant problems for clinicians and are associated with significant morbidity and mortality for both mother and baby. Pre-eclampsia and eclampsia remain one of the leading causes of maternal death worldwide. The majority of fatalities occur in settings with low healthcare resources. In the developed world, improvements over the last 60 years in antenatal and intrapartum care, along with national surveillance and audit, have led to tenfold and fivefold reductions in absolute mortality and severe morbidity from eclampsia and pre-eclampsia respectively. Conversely, the incidence of pre-eclampsia has been rising in the developed world as the average age of first maternity increases and rates of obesity and other medical conditions rise. It is therefore increasingly likely that hypertension may complicate the obstetric and anaesthetic management of pregnant women.
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Centers for Disease Control Prevention (U.S.) Global AIDS Program., National Institute of Public Health (Cambodia), National Institute of Statistics (Cambodia), and ORC Macro, eds. Cambodia demographic and health survey, 2005. Phnom Penh, Cambodia: National Institute of Public Health and National Institute of Statistics, 2006.
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7
Office, Philippines National Statistics, and ORC Macro MEASURE/DHS+ (Programme), eds. Philippines national demographic and health survey 2003. Manila, Philippines: National Statistics Office, 2004.
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8
Cantwell, Roch. Peripartum psychiatric disorders. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0049.
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Women are at greatest risk of suffering from mental illness during their reproductive years, and at very particular risk in relation to childbirth. Psychological adjustment, social challenges, and neurohormonal changes in pregnancy and parturition may all contribute to this risk. The consequences of maternal mental illness may be severe. Suicide is among the leading causes of maternal death in the United Kingdom and psychiatric factors are implicated in a further significant number of deaths in pregnancy and the first postnatal year. Increasing evidence points to the detrimental effect of untreated maternal anxiety and depression on infant development. Women may be taking psychotropic medication at conception, with antidepressants being one of the most frequently prescribed. Certain psychotropics have important adverse effects on the fetus and developing child, and may require careful management if prescribed in pregnancy. All professionals involved in the care of women at this time have an important role in identifying those at risk, reducing progression to future morbidity and mortality, and minimizing the adverse effects of prescribed medication.
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Barclay, Philip, and Helen Scholefield. High dependency and intensive care. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0030.
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The development of maternal critical care is essential in reducing morbidity and mortality due to a substandard level of care. The level of critical care should depend upon the patient’s severity of illness, not their physical location. Escalation to level 3 (intensive) care is uncommon in pregnancy, with a median admission rate of 2.7 per 1000 births, mainly due to hypertensive disorders of pregnancy and haemorrhage. Maternal ‘near misses’ occur more frequently, with 6.5 per 1000 births meeting Mantel’s criteria, of which 85% is due to major obstetric haemorrhage. The admission rate to maternal high dependency units (level 2 care) varies from 1% to 5%. Acute physiological scoring systems have been found to be reliable when applied to parturients receiving level 3 care but overestimate mortality. Maternal early warning scores have been derived from simplified versions of these systems, with allowance made for physiological changes seen in pregnancy. There are many different maternity scoring systems in use throughout England and Wales. All share the same principle that parameters should be recorded regularly during the hospital stay, with deviations from normal quantified, recorded, and acted upon. A chain of response is then required to ensure that suitably qualified staff, possessing appropriate critical care competencies, attend in a timely fashion. Appropriate resources must be available with equipment readily to hand and suitably trained staff so that invasive monitoring can be used. Clear admission criteria are required for level 2 care within the delivery suite and escalation to level 3, with suitable arrangements for transfer.
10
Naess, Halvor. Long-term prognosis. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198722366.003.0016.
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Knowledge of prognosis is important for patients in the prime of life in order to make informed decisions about treatment, choice of education, and profession. Median first-year mortality after first-ever cerebral infarction among young adults is about 4% while median annual average mortality after the first year is about 1.7%. Likewise, median first-year recurrence rate of cerebral infarction is 2% and thereafter 1.5% per year. Risk factors for recurrent cerebral infarction include hypertension, diabetes mellitus, symptomatic atherosclerosis, and smoking. Recurrent cerebral infarction and mortality are associated with increasing number of traditional risk factors. About 10% of patients develop post-stroke seizures within 6 years of the acute stroke. Almost 90% of patients report good functional outcome (modified Rankin Scale score ≤2) on long-term follow-up, but up to 30–50% of patients do not resume employment. Many patients have cognitive impairment. Fatigue and depression are also common on long-term follow-up.
11
Wood, Cristina. Stroke/Subarachnoid Hemorrhage and Pregnancy. Edited by Matthew D. McEvoy and Cory M. Furse. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190226459.003.0055.
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Death from neurological causes is a massive issue in maternal mortality, and the rate of deaths from neurological causes has remained essentially unchanged for the past thirty years. Two of the most common neurological causes of death are stroke and intracranial hemorrhage. These medical emergencies can be more challenging to diagnose and treat in the parturient. This is largely due to the physiologic changes that occur during pregnancy and in the postpartum period, but fetal considerations are also a factor. This chapter focuses on the pathophysiology, assessment, and management of stroke and subarachnoid hemorrhage in pregnancy. A thorough understanding of each of these components is necessary to ensure appropriate and timely care delivery for optimal outcome in the setting of these neurologic emergencies.
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Lopes, Eurides, and Jennifer Husson. Solid Organ Transplantation in HIV-Infected Individuals. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190493097.003.0025.
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End-organ disease has become a major cause of morbidity and mortality in HIV-infected patients due to increased life expectancy, increasing the demand for organ transplantation in these patients. The care of HIV-infected transplant recipients warrants a multidisciplinary team approach, including the transplant team, pharmacists, infectious disease specialists, nurses, and patients and their families. The immunosuppression of HIV-infected recipients post-transplant does not appear to further advance HIV disease. The post-transplant risk for HIV-infected recipients of opportunistic infections does not appear to be increased by immunosuppression. However, the overall rate of infections is high, and it is even higher in hepatitis C virus (HCV) co-infected transplant recipients. HIV/HCV co-infected recipients have worse outcomes compared to both liver and kidney HIV-infected recipients.
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Bramham, Kate, and Catherine Nelson-Piercy. Pregnancy in patients with chronic kidney disease and on dialysis. Edited by Norbert Lameire and Neil Turner. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199592548.003.0295_update_001.
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Chronic kidney disease (CKD) affects a small but increasing minority of women becoming pregnant. It is associated with additional risks depending on pre-pregnancy glomerular filtration rate, proteinuria, and hypertension. Some drugs are contraindicated in pregnancy. These are powerful reasons for counselling all women of childbearing age about pregnancy in CKD. With minor CKD the main issue is moderately increased risk of pregnancy-associated hypertension and pre-eclampsia. More advanced CKD is associated with reduced fertility, progressively increased risk of pre-term delivery and a significant chance of permanent loss of maternal renal function. Distinguishing pre-eclampsia from the natural effects of pregnancy on manifestations of CKD can be challenging. Blood pressure targets may be modified during pregnancy and angiotensin converting enzyme inhibitors and angiotensin receptor blockers are contraindicated. Dialysis may be initiated if pregnancy occurs at advanced levels of CKD. Pregnancy may also occur in patients on dialysis, usually in women with some residual native renal function. More intensive dialysis may improve outcomes.
14
Jacquemyn, Yves, and Anneke Kwee. Antenatal and intrapartum fetal evaluation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0006.
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Antenatal and intrapartum fetal monitoring aim to identify the beginning of the process of fetal hypoxia before irreversible fetal damage has taken place. Fetal movement counting by the mother has not been reported to be of any benefit. The biophysical profile score, incorporating ultrasound and fetal heart rate monitoring, has not been proven to reduce perinatal mortality in randomized trials. Doppler ultrasound allows the exploration of the perfusion of different fetal organ systems and provides data on possible hypoxia and fetal anaemia. Maternal uterine artery Doppler can be used to select women with a high risk for intrauterine growth restriction and pre-eclampsia but does not directly provide information on fetal status. Umbilical artery Doppler has been shown to reduce perinatal mortality significantly in high-risk pregnancies (but not in low-risk women). Adding middle cerebral artery Doppler to umbilical artery Doppler does not increase accuracy for detecting adverse perinatal outcome. Ductus venosus Doppler demonstrates moderate value in diagnosing fetal compromise; it is not known whether its use adds any value to umbilical artery Doppler alone. Cardiotocography (CTG) reflects the interaction between the fetal brain and peripheral cardiovascular system. Prelabour routine use of CTG in low-risk pregnancies has not been proven to improve outcome; computerized CTG significantly reduces perinatal mortality in high-risk pregnancies. Monitoring the fetus during labour with intermittent auscultation has not been compared to no monitoring at all; when compared with CTG no difference in perinatal mortality or cerebral palsy has been noted. CTG does lower neonatal seizures and is accompanied by a statistically non-significant rise in caesarean delivery. Fetal blood sampling to detect fetal pH and base deficit lowers caesarean delivery rate and neonatal convulsions when used in adjunct to CTG. Determination of fetal scalp lactate has not been shown to have an effect on neonatal outcome or on the rate of instrumental deliveries but is less often hampered by technical failure than fetal scalp pH. Analysis of the ST segment of the fetal ECG (STAN®) in combination with CTG during labour results in fewer vaginal operative deliveries, less need for neonatal intensive care, and less use of fetal blood sampling during labour, without a change in fetal metabolic acidosis when compared to CTG alone.
15
Rizzuto, Gabrielle A., and Anna I. Bakardjiev. Listeria monocytogenes. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190604813.003.0020.
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Listeria monocytogenes is a intracellular bacterial pathogen that causes serious foodborne illness in humans. Among all infectious diseases caused by gastrointestinal pathogens, listeriosis has the highest mortality rate, likely because of its ability to cross the gastrointestinal barrier and cause sepsis and infection of other organs such as the brain and placenta. Infection of the placenta leads to fetal infection, and otherwise healthy pregnant women have a significantly increased incidence of listeriosis than the general population, likely due to changes in the maternal cell-mediated immune response during pregnancy. Clinical manifestations include miscarriage, stillbirth, preterm labor, and neonatal infection and death. Neonates develop early-onset sepsis or late-onset meningitis. Physicians must evaluate pregnant women and neonates with febrile illnesses for listeriosis, since prompt treatment with antibiotics can cure it. It is important to note that L. monocytogenes is resistant to cephalosporins. Ampicillin is the treatment of choice in patients without penicillin allergy.
16
Luke, Jenny M. Delivered by Midwives. University Press of Mississippi, 2018. http://dx.doi.org/10.14325/mississippi/9781496818911.001.0001.
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Delivering babies was merely one aspect of the broad role of African American midwives in the twentieth-century South. Yet little has been written about the type of care they provided, or how midwifery and maternity care evolved under the increasing presence of local and federal health care structures. Using evidence from nursing, medical, and public health journals of the era; primary sources from state and county departments of health; and personal accounts from varied practitioners, Delivered by Midwives: African American Midwifery in the Twentieth-Century South provides a new perspective on the childbirth experience of African American women and their maternity care providers during the twentieth century. Moving beyond the usual racial dichotomy, the monograph exposes a more complex shift in childbirth culture to reveal the changing expectations and agency of African American women in their rejection of a two-tier maternity care system, and their demands to be part of an inclusive, desegregated society. This book identifies valuable aspects of a maternity care model that were discarded in the name of progress. Today concern about maternal mortality and persistent racial disparities have forced a reassessment of maternity care and elements of the long-abandoned care model are being reincorporated into modern practice, answering current health care dilemmas by heeding lessons from the past.
17
Durand, Eric, Aures Chaib, and Nicolas Danchin. Chest pain and chest pain units. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0008.
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Patients presenting at the emergency department with acute chest pain and suspected to represent an acute coronary syndrome were classically admitted as routine to the cardiology department, resulting in expensive and time-consuming evaluations. However, 2-5% of patients with acute coronary syndromes were discharged home inappropriately, resulting in increased mortality. To address the inability to exclude the diagnosis of acute coronary syndrome, chest pain units were developed, particularly in the United States. These provided an environment where serial electrocardiograms, cardiac biomarkers, and provocative testing could be performed to rule out an acute coronary syndrome. Eligible candidates included the majority of patients with non-diagnostic electrocardiograms and normal troponin measurements. The results have been impressive; chest pain units have markedly reduced adverse events, while simultaneously increasing the rate of safe discharge by 36%. Despite evidence to suggest that care in chest pain units is more effective for such patients, the percentage of emergency or cardiology departments setting up chest pain units remains very low in Europe.
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Durand, Eric, Aurès Chaib, Etienne Puymirat, and Nicolas Danchin. Chest pain and chest pain units. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0008_update_001.
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Patients presenting at the emergency department with acute chest pain and suspected to represent an acute coronary syndrome were classically admitted as routine to the cardiology department, resulting in expensive and time-consuming evaluations. However, 2-5% of patients with acute coronary syndromes were discharged home inappropriately, resulting in increased mortality. To address the inability to exclude the diagnosis of acute coronary syndrome, chest pain units were developed, particularly in the United States. These provide an environment where serial electrocardiograms, cardiac biomarkers, and provocative testing can be performed to confirm or rule out an acute coronary syndrome. Eligible candidates include the majority of patients with non-diagnostic electrocardiograms. The results have been impressive; chest pain units have markedly reduced adverse events, while simultaneously increasing the rate of safe discharge by 36%. Despite evidence to suggest that care in chest pain units is more effective for such patients, the percentage of emergency or cardiology departments setting up chest pain units remains low in Europe.
19
Hall, Andrew, and Shamima Rahman. Mitochondrial diseases and the kidney. Edited by Neil Turner. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0340.
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Mitochondrial disease can affect any organ in the body including the kidney. As increasing numbers of patients with mitochondrial disease are either surviving beyond childhood or being diagnosed in adulthood, it is important for all nephrologists to have some understanding of the common renal complications that can occur in these individuals. Mitochondrial proteins are encoded by either mitochondrial or nuclear DNA (mtDNA and nDNA, respectively); therefore, disease causing mutations may be inherited maternally (mtDNA) or autosomally (nDNA), or can arise spontaneously. The commonest renal phenotype in mitochondrial disease is proximal tubulopathy (Fanconi syndrome in the severest cases); however, as all regions of the nephron can be affected, from the glomerulus to the collecting duct, patients may also present with proteinuria, decreased glomerular filtration rate, nephrotic syndrome, water and electrolyte disorders, and renal tubular acidosis. Understanding of the relationship between underlying genotype and clinical phenotype remains incomplete in mitochondrial disease. Proximal tubulopathy typically occurs in children with severe multisystem disease due to mtDNA deletion or mutations in nDNA affecting mitochondrial function. In contrast, glomerular disease (focal segmental glomerulosclerosis) has been reported more commonly in adults, mainly in association with the m.3243A<G point mutation. Co-enzyme Q10 (CoQ10) deficiency has been particularly associated with podocyte dysfunction and nephrotic syndrome in children. Underlying mitochondrial disease should be considered as a potential cause of unexplained renal dysfunction; clinical clues include lack of response to conventional therapy, abnormal mitochondrial morphology on kidney biopsy, involvement of other organs (e.g. diabetes, cardiomyopathy, and deafness) and a maternal family history, although none of these features are specific. The diagnostic approach involves acquiring tissue (typically skeletal muscle) for histological analysis, mtDNA screening and oxidative phosphorylation (OXPHOS) complex function tests. A number of nDNA mutations causing mitochondrial disease have now been identified and can also be screened for if clinically indicated. Management of mitochondrial disease requires a multidisciplinary approach, and treatment is largely supportive as there are currently very few evidence-based interventions. Electrolyte deficiencies should be corrected in patients with urinary wasting due to tubulopathy, and CoQ10 supplementation may be of benefit in individuals with CoQ10 deficiency. Nephrotic syndrome in mitochondrial disease is not typically responsive to steroid therapy. Transplantation has been performed in patients with end-stage kidney disease; however, immunosuppressive agents such as steroids and tacrolimus should be used with care given the high incidence of diabetes in mitochondrial disease.
20
Whitworth, Caroline, and Stewart Fleming. Malignant hypertension. Edited by Neil Turner. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0216.
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Malignant hypertension (MH) is recognized clinically by elevated blood pressure together with retinal haemorrhages or exudates with or without papilloedema (grades III or IV hypertensive retinopathy); and may constitute a hypertensive emergency or crisis when complicated by evidence of end-organ damage including microangiopathic haemolysis, encephalopathy, left ventricular failure, and renal failure. Though reversible, it remains a significant cause of end-stage renal failure, and of cardiovascular and cerebrovascular morbidity and mortality in developing countries.MH can complicate pre-existing hypertension arising from diverse aetiologies, but most commonly develops from essential hypertension. The absolute level of blood pressure appears not to be critical to the development of MH, but the rate of rise of blood pressure may well be relevant in the pathogenesis. The pathogenesis of this transformation remains unclear.The pathological hallmark of MH is the presence of fibrinoid necrosis (medial vascular smooth muscle cell necrosis and fibrin deposition within the intima) involving the resistance arterioles in many organs. Fibrinoid necrosis is not specific to MH and this appearance is seen in other conditions causing a thrombotic microangiopathy such as haemolytic uraemic syndrome, scleroderma renal crisis, antiphospholipid syndrome, and acute vascular rejection post transplant. MH can both cause a thrombotic microangiopathy (TMA) but can also complicate underlying conditions associated with TMA.The pathophysiological factors that interact to generate and sustain this condition remain poorly understood. Risk factors include Afro-Caribbean race, smoking history, younger age of onset of hypertension, previous pregnancy, and untreated hypertension associated with non-compliance or cessation of antihypertensive therapy.Evidence from clinical studies and animal models point to a central role for the intrarenal renin–angiotensin system (RAS) in MH; there is good evidence for renal vasoconstriction and activation of the renal paracrine RAS potentiating MH once established; however, there may also be a role in the predisposition of MH suggested by presence of increased risk conferred by an ACE gene polymorphism in humans and polymorphisms for both ACE and AT1 receptor in an animal model of spontaneous MH. Other vasoactive mediators such as the endothelin and the inflammatory response may be important contributing to and increasing endothelial damage. There have been no randomized controlled trials to define the best treatment approach, but progressive lowering of pressures over days is considered safest unless made more urgent by critical clinical state. It seems logical to introduce ACE inhibition cautiously and early, but in view of the risk of rapid pressure lowering some recommend delay.