Complications of pregnancy and maternal infant outcomes in

Complications of pregnancy and maternal & infant outcomes in Uganda Assoc Professor Annettee Nakimuli Head of Department and Assoc Professor, Obstetrics and Gynaecology Makerere University Mulago Specialized Women and Neonatal Hospital & Kawempe National Specialized Hospital 1

A pregnant woman has one foot in the grave

Introduction o Most pregnancies are uneventful but all pregnancies are risky o About 15% of women develop potentially life-threatening complications o Women in Sub Saharan Africa (SSA) have a 100 -fold increase in the risk of dying during childbirth compared to high income settings o 1 in 180 fifteen-year old females will die from a maternal complication o The maternal mortality ratio in SSA is ~500/100, 000 live births o ~66% of global maternal deaths occur in SSA

Early pregnancy complications ØAbortion/Miscarriage o In Uganda defined as loss of a pregnancy before 28 weeks of gestation ØEctopic pregnancy (tubal pregnancy) o Pregnancy in which implantation is at a site other than uterine cavity o A rare form of extra uterine pregnancy is abdominal pregnancy ØHyperemesis gravidarum o Most severe form of nausea & vomiting in pregnancy o May cause dehydration, electrolytes & acid-base imbalances, nutritional deficiencies, & even death ØGestational trophoblastic disease/molar pregnancy o Typified by abnormal trophoblast proliferation and usually no fetus

Mid-late pregnancy complications (1) ØPre-eclampsia/eclampsia and other hypertensive disorders ØGestational diabetes mellitus o Predisposes to preeclampsia, foetal macrosomia, birth trauma, IUFD etc. ØPreterm labour & delivery o Labour & delivery that occurs before 37 completed weeks of gestation ØAbruptio placentae o Premature separation of placenta from uterus o Usually presents as painful bleeding ØPlacenta praevia o Is a low lying placenta o Usually presents as painless bleeding

Mid-late pregnancy complications (2) ØPlacenta accreta spectrum o Formerly morbidly adherent placenta ØPremature rupture of membranes (PROM) o Rupture of membranes after 37 weeks' gestation and prior to onset of labor ØPreterm premature rupture of membranes (PPROM) o Rupture of membranes prior to 37 weeks' gestation o Both PROM & PPROM predispose to maternal infections and increase neonatal morbidity and mortality ØPolyhydramnios o An abnormally high level of amniotic fluid

Mid-late pregnancy complications (3) ØOligohydramnios o Inadequate volume of amniotic fluid ØVenous thromboembolism (VTE) o Pregnancy increases risk of VTE 4 - to 5 -fold over that in nonpregnant state o Manifestations of VTE are deep venous thrombosis & pulmonary embolus ØAmniotic fluid embolism o Rare but catastrophic condition when amniotic fluid enters maternal circulation ØPost-term pregnancy o Pregnancy that extends beyond ≥ 42+0 weeks of gestation ØAnaemia o Defined as a hemoglobin concentration of less than 11 g/d. L

Fetal complications Ø Intrauterine fetal death ØFetal anomalies ØFeta growth restriction ØMacrosomia (very big baby- usually 4 Kg and above) ØVertically transmitted infections Eg: Toxoplasmosis , Rubella, Cytomegalovirus, Herpes simplex virus, HIV, Zika virus, syphilis, Hepatitis B virus

Intrapartum complications o Uterine rupture o Perineal trauma (lacerations, tears etc. ) o Labour dystocia including obstructed labour o Foetal compromise o Cord prolapse o Perinatal asphyxia o Chorioamnionitis

Postpartum complications o Postpartum haemorrhage – leading cause maternal mortality o Postpartum blues, depression and psychosis o Obstetric fistula and other sequelae of obstructed labour o Postpartum acute kidney injury o Puerperal infections (endometritis) including pelvic abscess o Puerperal mastitis o perineal pain, dyspareunia, sexual dysfunction o Etc

Medical records

Maternal and newborn outcomes in Uganda o Maternal outcomes can be measured by maternal mortality, near miss & proportion of women with postpartum morbidity o In Uganda maternal mortality ratio is 336 deaths per 100, 000 live births [2016 UDHS] o For every maternal death in Uganda, at least six survive with chronic and debilitating ill health o Neonatal mortality rate in Uganda- infant deaths btn 0 -28 days of life per 1, 000 live births is 27 deaths per 1, 000 live births [2016 UDHS] o Infant mortality rate - number of infants who die before first birthday per 1, 000 live births (43 deaths per 1, 000 live births [2016 UDHS]

Conclusions o Despite most pregnancies being uneventful, all pregnancies are at risk o Risk of complications higher in women of SSA o Risk benefit ratios for products could be different o Trials in pregnancy in SSA are a heavy investment directly and indirectly o Pregnancy trials very pertinent in this setting due to the high burden of pregnancy, disease and complications

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