CAUSES OF DEATH AND MORBIDITY IN PREGNANCY.

The question is, why become ill and die in pregnancy and childbirth? About 600,000 maternal deaths occur annually i.e. every minute a woman dies of pregnancy related complications. Throughout the developing world most deaths can be attributed to one of three causes bleeding (haemorhage), infection, eclampsia. The complications that lead to these conditions vary from place to place, however: for example, where women give birth young, as in much of Africa, prolonged obstructed labour leads to many deaths. Where family planning is not available, illegal abortion claims many lives.

1. DIRECT CAUSES OF DEATHS: Deaths from the diseases or complications that occur only during pregnancy are usually called direct obstetric deaths. Although, regional variations exist, bleeding, infection, eclampsia, obstructed labour almost always are listed as the major direct causes of maternal death. Ectopic pregnancy also often causes fatal bleeding.

1. BLEEDING (HEMORRHAGE): Bleeding before or around chldbirth or after abortion can be fatal in minutes if the bleeding is not stopped. Bleeding is most common just after delivery ( post partum haermorrhage). Post partum haemorrhage often occurs because the uterus does not contract vigorously enough to stop bleeding or expel the placenta. This condition UTERINE- ATONY is more common among women of more than four deliveries. Other common causes of severe bleeding before, during, or after delivery are: PROLONGED LABOR, UTERINE RUPTURE, TEARS IN THE CERVIX OR IN THE VAGINA FROM TRAUMATIC DELIVERIES OR FROM POORLY PERFORMED ABORTIONS, ABNORMAL POSITION OF THE PLACENTA, OR EARLY SEPARATION OF THE PLACENTA FROM THE UTERINE WALL.
2. INFECTION: Infection after child birth or illegal abortion is common in developing countries. In large Nigerian and Kenyan studies, for example, 8 and 20% of women, respectively, developed post partum uppper genital tract infections. Women who survive these infections face an increased risk of pelvic adhesion/ tubal damage later. They may also develop ectopic pregnancy, infertility, and chronic pelvic pain.

Unless they have sexually transmitted disease (STDs), women with uncomplicated vaginal deliveries usually do not get infections. The chances of infection increase if labour and delivery are long or if the membranes rupture more than 24 hours before delivery. Frequent vaginal examinations, any surgery or use of instruments during labor and delivery, and lack of sterile technique also make infection more likely. Illegal and poorly performed abortions also lead to infection. Sexually transmitted diseases, particularly gonorrhea and Chlamydia infections often cause postpartum and post abortal infections.

3. ECLAMPSIA AND PRE ECLAMPSIA.

These are poorly understood complications of pregnancy. Pre- eclampsia, the early stage of the disorder, is characterized by HIGH BLOOD PRESSURE, FLUID RETENTION (oedema), and PROTEIN IN URINE. It usually occurs in the second or third trimester of pregnancy. If untreated, pre eclampsia may progress to eclampsia, with very high blood pressure, convulsions or cerebral hemorrhage. Once eclampsia develops, immediate treatment and rapid delivery are needed. Even with treatment, however, the prognosis is poor. Those who survive may suffer such complications as paralysis, blindness or chronic hypertension and kidney damage. Women pregnant for the first time are more likely to develop pre eclampsia and eclampsia.

4. PROLONGED LABOR.

Prolonged labor can kill through blood loss, dehydration, or metabolic disturbances. Fatal bleeding can be due to a ruptured uterus, caused by persistent contractions. When labor lasts too long, the baby must be delivered by forceps, caesarean section or symphysiotomy. When has labor gone on too long? There is no standard answer. First births usually take longer than subsequent births. In general, however, a woman needs medical help if she has labored for more than 12hours from active phase of labor (from cervical dilatation of more than or equals 4cm).

Prolonged labor is common in developing countries. It has various causes as,

1. Celphalopelvic disproportion: when the foetal head cannot pass through the pelvis leading to obstructed labor. The woman’s pelvis is too small for many reasons e.g. in Africa due to poor nutrition and stunting in childhood which kept her pelvis from developing normally or because she became pregnant too young, before pelvic growth was complete. Other causes of prolonged or obstructed labor are weak uterine contractions, which are particularly among women who have had many children, deformity or abnormal position of the fetus, and abnormalities of the cervix or vagina, sometimes caused by female circumcision.

5. ILLEGAL ABORTION: Illegal abortion leads to complications that cause 115,000 to 200,000 maternal deaths each year. Infection or bleeding from uterine or cervical lacerations causes most of these deaths.
6. ECTOPIC PREGNANCY: Implantation of a fertilized egg outside the uterus can cause life threatening bleeding. Surgery to stop bleeding is necessary. Many preventable deaths occur, however, because ectopic pregnancy is misdiagnosed or because women cannot get care as soon as the symptoms begin.

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