Table 26.1Maternal and Perinatal Focus Conditions and Risk Factors for These Conditions

Risk factors for condition Risk factors for death from condition
Condition Definition or complications and sequelae Case fatality ratea (percent) Average duration until death if condition fatal Timing of presentation Distal or proximate Direct, physiological Distal or proximate Direct, physiological
Maternal
HemorrhageDefinition
Antepartum hemorrhage: bleeding from the genital tract during the last 3 months of pregnancy
Not available12 hours28 weeks of gestation up to deliveryPrimigravidity Grand multiparity (greater than 4)
Fibroids
Anemia
Placental abnormalities (including placenta previa; abruption; placenta accreta, percreta, increta; other adhesions)Remote location
Anemia
Coagulopathies
Lack of blood transfusion
Badly managed third stage of labor
Delay or absence of oxytocic treatment
Primary postpartum hemorrhage: excessive bleeding (more than 500 milliliters) from the genital tract following delivery1.0b2 hoursDelivery to 24 hours after deliveryPolyhydramnios
Multiple gestation
Previous third-stage complication
Previous cesarean section
Preeclampsia, eclampsia
Intrauterine death
Hepatitis
Induced labor
Prolonged labor
Precipitate labor
Forceps delivery
Cesarean section
Chorioamnionitis
Disseminated intravascular coagulation
SepsisDefinition
Infection of the genital tract or extragenital infections following childbirth
1.36 daysDelivery to 6 weeks postpartumImmunosuppression
Anemia
Sexually transmitted infections
Inadequate prenatal care
Prolonged labor
Obstructed labor
Premature rupture of membranes
Frequent pelvic examinations
Intrauterine death
Foreign body insertion (for example, herbs)
Episiotomy
Instrumental delivery
Cesarean section
Unhygienic delivery conditions
Retained products of conception
Delivery by untrained personnel
Immunosuppression
Anemia
Lack of knowledge about warning signs
Lack of postnatal care
Cultural practices
Misdiagnosis
Inappropriate use of antibiotics
Lack of access to intravenous antibiotics
Hypertensive disorders of pregnancyDefinition
Raised blood pressure with proteinuria
1.72 days (eclampsia)28 weeks of gestation to 2 days postpartumExtremes of maternal age
Primigravidity
Genetic predisposition
Racial or geographical predisposition
Diabetes and chronic hypertension
Lack of prenatal care
Multiple gestations
Molar pregnancy
Previous history of pregnancy-induced hypertension or chronic hypertension
Cultural practices
Lack of knowledge
Lack of prenatal care
Appearance of complications, such as cardiovascular and cerebral complications, hemolysis, elevated liver enzyme, low platelets syndrome
Disseminated intravascular coagulation
Eclampsia
Obstructed laborDefinition
Labor in which progress is arrested by mechanical factors
0.73 daysDuring laborMalnutrition
Rickets in childhood
Bony deformity of pelvis
Achondroplasia
Short stature
Primigravidity
Grand multiparity
Adolescent pregnancy
Cephalopelvic disproportion
Malpresentation, position
Lack of access to cesarean delivery
Lack of access to instrumental delivery and symphysiotomy
Scarred uterus
Inappropriate use of oxytocin
Uterine rupture
Hemorrhage
Sepsis
Exhaustion, dehydration
Unsafe abortionDefinition
Procedure for terminating an unintended pregnancy carried out by people lacking the necessary skills or in an environment that does not conform to minimal medical standards or both
0.36 hours to 6 daysAfter first missed period to 22 weeks of gestation or fetal weight of less than 500 gramsUnwanted pregnancy
Adolescence
Unmarried status
Absence of legal abortion services
Lack of access to contraception
Lack of access to safe abortion services
Sexually transmitted infections
Absence of aseptic technique
Foreign body insertion
Poisoning from abortifacients
Sociocultural factors
Lack of access to safe termination services
Lack of access to postabortion care
Perforated uterus
Poisoning from abortifacients
Peritonitis
Septic shock
Acute renal failure
Hepatorenal failure
Bowel injury, perforation
Hemorrhagic shock
Peritonitis
Perinatal c
Low birthweight (less than 2,500 grams)dComplications or sequelae
Respiratory insufficiency in preterm infants with lung immaturity presenting as respiratory distress syndrome because of surfactant deficiency
Neonatal cerebral injury caused by periventricular hemorrhage mediated by perinatal stress such as hypotension or trauma
Severe physiological jaundice of preterm infant
Difficulties in establishing spontaneous feeding and inability to tolerate feeds resulting from prematurity
Failure of closure of the ductus arteriosus, frequently seen in preterm babies with lung disease
Hypoglycemia and other metabolic disorders related to prematurity
50
80
50
20
70
2
5 days
3 days
1–5 days
1–14 days
3 days to months
7 days
Less than 24 hours
1–4 days
2–5 days
First day
3–14 days
Birth
Extremes of maternal age
Race, ethnicity
Low socioeconomic status
Unmarried status
Lack of education
Parity (0 or greater than 4)
Smoking, alcohol use
Maternal malnutrition
Maternal diabetes or hypertension
Genetic factors
Rubella, other viral infection
Poor obstetric history
Diethylstilboestrol, other toxic exposure
High altitude
Absent or inadequate prenatal care
Multiple pregnancy
Short interpregnancy interval
First or second trimester bleeding
Placenta previa
Preeclampsia
Anemia
Hyperemesis
Isoimmunization
Fetal abnormalities
Cervical incompetence
Oligohydramnios or polyhydramnios
Lack of adequate neonatal care facility
Lack of knowledge and understanding
Birth asphyxia
Intraventricular hemorrhage
Central nervous system injury
Respiratory infection
Respiratory distress syndrome
Necrotizing enterocolitis
Cholestatic liver disease
Other infections
Sudden infant death syndrome
Neonatal coagulopathy
Birth asphyxia (excluding birth trauma)Complications or sequelae
Absent or depressed breathing at birth
Neonatal encephalopathy: clinically evident disturbance in neurological behavior, commonly with early neonatal seizures in term babies, resulting from an event causing hypoxia during delivery
20
30
20 minutes
3 days to life
Birth (5 minutes)
Birth to first 12 hours
Drugs taken during labor, including anesthesia
Maternal diabetes
Maternal hypertension
Preeclampsia
Any other severe illness
Prolonged or obstructed labor
Abruptio placentae
Placental infarct, insufficiency
Postmaturity
Prematurity or low birthweight
Multiple pregnancies
Placenta previa or separation
Cord prolapse
Badly conducted labor
Lack of fetal monitoring
Lack of partograph
Lack of neonatal resuscitation facilities
Central nervous system injury
Neonatal encephalopathy (seizures and recurrent apnea)
InfectionComplications or sequelae
Neonatal sepsis of early onset resulting from intrauterine or intrapartum infection
Neonatal sepsis of late onset resulting from nosocomial infection or lack of immunity to commensal bacteria
Tetanus neonatorum, commonly resulting from unhygienic cutting of the cord or care of the cord stump
Congenital syphilis resulting from transplacental infection with Treponema pallidum after 18 weeks gestation
HIV infection transmitted either intrapartum or postpartum
30–40
15
80
30
5 days
5 days
3–7 days
5 days
First 3 days
After 3 days
3–14 days
Birth onward
Direct effects mainly after neonatal period
Lack of adequate prenatal care
Maternal infection
Lack of maternal immunization
Unhygienic cultural practices
Premature rupture of membranes
Preterm delivery
Birth asphyxia
Unhygienic delivery and cord care
Congenital HIV infection
Lack of adequate neonatal care
Preterm delivery
Septic shock
Respiratory failure
Hepatorenal failure
Coagulopathies

Source: Maternal conditions: Chamberlain 1995; case fatality rates: AbouZahr 2003; mechanical factors of obstructed labor: WHO 1994; unsafe abortion: WHO 1992b; low birthweight: Bale and others 2003, Robertson 1993, Yasmin and others 2001; birth asphyxia: Bale and others 2003, p. 324, Robertson 1993; infections: Robertson 1993; risk factors: Calder and Dunlop 1992, Murray and Lopez 1998.

a. Case fatality rates assume that no intensive care is available, because this is the norm in South Asia and Sub-Saharan Africa.

b. Case fatality for severe pph (blood loss ≥1000 ml).

c. Excludes stillbirths.

d. Includes preterm deliveries and small for gestational age.

From: Chapter 26, Maternal and Perinatal Conditions

Cover of Disease Control Priorities in Developing Countries
Disease Control Priorities in Developing Countries. 2nd edition.
Jamison DT, Breman JG, Measham AR, et al., editors.
Copyright © 2006, The International Bank for Reconstruction and Development/The World Bank Group.

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