Transcript Perinatal mortality

Perinatal mortality
Congenital malformations
Birth trauma
Dr Renu Singh
Perinatal mortality(PNM)
• Includes late fetal deaths &early neonatal
deaths
• Late fetal deaths (stillbirths): ≥ 28 weeks
gestation till delivery
• Early neonatal deaths: ≤ 7 days of birth
• Perinatal mortality in developed nations :<10
per 1000 births
• Developing countries: high,32-35 per 1000 in
India
Definition
• Perinatal mortality: all fetal & neonatal deaths
weighing 1000g or more between 28 weeks of
gestation to first week of neonatal life(WHO)
• Perinatal mortality rate: expressed in terms of
perinatal deaths per 1000 total births
Factors affecting PNM
• Maternal age
– Teenage pregnancies, elderly gravida
• Parity
– Anemia, inadequate prenatal care, inadequate rest,
Malpresentation, multiple births
• Socioeconomic factors
– Lower socioeconomic status vs upper strata
• Obstetric factors
– Placental insufficiency, APH, intrapartum care,
malpresentation ,multiple births
Causes of PNM
• Antenatal causes
– Maternal diseases, APH
• Intranatal causes
– Birth injuries, prolonged & difficult labor
– Birth asphyxia
• Postnatal causes
–
–
–
–
Prematurity
RDS
Respiratory, alimentary tract infections
Congenital malformations
• Unknown: 30-35%
At risk pregnancies
•
•
•
•
•
•
•
Low socioeconomic status
Elderly gravida,
Teenage pregnancy
Poor past obstetric history
Malnutrition & severe anemia
Multiple pregnancy
Present pregnancy complications
Perinatal mortality rate
•
•
•
•
•
•
India (2010):
Kerala:
UP:
Rajasthan:
Odisha:
MP:
32 per 1000 births
12 per 1000 births
35 per 1000 births
37 per 1000 births
41 per 1000 births
42 per 1000 births
Reducing PNM
• Education ,Improving living standards, raise social
status
• Universal prenatal care for all
• Identify at risk pregnancies
• Facilitate early & timely transfer of high risk women
to higher centre
• Strengthen the referral system
• Essential newborn care to all,neonatal resuscitation
• Accessible neonatal services
Congenital malformations
Congenital malformations
• Structural abnormality which is present at
birth
• Incidence of fetal malformations: 2-5%
• Account for 20% of perinatal deaths
• WHO estimate: 2.76 million perinatal deaths
due to congenital malformations(2013)
Terminology
• Malformation:
an abnormality of the
development process (spina bifida)
• Deformation: mechanical interference with
normal development (talipes)
• Disruption: interference with normal growth
after a period of normal development(bowel
atresia)
etiology
• Chromosomal abnormalities: Trisomy
(21,13,18),XO
• Single gene mutation: Achondroplasia(AD)
• Genetic predisposition
• Multifactorial: NTD, congenital heart defects, cleft lip,
palate
• Drugs : lithium,valproate
• Infection during pregnancy: Rubella,CMV
• Mechanical factors: Talipes, potter sequence
High risk pregnancies
•
•
•
•
•
•
•
•
Uncontrolled diabetes in mother
Elderly gravida
Exposure to teratogenic drugs in 1st trimester
Maternal rubella in first trimester
H/O an affected sibling
Polyhydramnios/oligoamnios
Fetal growth restriction
Single umbilical artery
investigations
• Biochemical screen:
– MSAFP
– Acetylcholine-esterase,hCG,uE3,inhibin A
• Ultrasound soft markers
– Echogenic foci in heart, echogenic bowel, pyelactasis
• Ultrasonography
– detailed structural anatomy,2D/3D
• Targeted imaging for fetal anomalies(TIFA)
– DM, hypothyroid, antiepileptic drugs
Investigations
• Invasive procedures
– CVS(chorionic villus sampling): obtain chorionic
tissue
– Amniocentesis: amniotic fluid
– Cordocentesis: fetal blood
– Fetoscopy : see fetal malformations
• Fetal echocardiography: suspected CVS
anomalies ,diabetes
Congenital malformations
• Malformations of the CNS:
– spina bifida, anencephaly, hydrocephalus
• Skeletal malformations
– Clubfoot, congenital dislocation of hip, skeletal
dysplasias
• GIT malformations
– Omphalocele, gastroschisis, ileal atresia, duodenal
atresia,Tracheoesophageal fistula
• Genitourinary abnormalities
• CVS abnormalities
Spina bifida
• Failure of closure of the neural tube
• Spina bifida occulta: defect is covered with
skin
• Spina bifida aperta: swelling seen over the
spinal defect with defective skin covering
• Meningocele
• Myelomeningocele(spinal cord is involved)
• Cephaloencephalocele(brain tissue involved)
Spina bifida
Spina bifida
• Lumbar defects : common
• Complications associated are
–
–
–
–
Paralysis of lower limbs
Urinary ,fecal incontinence
Hydrocephalus
Limb deformity
• Prognosis:60% survive with severe mental &
physical handicap in 1/3rd ( immediate closure of
defect)
anencephaly
• Rudimentary brain with absent cerebral
hemispheres ,absent vault
• Most severe form of NTD
• Prenatal diagnosis as early as 14 weeks
• Offered MTP
• Uniformly lethal
anencephaly
NTD: screening & prevention
• MSAFP at 16-18 weeks : elevated ,2.5 MoM(95%
DR)
• Targeted Ultrasonography
• Prognosis : Site &size of lesion, associated anomalies
• Prevention: periconceptional administration of folic
acid
• Low risk women: 0.4-0.5 mg /day
• h/o NTD: 5mg/day
• Role of preconception counseling
Exomphalos
• Midline abdominal wall defect
• Herniation of bowel contents or liver into the
umbilical stump with membranous covering
• Raised MSAFP, USG,invasive prenatal
procedures
• Associated chromosomal abnormalities
• Treatment is surgical
gastroschisis
• Prolapse of intestine through paramedian
abdominal wall defect
• No covering membrane
• Urgent surgical treatment
omphalocele
Gastroschisis
Cleft lip ,cleft palate
• Cleft lip(hare lip): unilateral/bilateral
• Cleft palate: defect in roof of hard palate
• Associated
abnormalities:
micrognathia
/retrognathia
• Feeding difficulties ,more with cleft palate
• Small plastic plate ,obturator fits into the roof
blocks the opening ,helps in feeding
• Definitive t/t: surgery:3-4mths(hare lip),1-1/2
yrs
Birth trauma
• Injuries sustained during labor & delivery
• Stillbirth,neonatal deaths,morbidities
• Important cause of PNM
Predisposing factors
•
•
•
•
•
•
•
•
Prolonged labor,obstructed labor
Fetal macrosomia
CPD
Malpresentation(breech)
Instrumental delivery(forceps/ventouse)
Shoulder dystocia
Precipitate labor
Internal podalic version
Soft tissue
Skin laceration, abrasion
Nerve injury
Facial nerve injury
Brachial plexus injury
Visceral injury
Rupture of liver, spleen
scalp
Laceration, cut, hemorrhage
skull
Cephalhematoma, subgaleal
hematoma
intracranial
Intracranial hemorrhage
bones
Fracture of femur, clavicle
,humerus
dislocation
Hip, shoulder
cephalhematoma
• Blood collection between pericranium & flat skull
bone
• Unilateral, over parietal bone
• Rupture of small emissary vein
• Forceps delivery, normal delivery
• Never present at birth, develops over 12-24 hrs
• Swelling limited by suture lines
• Good prognosis, blood gets absorbed in 6-8 wks
• Vs.Caput succadaneum,meningocele
Intracranial hemorrhage
• Traumatic
– Fracture of skull bone : extradural or subdural
hemorrhage
– Neurological symptoms: acutely or insidious
onset(vomiting, irritability)
– Massive subdural hemorrhage : tear of tentorium
cerebelli, injury to superior saggital sinus
Intracranial hemorrhage
• Mechanism of tentorial tear
– Excessive moulding in deflexed vertex with gross
CPD
– Rapid compression & decompression of after
coming head of breech
– Forcible forceps traction after wrong application
of blades
• Outcome: fatal, severe respiratory depression
Anoxic ICH
• Intraventricular : intense congestion of fragile
choroidal plexus due to anoxia
• Subarachnoid: tear of tributary veins from
brain to sinuses
• Intracerebral: petechial hemorrhage in brain
substance due to anoxia
Prevention of intracranial injuries
• Comprehensive antenatal & intranatal care
• Intensive fetal monitoring during labor : early
detection of fetal hypoxia
• Avoid difficult or traumatic vaginal delivery
• Breech delivery: liberal use of CS,precautions
while delivering limbs & aftercoming head
• Vit.K 1mg IM after birth
Treatment of ICH
• Supportive treatment
– Maintain temperature,humidity,oxygen
– Feeding by nasogastric tube,maintain fluid
balance
• Anticonvulsants: phenobarbitone(510mg/kg/day in divided doses) ,6 hrly
intervals,IM
• Subdural tap/surgical removal of clot
Skin & subcutaneous tissue
• Bruises & lacerations over Face
• Edematous & bruised scalp
• Buttocks, genitalia gets edematous & bruised
in breech presentation
• Eyelids, nose,lips get bruised in face
presentation
• Needs no treatment
Muscles
•
•
•
•
•
Sternomastoid hematoma
Junction of upper & middle third
Appears 7-10 days after birth
Rupture of muscle fibres & blood vessels
Difficult breech delivery, excessive lateral
flexion of neck in normal delivery, shoulder
dystocia
• Conservative, disappears by 6 mths age
Nerve injuries
• Facial nerve palsy
– Direct pressure of forceps blade
– Hemorrhage & edema around nerve
– Eye of affected side remains open
– Angle of mouth drawn to unaffected side
– Usually disappears in weeks, if isolated
• Erb’s palsy
– 5th & 6th cervical nerve roots involved
– Waiter’s tip(extension of elbow, pronation of
forearm, flexion of wrist)
Nerve injuries
• Klumpke’s palsy
– 7th ,8th cervical or 1st thoracic nerve roots
– Arm flexed at elbow,forearm supinated ,claw like
deformity of hand
– Horner’s syndrome(homolateral ptosis,small
pupil)
• treatment
– Splint
– Full recovery, permanent disability
Fracture long bones
•
•
•
•
•
•
Fracture femur, humerus,radius,ulna
Breech delivery
Greenstick or complete type:X-ray
Rapid union occurs with callus formation
Deformity is rare
Treatment: splinting, closed reduction &
casting
Fracture humerus
Prevention of newborn injuries
• Screen out the high risk women in antenatal
period: CPD, malpresentation::CS
• Intranatal period
– Continuous fetal monitoring
– Difficult forceps to be avoided
– Judicious selection of suitable candidates for
instrumental delivery
– Breech delivery by skilled personnel
Perinatal mortality
• Role of fetal autopsy: ability to pick up minor
anomalies /anomalies not detected on USG
• Ethical, religious concerns
• Careful examination, photograph & radiograph of
fetus
• Postmortem MR imaging : structural information of
CNS anomalies
• Helps in identifying the cause of fetal loss
• Facilitates genetic counseling
Summary
• Perinatal mortality is high in developing
countries
• India : 32per 1000 births(rural:35,urban:22)
• Comprehensive antenatal and intranatal care
is key to success in reduction of birth trauma
& subsequently reduction in perinatal
mortality
• At birth ,essential newborn care to all
MCQ1
• Babies chosen for perinatal statistics include
all except
1. Late fetal deaths
2. Early neonatal deaths
3. Body length (CHL) of 35 cm
4. 800 g at birth
MCQ1
• Babies chosen for perinatal statistics include
all except
1. Late fetal deaths
2. Early neonatal deaths
3. Body length (CHL) of 35 cm
4. 800 g at birth
MCQ2
• One of the following drug is safe in pregnancy
1. Thalidomide
2. Sodium valproate
3. Ferrous sulfate
4. coumarins
MCQ2
• One of the following drug is safe in pregnancy
1. Thalidomide
2. Sodium valproate
3. Ferrous sulfate
4. coumarins
MCQ3
• One of the following is not true in relation to
cephalhematoma
1. Present at birth
2. usually unilateral
3. Limited by suture line
4. Resolves in few weeks
MCQ3
• One of the following is not true in relation to
cephalhematoma
1. Present at birth
2. usually unilateral
3. Limited by suture line
4. Resolves in few weeks
MCQ4
• Which of the following malformations in a
newborn is specific for maternal insulin
dependent diabetes mellitus
1. Transposition of great vessels
2. Caudal regression
3. Holoprosencephaly
4. meningomyelocele
MCQ4
• Which of the following malformations in a
newborn is specific for maternal insulin
dependent diabetes mellitus
1. Transposition of great vessels
2. Caudal regression
3. Holoprosencephaly
4. meningomyelocele
MCQ 5
• Thalidomide tragedy has been associated
with this congenital anomaly
1. Cleft lip &palate
2. Vaginal adenoma
3. Microcephaly
4. phocomelia
MCQ 5
• Thalidomide tragedy has been associated
with this congenital anomaly
1. Cleft lip &palate
2. Vaginal adenoma
3. Microcephaly
4. Phocomelia
MCQ6
• The perinatal mortality rate(per 1000 births)
of India(urban) at present is
1. 22
2. 32
3. 35
4. 40
MCQ6
• The perinatal mortality rate(per 1000 births)
of India(urban) at present is
1. 22
2. 32
3. 35
4. 40