Lecture 18

Question 1

Ignac Semmelweis

Answer 1

• puerperal fever and handwashing
• physicians and students performed autopsies and then delivered

Question 2

Maternal mortality

Answer 2

death of a woman while pregnant or within 42 days of the end of pregnancy
- not accidental causes

Question 3

Types of maternal morality

Answer 3

• direct: resulting from obstetric complications
• indirect: not caused by obstetric complications
• later: 42 days to 1 year after pregnancy

Question 4

Direct estimates

Answer 4

• 75% of maternal deaths are from direct cause
• 27% hemorrhage
• 14% hypertensive disorders/preeclampsia
• 11% sepsis

Question 5

Indirect estimates

Answer 5

• most deaths in HICs (underlying medical issues)
• 27% cardiac disease
• 13% thrombosis and thromboembolism
• 10% hemorrhage

Question 6

Maternal mortality ratio

Answer 6

• both chance of pregnancy and chance of death during pregnancy
• most commonly used measure
  = number of maternal deaths/100,000 live births

Question 7

Maternal mortality rate

Answer 7

• does not consider fertility rate
• maternal deaths/100,000 women 15-49yo

Question 8

Data sources

Answer 8

• hard to measure
• civil registration of births and deaths (likely to underestimate true maternal mortality)
• household surveys
• census data
• mortality studies
• verbal autopsy

Question 9

Distribution worldwide

Answer 9

• 99% of deaths occur in LMICs
• Sub-Saharan Africa, South Asia
• MMR higher in LMICs and poor urban settings in HICs
• low SES, rural areas, younger than 15
• complications in pregnancy/childbirth are leading cause for young girls in LMICs

Question 10

Puerperal sepsis

Answer 10

bacterial infection of the genital tract that occurs within 28 days after miscarriage, abortion, or childbirth
- prevention leads to significant gains in mortality
- c section has greatest incidence

Question 11

Septicemia and meningitis

Answer 11

• acute bacterial meningitis

Question 12

Conjunctivitis

Answer 12

• c trachomatis, s aureus, n gonorrhea

Question 13

osteomyelitis and pyogenic arthritis

Answer 13

• bone and joint infections
• mostly young infants

Question 14

skin and soft tissue infections

Answer 14

• cellulitis, abcesses, omphalitis
• s aureus

Question 15

Neonatal sepsis

Answer 15

can look like multiple things, multiple sources of infection
- septicemia/meningitis, conjunctivitis, osteomyelitis/pyogenic arthritis, skin and soft tissue infections

Question 16

neonatal sepsis epi

Answer 16

• african american infants have 3x death rates in US
• prevalent in LMICs
• categorized by early, late, and late, late onset: distinct epidemiologies, outcomes

Question 17

Early onset

Answer 17

• less than 3 or 7 days
• 25% incidence
• premies: lack of maternal antibodies, infections leading cause of prematurity

Question 18

Late, late onset

Answer 18

• after 90 days
• median birth weight < 1000 g
• either really premie and still in hospital or healthy

Question 19

Early - symptom onset

Answer 19

• signs of illness w/in 36 hours in 96%
• almost all by first 12-24 hours

Question 20

Early onset in late premie/term

Answer 20

• group B step and e. coli (common colonizers of GI + vaginal tract)
• treatment: empiric treatment with ampicillin and gentamicin

Question 21

Group B strep

Answer 21

• emerged in 1970s as leading cause
• most infections w/in first 3 months
• intrapartum antibiotic prophylaxis to prevent
• universal culture based screening of all pregnant women 35-37 weeks

Question 22

Group B strep risk factors

Answer 22

• maternal intrapartum GBS colonization
• gestational age less than 37 weeks
• membrane rupture of greater than 12 hours
• temp greater than 99.5 F
• intra amniotic infection
• young maternal age
• black race
• low maternal antibodies

Question 23

GBS risk factor specific

Answer 23

• previous delivery of invasive GBS
• 50-70% of infections occur in absence of risk factors

Question 24

Management strategies

Answer 24

• categorical risk assessment: most treated
• multivariate risk assessment: more complicated, less treated
• serial examination: follow baby for signs of illness

Question 25

Early onset in preterm

Answer 25

- preemies highly vulnerable - e.coli most frequent - worst outcomes

Question 26

hospital acquired late onset

Answer 26

- extremely low gestational age and birthweight infants - flora replaced by hospital acquired bacteria - coagulase-negative staphylococci, s aureus, e. coli and other gram negatives

Question 27

community acquired late onset

Answer 27

- term infants after 3 days of age - e. coli and GBS

Question 28

Prognosis and sequalae

Answer 28

- VLBW infants: poorer neurodevelopmental outcomes (cerebral palsy, cognitive impairment) - bacterial meningitis: high rates of long term disability among survivors

Question 29

Prevention

Answer 29

- prenatal care and intrapartum antibiotic prophylaxis reduce early onset GBS by 85%