Complications of Pregnancy and Maternal & Infant Outcomes in Uganda

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

2. A pregnant woman has one foot in the grave

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

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

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

6. Mid-late pregnancy complications (2) • Placenta accreta spectrum • Formerly morbidly adherent placenta • Premature rupture of membranes (PROM) • Rupture of membranes after 37 weeks' gestation and prior to onset of labor • Preterm premature rupture of membranes (PPROM) • Rupture of membranes prior to 37 weeks' gestation • Both PROM & PPROM predispose to maternal infections and increase neonatal morbidity and mortality • Polyhydramnios • An abnormally high level of amniotic fluid

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

8. Fetal complications • Intrauterine fetal death • Fetal anomalies • Feta growth restriction • Macrosomia (very big baby- usually 4 Kg and above) • Vertically transmitted infections Eg: Toxoplasmosis , Rubella, Cytomegalovirus, Herpes simplex virus, HIV, Zika virus, syphilis, Hepatitis B virus

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

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

11. Medical records

12. Maternal and newborn outcomes in Uganda • Maternal outcomes can be measured by maternal mortality, near miss & proportion of women with postpartum morbidity • In Uganda maternal mortality ratio is 336 deaths per 100,000 live births [2016 UDHS] • For every maternal death in Uganda, at least six survive with chronic and debilitating ill health • 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] • 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]

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

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