birth_trauma_congenital_malformations_perinatal_mortality.ppt

Perinatal mortality�Congenital malformations�Birth trauma�

1. Perinatal mortality
Congenital malformations
Birth trauma
Dr Renu Singh

2. Perinatal mortality(PNM)
•Includes late fetal deaths &early neonatal
deaths
•Late fetal deaths (stillbirths): ≥ 28 weeks
gestation till delivery
•Early neonatal deaths: ≤ 7 days of birth
•Perinatal mortality in developed nations :<10
per 1000 births
•Developing countries: high,32-35 per 1000 in
India

3. Definition
•Perinatal mortality: all fetal & neonatal
deaths weighing 1000g or more between 28
weeks of gestation to first week of neonatal
life(WHO)
•Perinatal mortality rate: expressed in terms of
perinatal deaths per 1000 total births

4. Factors affecting PNM
•Maternal age
–Teenage pregnancies, elderly gravida
•Parity
–Anemia, inadequate prenatal care, inadequate rest,
Malpresentation, multiple births
•Socioeconomic factors
–Lower socioeconomic status vs upper strata
•Obstetric factors
–Placental insufficiency, APH, intrapartum care,
malpresentation ,multiple births

5. Causes of PNM
•Antenatal causes
–Maternal diseases, APH
•Intranatal causes
–Birth injuries, prolonged & difficult labor
–Birth asphyxia
•Postnatal causes
–Prematurity
–RDS
–Respiratory, alimentary tract infections
–Congenital malformations
•Unknown: 30-35%

6. At risk pregnancies
•Low socioeconomic status
•Elderly gravida,
•Teenage pregnancy
•Poor past obstetric history
•Malnutrition & severe anemia
•Multiple pregnancy
•Present pregnancy complications

7. Perinatal mortality rate
•India (2010): 32 per 1000 births
•Kerala: 12 per 1000 births
•UP: 35 per 1000 births
•Rajasthan: 37 per 1000 births
•Odisha: 41 per 1000 births
•MP: 42 per 1000 births

8. Reducing PNM
•Education ,Improving living standards, raise social
status
•Universal prenatal care for all
•Identify at risk pregnancies
•Facilitate early & timely transfer of high risk women
to higher centre
•Strengthen the referral system
•Essential newborn care to all,neonatal resuscitation
•Accessible neonatal services

9. Congenital malformations

10. Congenital malformations
•Structural abnormality which is present at
birth
•Incidence of fetal malformations: 2-5%
•Account for 20% of perinatal deaths
•WHO estimate: 2.76 million perinatal deaths
due to congenital malformations(2013)

11. Terminology
•Malformation: an abnormality of the
development process (spina bifida)
•Deformation: mechanical interference with
normal development (talipes)
•Disruption: interference with normal growth
after a period of normal development(bowel
atresia)

12. etiology
•Chromosomal abnormalities: Trisomy
(21,13,18),XO
•Single gene mutation: Achondroplasia(AD)
•Genetic predisposition
•Multifactorial: NTD, congenital heart defects, cleft lip,
palate
•Drugs : lithium,valproate
•Infection during pregnancy: Rubella,CMV
•Mechanical factors: Talipes, potter sequence

13. High risk pregnancies
•Uncontrolled diabetes in mother
•Elderly gravida
•Exposure to teratogenic drugs in 1
st
trimester
•Maternal rubella in first trimester
• H/O an affected sibling
•Polyhydramnios/oligoamnios
•Fetal growth restriction
•Single umbilical artery

14. investigations
•Biochemical screen:
–MSAFP
–Acetylcholine-esterase,hCG,uE3,inhibin A
•Ultrasound soft markers
–Echogenic foci in heart, echogenic bowel, pyelactasis
•Ultrasonography
–detailed structural anatomy,2D/3D
•Targeted imaging for fetal anomalies(TIFA)
–DM, hypothyroid, antiepileptic drugs

15. Investigations
•Invasive procedures
–CVS(chorionic villus sampling): obtain chorionic
tissue
–Amniocentesis: amniotic fluid
–Cordocentesis: fetal blood
–Fetoscopy : see fetal malformations
•Fetal echocardiography: suspected CVS
anomalies ,diabetes

16. Congenital malformations
•Malformations of the CNS:
–spina bifida, anencephaly, hydrocephalus
•Skeletal malformations
–Clubfoot, congenital dislocation of hip, skeletal
dysplasias
•GIT malformations
–Omphalocele, gastroschisis, ileal atresia, duodenal
atresia,Tracheoesophageal fistula
•Genitourinary abnormalities
•CVS abnormalities

17. Spina bifida
•Failure of closure of the neural tube
•Spina bifida occulta: defect is covered with
skin
•Spina bifida aperta: swelling seen over the
spinal defect with defective skin covering
•Meningocele
•Myelomeningocele(spinal cord is involved)
•Cephaloencephalocele(brain tissue involved)

18. Spina bifida

19. Spina bifida
•Lumbar defects : common
•Complications associated are
–Paralysis of lower limbs
–Urinary ,fecal incontinence
–Hydrocephalus
–Limb deformity
•Prognosis:60% survive with severe mental &
physical handicap in 1/3
rd
( immediate closure of
defect)

20. anencephaly
•Rudimentary brain with absent cerebral
hemispheres ,absent vault
•Most severe form of NTD
•Prenatal diagnosis as early as 14 weeks
•Offered MTP
•Uniformly lethal

21. anencephaly

22. NTD: screening & prevention
•MSAFP at 16-18 weeks : elevated ,2.5 MoM(95%
DR)
•Targeted Ultrasonography
•Prognosis : Site &size of lesion, associated anomalies
•Prevention: periconceptional administration of folic
acid
•Low risk women: 0.4-0.5 mg /day
• h/o NTD: 5mg/day
•Role of preconception counseling

23. Exomphalos
•Midline abdominal wall defect
•Herniation of bowel contents or liver into the
umbilical stump with membranous covering
•Raised MSAFP, USG,invasive prenatal
procedures
•Associated chromosomal abnormalities
•Treatment is surgical

24. gastroschisis
•Prolapse of intestine through paramedian
abdominal wall defect
•No covering membrane
•Urgent surgical treatment

25. Gastroschisis
omphalocele

26. Cleft lip ,cleft palate
•Cleft lip(hare lip): unilateral/bilateral
•Cleft palate: defect in roof of hard palate
•Associated abnormalities: micrognathia
/retrognathia
•Feeding difficulties ,more with cleft palate
•Small plastic plate ,obturator fits into the roof
blocks the opening ,helps in feeding
•Definitive t/t: surgery:3-4mths(hare lip),1-1/2
yrs

27. Birth trauma
•Injuries sustained during labor & delivery
•Stillbirth,neonatal deaths,morbidities
•Important cause of PNM

28. Predisposing factors
•Prolonged labor,obstructed labor
•Fetal macrosomia
•CPD
•Malpresentation(breech)
•Instrumental delivery(forceps/ventouse)
•Shoulder dystocia
•Precipitate labor
•Internal podalic version

29. Soft tissue Skin laceration, abrasion
Nerve injury Facial nerve injury
Brachial plexus injury
Visceral injury Rupture of liver, spleen
scalp Laceration, cut, hemorrhage
skull Cephalhematoma, subgaleal
hematoma
intracranial Intracranial hemorrhage
bones Fracture of femur,
clavicle ,humerus
dislocation Hip, shoulder

30. cephalhematoma
•Blood collection between pericranium & flat skull
bone
•Unilateral, over parietal bone
•Rupture of small emissary vein
•Forceps delivery, normal delivery
•Never present at birth, develops over 12-24 hrs
•Swelling limited by suture lines
•Good prognosis, blood gets absorbed in 6-8 wks
•Vs.Caput succadaneum,meningocele

32. Intracranial hemorrhage
•Traumatic
–Fracture of skull bone : extradural or subdural
hemorrhage
–Neurological symptoms: acutely or insidious
onset(vomiting, irritability)
–Massive subdural hemorrhage : tear of tentorium
cerebelli, injury to superior saggital sinus

33. Intracranial hemorrhage
•Mechanism of tentorial tear
–Excessive moulding in deflexed vertex with gross
CPD
–Rapid compression & decompression of after
coming head of breech
–Forcible forceps traction after wrong application
of blades
•Outcome: fatal, severe respiratory depression

34. Anoxic ICH
•Intraventricular : intense congestion of fragile
choroidal plexus due to anoxia
•Subarachnoid: tear of tributary veins from
brain to sinuses
•Intracerebral: petechial hemorrhage in brain
substance due to anoxia

35. Prevention of intracranial injuries
•Comprehensive antenatal & intranatal care
•Intensive fetal monitoring during labor : early
detection of fetal hypoxia
•Avoid difficult or traumatic vaginal delivery
•Breech delivery: liberal use of CS,precautions
while delivering limbs & aftercoming head
•Vit.K 1mg IM after birth

36. Treatment of ICH
•Supportive treatment
–Maintain temperature,humidity,oxygen
–Feeding by nasogastric tube,maintain fluid
balance
•Anticonvulsants:
phenobarbitone(5-10mg/kg/day in divided
doses) ,6 hrly intervals,IM
•Subdural tap/surgical removal of clot

37. Skin & subcutaneous tissue
•Bruises & lacerations over Face
•Edematous & bruised scalp
•Buttocks, genitalia gets edematous & bruised
in breech presentation
•Eyelids, nose,lips get bruised in face
presentation
•Needs no treatment

38. Muscles
•Sternomastoid hematoma
•Junction of upper & middle third
•Appears 7-10 days after birth
•Rupture of muscle fibres & blood vessels
•Difficult breech delivery, excessive lateral
flexion of neck in normal delivery, shoulder
dystocia
•Conservative, disappears by 6 mths age

39. Nerve injuries
•Facial nerve palsy
–Direct pressure of forceps blade
–Hemorrhage & edema around nerve
–Eye of affected side remains open
–Angle of mouth drawn to unaffected side
–Usually disappears in weeks, if isolated
•Erb’s palsy
–5
th
& 6
th
cervical nerve roots involved
–Waiter’s tip(extension of elbow, pronation of
forearm, flexion of wrist)

41. Nerve injuries
•Klumpke’s palsy
–7
th
,8
th
cervical or 1
st
thoracic nerve roots
–Arm flexed at elbow,forearm supinated ,claw like
deformity of hand
–Horner’s syndrome(homolateral ptosis,small pupil)
• treatment
–Splint
–Full recovery, permanent disability

42. Fracture long bones
•Fracture femur, humerus,radius,ulna
•Breech delivery
•Greenstick or complete type:X-ray
•Rapid union occurs with callus formation
•Deformity is rare
•Treatment: splinting, closed reduction &
casting

43. Fracture humerus

44. Prevention of newborn injuries
•Screen out the high risk women in antenatal
period: CPD, malpresentation::CS
•Intranatal period
–Continuous fetal monitoring
–Difficult forceps to be avoided
–Judicious selection of suitable candidates for
instrumental delivery
–Breech delivery by skilled personnel

45. Perinatal mortality
•Role of fetal autopsy: ability to pick up minor
anomalies /anomalies not detected on USG
•Ethical, religious concerns
•Careful examination, photograph & radiograph of
fetus
•Postmortem MR imaging : structural information of
CNS anomalies
•Helps in identifying the cause of fetal loss
•Facilitates genetic counseling

46. Summary
•Perinatal mortality is high in developing
countries
•India : 32per 1000 births(rural:35,urban:22)
•Comprehensive antenatal and intranatal care
is key to success in reduction of birth trauma
& subsequently reduction in perinatal
mortality
•At birth ,essential newborn care to all

47. MCQ1
•Babies chosen for perinatal statistics include
all except
1.Late fetal deaths
2.Early neonatal deaths
3.Body length (CHL) of 35 cm
4.800 g at birth

48. MCQ1
•Babies chosen for perinatal statistics include
all except
1.Late fetal deaths
2.Early neonatal deaths
3.Body length (CHL) of 35 cm
4.800 g at birth

49. MCQ2
•One of the following drug is safe in pregnancy
1.Thalidomide
2.Sodium valproate
3.Ferrous sulfate
4.coumarins

50. MCQ2
•One of the following drug is safe in pregnancy
1.Thalidomide
2.Sodium valproate
3.Ferrous sulfate
4.coumarins

51. MCQ3
•One of the following is not true in relation to
cephalhematoma
1.Present at birth
2. usually unilateral
3.Limited by suture line
4.Resolves in few weeks

52. MCQ3
•One of the following is not true in relation to
cephalhematoma
1.Present at birth
2.usually unilateral
3.Limited by suture line
4.Resolves in few weeks

53. MCQ4
•Which of the following malformations in a
newborn is specific for maternal insulin
dependent diabetes mellitus
1.Transposition of great vessels
2.Caudal regression
3.Holoprosencephaly
4.meningomyelocele

54. MCQ4
•Which of the following malformations in a
newborn is specific for maternal insulin
dependent diabetes mellitus
1.Transposition of great vessels
2.Caudal regression
3.Holoprosencephaly
4.meningomyelocele

55. MCQ 5
•Thalidomide tragedy has been associated
with this congenital anomaly
1.Cleft lip &palate
2.Vaginal adenoma
3.Microcephaly
4.phocomelia

56. MCQ 5
•Thalidomide tragedy has been associated
with this congenital anomaly
1.Cleft lip &palate
2.Vaginal adenoma
3.Microcephaly
4.Phocomelia

57. MCQ6
•The perinatal mortality rate(per 1000 births)
of India(urban) at present is
1.22
2.32
3.35
4.40

58. MCQ6
•The perinatal mortality rate(per 1000 births)
of India(urban) at present is
1.22
2.32
3.35
4.40