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31.01.2015
But substantial progress has been made, which, in human terms, means that hundreds of thousands of maternal deaths have been prevented.
These roll-up figures mask a wide variation in the distribution of maternal mortality; in 2010, an astounding 99% of deaths occurred in the developing world (56% in sub-Saharan Africa alone), and the MMR in developing countries is, on average, 15 times higher than in developed countries. Scan the list of countries and it becomes clear that the MMR problem is clustered in Africa, with few exceptions; there’s wide variation among developing countries, too.
Treatment of pre-eclampsia and eclampsia involves the injection of magnesium sulphate, a cheap compound (in the West, the non-pharmaceutical preparation is known as Epsom salt). Prevention of puerperal fever*, or sepsis more generally, is a matter of maintaining proper sanitation before, during, and after a birth. Here’s what’s clear: the devil isn’t in the details – it’s in the diffusion of pharmaceuticals, health care workers, and knowledge through health systems, and in improving those systems holistically. The complex task of reducing maternal mortality demands a multifactorial solution that draws on a wide coalition of government departments and private organizations – and each country has to find a solution that meshes with its own cultural and structural realities. The imminent failure to reach the goal of reducing the MMR by 75% by 2015 shouldn’t obscure the fact that there are hundreds of thousands of mothers alive who, without the focus on maternal mortality, may not be otherwise.
Post-Partum Haemorrhage (PPH) is blood loss in excess of 500mL after the birth of the child.
Eclampsia is hypertension caused by pregnancy which can lead to seizures, liver and kidney damage, and death. Sepsis is an umbrella term for a range of blood infections; one of the most common during pregnancy is puerperal sepsis, which occurs when bacteria is introduced during the course of birth. While the primary objective of pre-natal care is to reduce maternal and fetal morbidity and mortality, it is also a unique opportunity to see women regularly and impact their health long term. Prenatal care includes education, preventive health care, and identification and mitigation of risks to mother and child. Signs of pregnancy include absence of menstrual period, breast tenderness and fullness, fatigue, nausea, and urinary frequency.
Biochemical testing is done by detecting the beta subunit of the human chorionic gonadotropin (hCG) in urine or blood. Blood tests are typically positive 9 days post-conception, while urine tests are usually positive 14 days post-conception. The initial visit should occur within 12 weeks of the LMP, or earlier if the pregnancy is higher risk.


Gestational age is important to determine overdue status, for planning the birth and identifying the proper windows for screening. From the date (first day) of the LMP, add 7 days and subtract 3 months from women with 28-day cycles. Cycle regularity is important if using dates; ask the patient about regularity and contraception. If the patient is unsure of their LMP, the most accurate method is the earliest done ultrasound, if available. Begin with personal and demographic information to learn more about the patient as a person. Physical exam is done to ensure current maternal health and predict any potential problems with the pregnancy.
Given the above risks, it is important to prepare for poor outcomes before, during, and after labour. Urinanalysis is done, though dipsticks will miss up to 25% of asymptomatic bacteriuria (ASB). Subsequent visits should occur every 4-6 weeks until 28 weeks, every 2 weeks until 36 weeks, and every week thereafter. If there is concern regarding mood disorders, the Edinburgh Postnatal Depression Scale is one of the most frequently used tools. At each visit, urine dip for protein (kidney function) and glucose (gestational diabetes) should be carried out. If significant leukocytes are seen on urinalysis, sending for urine culture may be helpful to rule out asymptomatic bacteuria (which must be treated). Feel free to use and share this material as widely as possible, according to our Creative Commons license. It’s worth taking a step back to understand the scope and scale of the problem, and to think through the interventions that have been successful in myriad developing and developed countries. In 2010, an estimated 287,000 mothers died from pregnancy-related causes, or 210 deaths per 100,000 live births; it’s an almost 50 percent reduction from 1990, when an estimated 543,000 mothers died, or 400 per 100,000 live births. According to the World Bank, the country with the highest MMR in 2010 was Chad, the lowest Estonia, at 1,100 and 2 per 100,000 live births, respectively.
A Randomized Controlled Trial (RCT) found that women who received AMTSL experienced PPH 6.8% of the time vs.


Unfortunately, it may take more than 20 or 25 years to build out this basic scaffolding on which to build sustainable change.
While there are risk factors most women who develop PPH have none; in other words, all women are at risk. Prenatal care can be provided by a number of individuals, including family doctor, nurse practitioner, obstetrician, midwife, or a combination of these. Topics should include nutrition, folic acid supplementation, substance use, and violence and abuse.
Home testing has a sensitivity of 75%, while clinical laboratory testing has a sensitivity between 97-100% for both blood and urine. It includes a complete history, physical examination, appropriate lab investigations, and counselling. Urine culture should be done between 12-16 weeks, as this detects 80% of women with ASB during pregnancy. If gestational age estimated from the 1st trimester ultrasound is more than 5 days apart from the age calculated from the LMP, the due date should be changed to reflect the dates based on ultrasound. And keep in mind: that’s only if the mother has a trained health care worker by her side, which in sub-Saharan Africa puts her in the minority, with only about 46% of births attended by skilled health personnel in 2008.
ASB occurs in 2-7% of pregnant women and can lead to pyelonephritis, low birth weight, and preterm delivery and therefore must be treated (Bachman et al, 1993). If the 2nd trimester ultrasound is off by 10 days, the dates should also be changed to reflect this assessment. A history of rubella and varicella infection or vaccination should be evaluated, with titres or immunization potentially required.
Chronic health conditions such as diabetes, asthma, hypertension, heart disease, kidney disease, or depression should be optimized.



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