Community sheet # 7 - Ala'a 7amdan

[Shadi Jarrar]

بسم الله الرحمن الرحيم

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http://www.4shared.com/document/SNxylmm7/commudnity_7.html
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بسم الله الرحمن الرحيم
- In the previous lecture we started talking about maternal and infant health care, this group is important because they are the most human being affected by environmental factors.
- The term "Maternal mortality" is very important because it reflect the maternal health care services. 98% of the maternal deaths occur in developing countries and the minimal morality rate reaching 0% in some developed countries.
- The most morality rate in sub-Saharan Africa.
- We must know what are the risk factors that increase the infant and maternal mortality rate.
- The risk factors are:
1. Age: any woman less than 20 and more than 35 years is a risky pregnant.
2. Parity: number of pregnancies, the most important are the
Prime pregnancy and multigravida(??Spelling) (more than five pregnancies).
3. Height and Weight:
A. Weight: very important , before the pregnancy the lady must control her weight , if not the pregnant will be at high risk to preeclampsia ( pregnancy induced hypertension ) and obesity .


Q : why do we say pregnancy induced hypertension ???
Because , the lady suffering from hypertension during pregnancy but after delivery this hypertension will disappear .

B. Height : related to the size of pelvis .
shorter woman is the more obstructed pelvis .
there's something called obstructive labor : disproportion between size of pelvis and the circumference of baby head and that indicate cesarean section , so that in Jordan if the height of pregnant is 150 cm or less we make something called pluviometer after 36 weeks ( in USA 155 cm ) .
note : in Jordan and many surrounded countries cesarean section done just for high risky delivery , because cesarean itself is risky due to anesthesia and infection .


4. Residency :
A. primary health care must be available for all. in Jordan , primary health care clinics available everywhere, and the most important services given by that clinics are maternal and infant health care services .
B. Income of the family
- the most social economic risk factor on pregnancy is poverty in order to that most of maternal and infant deaths occur in developing countries .

5. Education : most educated mother , less mortality ...
- educated woman has a scientific not traditional background about maternal and infant health care during pregnancy .
- the most difficult to change is social believing such as :
" you must eat to two persons " , here increasing in weight reaching 25 to 30 kg during pregnancy and that leads to obesity and leads to pregnancy induced hypertension , so poor pregnancy and poor outcome are the result .
note : if the weight of the pregnant increasing more than 15 kg is dangerous ---->>>> ( high risk pregnancy ) .

6. Income : high income --->> high services --->> better pregnancy .

7. Past - medical history : history of any chronic disease ( diabetes , COPD , hypertension , epilepsy , depression , ...... , etc ) .
- all of these chronic diseases affect the pregnancy and the outcome of pregnancy .
FOR EXAMPLE:
If woman has a history of depression, she will have a relapse of depression after delivery (increasing in depression) and need management either medical or psychological after delivery.
note: all woman have some kind of depression after labor and called Postmortem plu(??Spelling) , but this type decreasing with time .

8. past - obstetric history:
- History of cesarean sections.
- Smoking or drug therapy during pregnancy
- History of premature labor: delivery before 36 weeks.
(if the delivery occurs before 28 weeks we call that ABORTION )
* in Jordan labor before 32 weeks rarely to success ( high mortality rate)

9. General condition of the woman pre-concept ional, pre-pregnancy health condition related to her past-medical history.

10. Hb level, nutritional , blood pressure and general condition :
The most important nutritional deficiency is iron deficiency .
Note : we must give pregnant health services for all pregnant but we give priority for risky pregnancies .

There's another slide talking about maternal risk factors :
1. first pregnancy .
2. new partner / paternity .
3. age younger than 18 and older than 35 years .
4. history of preeclampsia ( pregnancy related hypertension ) : genetic related disease , so if the mother of the pregnant had preeclampsia so this pregnant at high risk to get preeclampsia .
- And if the preeclampsia presents in first baby in this case also she at high risk to have preeclampsia in the second baby and so on .
- The most affected pregnancy is the prime ( disease of the prime ) and if she get preeclampsia in the first pregnancy the risk to get it in the second one is more .
5. black race more affected than white race .
6. family history of preeclampsia .

MEDICAL risk :

1. chronic hypertension .
2. second causes of chronic hypertension such as , hypercorticolism , hyperaldosteronism , phenochromocytoma or renal artery stenosis .
- Here the hypertension is essential that means the pregnant has hypertension before pregnancy .

- Q: what are the differences between essential and pregnancy induced hypertension ????
-->>> Essential hypertension : in this case the hypertension problems appear in the first , second , third pregnancies .... etc , and the risk increases in the second more than in the first , and in the third more than in the second an so on .
- But , in pregnancy induced hypertension :
the highly risk pregnancy is the prime one , then there are two cases, if this problem appears in the first pregnancy then the second one has high risk to be affected by this disease, and the third more than the second . and if there's no problem with the first pregnancy then the second one has low risk and the third low and low risk .
3. Pre-existing diabetes ( type 1 or 2 ) especially with microvascular disease .
4. Rend disease .
5. Systemic lupus erythromatosis ( SLE ) : autoimmune disease , during pregnancy required special treatment and management .
6. Obesity .

Now , we have new topic about newly born :

- Very sensitive human being need special environment & nutrition.
- Immature immune system , organs and systems ( specially lungs ) , have soft heads , so they most affected to disease in the first day more than first week, and first week more than first month and so on .
- Improving new born survival will dramatically reduce infant mortality world wise .
- Infant mortality much higher than adult mortality rate so we take the infant morality rate per 1000 life births .
- of the 7.1 million infants who die each year , approximately two thirds die in the first 28 days ( 75%of deaths occur at the first month and 75% of deaths which occur during first month occur in the first week ) . , the most effected diseases in this period are infections diseases .
- most infants morality rate concentrated in premature, because most organs and systems specially lungs completed at the last 4 weeks of pregnancy.
- so that here there's high risk or respiratory distress syndrome .
- 98% of infant morality rate occurs in developing countries in order to low level of health services founded there .
- Note : premature infant health services depend on the economy of the country , because they required special environment such as neonatal units , incubators, oxygen ,,, etc reaching to 5000JD for every premature baby!! .

- Q : Do we consider baby who die before he labored in infant mortality rate ??
No , those called stillbirth(??) .

- Basic needs of newborn that can help ensure a healthy start in life .
- Skilled attendance provide safe management of normal delivery and timely referral for complication ( where and how attendance )
- Infection control-ensure clean delivery ( instruments , incubators).
- Manage and complications , such as respiratory distress syndrome.

FOLLOWING birth, newborn needs :
* AIR : stimulating infants who are not breath .
* WARMTH : dry the body at birth .
* BREASTFEEDING :
a. very important in the first minute in some developed countries baby before washing , immediately after delivery gives breastfeeding .
b. for the mother , breastfeeding decrease postmortem depression, and physiological normal changes of the mother after delivery , so breastfeeding is important to both mother and infant.

NOW DR. show us a picture titled by : proportional mortality among < 5 years , WHO report 2002 / world wide . ( this report talking about infancy + early childhood ) .
we know that 98% of maternal mortality in developing countries and 99% of infant mortality in developing countries .
There are different causes to infant mortality according to this report :
18% ARI ( Airways Respiratory Infections ) then
15% diarrhea
10% malaria
5% mealase
and other causes .

don't memories the numbers but memories how is it the percentage .
if we notice that most of mortality causes in infections causes and the most affected by infection diseases are premature infants .
- 80% of prematurity for unknown causes normally , when the pregnancy is health we get good outcome and healthy infant but in a lot of cases although the pregnancy is health but the infant is premature to unknown causes .
- Most important cause of infant mortality in Jordan is premature labor .
- The earlier is the death is the higher rate of mortality .
- There are periods of infant mortality rate , we must know them:
* perinatal death = one week before labor and one week after labor .
* Early neonatal = first week after labor.
* Late neonatal = first month after labor .
* Post neonatal infant = first year .

- prenatal more sensitive and higher mortality risk than early neonatal and early neonatal more sensitive than late neonatal and late neonatal more sensitive than post neonatal ( the earlier is the higher risk ) .

IMPORTANT causes of infant and child death in developing countries :
1. Prematurely, low birth weight , birth injuries and neonatal infections .
2. multipregnances with no spacing ( about 5 pregnancies ) .
3. Early or late pregnancy .
4. Respiratory infection : most important of infection diseases that cause death in infant .
5. GIT disease .
6. Infection diseases / malaria.
7. Poor income and large families leading to poor nutrition, education and living standards .
8. Environmental factors like poor watery supply , poor housing and air pollution .
9. accidents ( cars , burns , traumas ...... etc ) being the first cause of mortality rate between 5-15 years ( late childhoods ) , in Jordan the first cause of child death is car accidents .
10. Congenital abnormalities .



Done by: Ala'a Hmdan
Date of lecture: 28/02/2011