1) Thromboembolism:

Changes in the clotting factors and venous stasis and thromboembolism (especially after cesarean section).

Thromboembolism may cause death in any of the trimesters of pregnancy.

Thrombolism may also occur after delivery (postpartum).High risk factors for postpartum thrombolism include age over 35 , obesity, post cesarean section.

Mutations in Factor V Leiden and heterozygous factor II can also increase the risk of venous thromboembolism in pregnancy.

The incidence of venous thromboembolism is much higher in women who have both Factor V and factor II mutations.

Increased use of prophylaxis (such as compression stockings in high risk women), can reduce the risk of thromboembolism.

Very high risk pregnant patients (such as patients with a family history and/or personal history of thromboembolism) must be on heparin prophylaxis.

Numerous studies have shown that the use unfractionated heparin (or low molecular weight heparin) with low dose aspirin throughout pregnancy improves fetal outcomes.

2)Haemorrhage:

Postpartum haemorrhage accounts for 50% of the cases of haemorrhage related to pregnancy. The remaining 50% is due to antepartum haemorrhage (This includes placenta praevia and abruptio placentae.) 25% are due to placenta praevia and the remaining 25% is due to abruptio placentae.

Placenta praevia

Placenta praevia is particularly dangerous if it is implanted over a uterine scar. Only a consultant or a senior registrar must carry out the cesarean section for placenta praevia.

Abruptio Placenta

Usually associated with severe pain, but may not have  bleeding per vaginum. Coagulopathy could complicate abruptio placenta.

Postpartum haemorrhage

This topic will be covered in numerous posts .All hospitals must have clear guidelines for the management of postpartum haemorrhage.

3) Hypertensive disorders in pregnancy:

Severe hypertensive disease usually presents around 32 weeks of gestation. Some of the complications of hypertensive disorders in pregnancy include intracranial haemorrhage, acute respiratory distress syndrome,pulmonary edema, cerebral edema etc.

4)Amniotic fluid embolism:

When amniotic fluid finds its way to the maternal circulation, there is a sudden severe reaction in the lungs. This can cause sudden collapse and death, usually during labour.

Proof of the diagnosis is by finding fetal squames in the mothers lungs at autopsy.

5)Puerperal Sepsis:

This is common in developing countries. Prophylactic antibiotics may be given in cesarean section. Prophylactic antibiotics are not recommended in normal vaginal delivery.

6)Deaths during early pregnancy:

This refers to deaths occuring before 24 weeks of gestation.

The common causes of death during this period include ectopic pregnancy, spontaneous abortion and termination of pregnancy.

Ectopic pregnancy presents as abdominal pain with a positive pregnancy test.This can progress to shock and death rapidly if not managed immediately.

7 Deaths due to anaesthesia

This is very rare these days, due to use of modern equipments and anaesthetics.

8)Death due to genital tract trauma

Such as uterine rupture and uterine perforation. This can follow instrumental vaginal delivery.

References:

Pages 175 to 181. Chapter 21. Thrombophilia in Pregnancy by Pankaj Desai and Purvi Patel. Medical Disorders in pregnancy-An Update. Edited by Hiralal Konar and Pralhad Kushtagi. Federation of obstetric and gynaecological societies of India.

Pages 20 to 32.Chapter 3. Maternal and Perinatal Mortality.Obstetrics by Ten Teachers.Seventeenth edition. Edited by Stuart Campbell and Christoph Lees.

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Causes of Maternal Mortality:

1)Severe bleeding- 25%

2)Indirect Causes -20% eg anaemia,malaria and heart disease.

3)Infection- 15%

4)Eclampsia-12%

5)Unsafe abortion-13%

6)Obstructed labour-8%

7)Other direct causes-eg embolism, ectopic pregnancy and anaesthesia related.

The causes of maternal mortality are the same in developed and

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Clear definitions of maternal mortality must be made so that we can compare these rates from different communities/countries. By allowing us to focus on the causes of mortality (especially the common causes), we will be able to reduce the maternal mortality rate.

Important definitions in maternal mortality:

Maternal Mortality rate:

This is the risk of women dying from "puerperal causes".

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i) There should be no delay in the examination:

Valuable time should not be lost when a woman complains of rape. She should be brought immediately for medical examination.

The police should bring the alleged rape victim as soon as possible. Detail statements may be taken by the police after the medical examination.

Medical evidence is very important in cases of… Continue reading

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Drugs to be given to rape victims:

i) Analgesics or sedatives should be administered if indicated.

ii) Tetanus toxoid should be given if deep lacerations are present.

iii)Antibiotic -Ceftriaxone, 125mg intramuscularly to prevent gonorrhea.

-Give metronidazole 2 g (single dose) and azithromycin 1g orally (or doxycycline 100mg twice daily-for 7 days) to prevent chlamydial infection.

Syphilis: The above antibiotics will probably… Continue reading

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Because of the gravity of the situation, the emergency staff/ clinician who first sees a rape victim must be empathetic.

1)Written consent must be obtained for the gynaecological examination.

Photographs may also be taken if they are to be used as evidence. The written consent may be obtained either from the patient or guardian/next of kin.

The police should also be notified as soon as… Continue reading

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Rape has many definitions ,depending on various jurisdictions. It is important for emergency staff and clinicians who deal with rape victims to be familiar with the laws pertaining to rape (sexual assault )in their own country and state (laws vary in different us states).

About 95% of rape victims are women. It is also essential to note that people involved in the management of rape victims understand… Continue reading

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History of Menstruation

These are questions that will be asked by your doctor. It is very important in gynaecological disorders.

i)How old were you when the monthly periods (menstrual periods) began. This is the age of menarche.

ii) What is the date of your last period?Can you remember it. What the the period before the last one?

iii)How often do you have… Continue reading

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The patients should be educated about the start-up symptoms of HRT.

These inclede:

-Breast tenderness

-Nipple sensitivity

-Rise in appetite

-Weight gain

-Cramps in the calf

Patients should be informed that during starting the HRT symptoms similar to early pregnancy will be common.These symptoms usually remit at about 12 to 14 weeks of gestation.

Patients receiving HRT should ideally be

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Weather to take postmenopausal hormonal therapy or not is one of the most complex health care decisions facing women. It is also a complex decision for doctors to determine which of their patients will benefit from postmenopausal hormonal replacement therapy.

In the United States about 30% of postmenopausal women use hormonal replacement therapy.

Please do not forget to read my post on the benefits and risks… Continue reading

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