HO OnG Notes

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OBSTETRICS AND

GYNAECOLOGY

BY: FAREHA HATTA

MBBS (UiTM)

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OnG$

Dear%colleagues,%%These%are%some%of%the%important%topics%in%OnG%which%I%think%will%help%most%of%us%to% grasp% the% practical% knowledge% of% the% subject.% I% have% emphasized% on% the%fundamental% aspect% and% stuff% that% we% need% to% know% to% achieve% a% better%understanding% in% OnG.% Different% people% have% different% opinions% about%management,% thus% there% is% no% exact% management% per% se.% It% is% all% about%experience.% Always% refer% to% your% hospital% protocol% for% the% latest% updates% on%management.%!!TOPICS!%

1! DEFINITION%IN%OBSTETRICS%2! IOL%&%AUGMENTATION%OF%LABOUR%3! INSTRUMENTAL%DELIVERIES%4! CAESAREAN%SECTION%5! HYPERTENSION%IN%PREGNANCY%6! GESTATIONAL%DIABETES%MELLITUS%7! PPROM%&%PROM%8! POSTPARTUM%HEMORRHAGE%9! MISCARRIAGES%10! ECTOPIC%PREGNANCY%11! GESTATIONAL%TROPHOBLASTIC%DISORDERS%12! MENORRHAGIA%%%%%%Thank%you%Allah%for%giving%me%the%strength%and%patience%to%go%through%one%of%the%most% difficult% postings% in% housemanship.% Alhamdulillah,% I% survived% in%OnG.% Ive%gained%so%much%from%this%posting%and%no%word%can%describe%my%%excitement%upon%successful%completion%of%the%posting.%Alhamdulillah.%!%%With%that,%I%present%to%you%my%latest%personal%HO%notes%in%OnG.%%%%Dr%Nurfareha%Mohd%Hatta%MBBS%(UiTM)%Hosp.%Tengku%Ampuan%Rahimah,%Klang.%

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$DEFINITION$!

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DEFINITION(IN(OBSTETRICS($$Presentation$

The$part$of$the$fetus$in$the$lower$pole$of$uterus$overlying$the$pelvic$brim$ Example:$cephalic$(vertex,$face,$brow),$breech$(frank,$complete,$footling),$shoulder$

$Attitude$

Relation$of$the$different$part$of$fetus$to$one$another$$Lie$

The$relation$of$the$long$axis$of$the$fetus$to$the$uterus$ Example:$longitudinal,$transverse,$oblique$

$Position$

The$relationship$of$the$presenting$part$to$the$mothers$pelvis$$$$$!!! !!!!!!

Presenting$part$ The$leading$point$of$the$fetus$in$the$lower$pole$of$uterus$overlying$the$pelvic$brim$

(on$VE)$ Example:$vertex,$buttocks,$feet$

$Denominator$

Arbitrary$part$of$the$presentation$of$the$fetus$(the$bony$point)$ Example:$occiput$in$vertex$presentation,$sacrum$in$breech$presentation,$mentum$in$

face$presentation$$Engagement$

Descent$of$the$biparietal$diameter$through$the$pelvic$brim$$Vertex$

DiamondLshaped$area$of$the$fetal$skull$bounded$by$the$2$parietal$eminences$and$anterior$and$posterior$fontanelles$

$Effacement$

Shortening$of$the$cervix$ Normal$cervical$length:$~$2.5$cm$

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OA!

OP!LOT!ROT! LOA!ROA! LOP!ROP!

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Station$ The$level$of$the$presenting$part$in$relation$to$ischial$spine$

$Caput$

Diffuse$swelling$of$the$scalp$caused$by$pressure$of$the$scalp$against$the$dilating$cervix$during$labour$

$Moulding$

Overlapping$of$the$bones$of$the$fetal$head$ Parietal$bones$overlap$occipital$and$frontal$bones$ Significant$moulding$and$caput$!$sign$of$CPD$ Degree$of$moulding$

No$moulding$ +1$$parietal$bones$are$touching$ +2$$parietal$bones$are$overlapped$but$easily$reduced$ +3$$irreducible$(sign$of$relative/absolute$CPD)$

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INDUCTION(AND(AUGMENTATION(OF(LABOUR($Induction$$Stimulation$of$contractions$before$the$spontaneous$onset$of$labour$Augmentation$$Stimulation$of$spontaneous$contractions$that$are$considered$inadequate$$Indications$of$IOL:$ Post$dates$ Maternal$factors$

Significant$APH$ Gestational$HPT$disorders$ GDM$ Underlying$renal$or$lung$disease$

Fetal$factors$ Suspected$fetal$jeopardy$ Reduced$fetal$movement$at$term$ Fetal$demise$(IUD),$severe$IUGR$

MaternalOfetal$factors$ Prolonged$PROM$(if$more$than$24$hours)$ Chorioamnionitis$$

$Contraindications$of$IOL$$

Maternal$ Fetal$Small$pelvis$(in$case$of$CPD)$ Macrosomia,$CPD$Abnormal$placentation$ Multifetal$gestation$Active$genital$herpes$infection$ Severe$hydrocephalus$Cervical$abnormalities$ Malpresentation$(obstructed$labour),$

transverse$fetal$lie$Prior$classical$or$other$high$risk$caesarean$incision$

NonOreassuring$fetal$status$

Placenta$praevia$or$vasa$praevia$ Umbilical$cord$prolapse$$Bishop$score$$ To$assess$whether$cervix$is$favourable$and$to$determine$whether$the$patient$needs$

cervical$ripening$or$to$proceed$with$augmentation$ If$Bishop$score$


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Methods$of$induction$$1. Prostaglandin$E2$(Prostin)$

To$promote$cervical$ripening$if$cervix$is$not$favourable$(Bishop$score$


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Amniotomy$plus$oxytocin$is$MORE$EFFECTIVE$than$amniotomy$alone$!$shortened$the$time$to$delivery$by$44$minutes$

After$ARM,$ For$CTG$postOARM$with$20$minutes$tracing$ Review$VE$in$4$hours$ Review$contractions$ Plot$partogram$ If$CTG$reactive,$to$start$Syntocinon$as$per$regime,$to$aim$for$moderate$

contraction$4:10$ For$CTG$hourly$if$CTG$reactive$ Hydration$with$1$pint$Hartmann$solution$over$4$hours$as$maintenance$ For$IM$Pethidine$75mg$and$IM$Phenergen$25mg$stat$once$contraction$

moderate$and$CTG$reactive$OR$to$offer$epidural$$Augmentation$of$labour$ Indicated$when$the$patient$is$in$labour$and$CPD$has$been$ruled$out$ When$there$is$poor$progress$of$labour$secondary$to$poor$uterine$contractions$based$

on$the$partograph$ Initial$steps$

Assess$general$condition$of$mother$$vital$signs$and$hydration$status$ Review$partogram$and$assess$the$progress$of$labour$ Palpate$the$abdomen$and$assess$

" Strength$&$frequency$of$contraction$" Estimate$the$size$of$baby$(compare$with$previous$baby)$" Engagement$of$the$head$" ?Full$bladder$(to$catheterize$before$VE)$

Do$VE$and$assess$" Cervical$effacement$" Cervical$os$dilatation$" Position$of$fetus$$OA/OP/OT$" Degree$of$caput$or$moulding$if$present$" Nature$of$liquor$if$present$

Baseline$CTG$before$augmentation$with$at$least$20$minutes$tracing$to$ensure$fetal$wellbeing$is$not$compromised$

Augmentation$regime$ Primigravida$$2,$4,$8$units$ Gravida$2O5$$1,$2,$4$units$ Multipara$with$previous$scar$$may$consider$,$1,$2$units$

For$every$increase$in$the$strength$of$oxytocin$infusion,$CTG$monitoring$is$mandatory$ Good$effective$contraction$!$4O5$contractions$in$10$mins$

$Side$effects$of$oxytocin:$ Uterine$hyperstimulation$(def:$>$5$contractions$in$10$mins)$ Uterine$rupture$(especially$in$scarred$uterus)$ Hyponatremia$due$to$excessive$water$retention$(oxytocin$has$ADH$properties,$when$

administered$in$high$doses)$ Hypotension$(as$a$result$from$rapid$IV$injection$of$oxytocin)$ Fetal$distress$

$FAILED$INDUCTION$&$AUGMENTATION$!$CAESAREAN$SECTION$


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References:$1. HTAR$OnG$protocol$2. Ten$Teachers$Obstetrics$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$INSTRUMENTAL$DELIVERY$!

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INSTRUMENTAL+DELIVERY+$a.k.a$Operative$Vaginal$Delivery$$A$delivery$in$which$the$operator$uses$forceps$or$a$vacuum$device$to$assist$the$mother$in$transitioning$the$fetus$to$extrauterine$life.$$Indications$ Prolonged$2nd$stage$of$labour$

Nulliparous$$3$hours$with$regional$anaesthesia,$2$hours$without$ Multiparous$$2$hours$with$regional$anaesthesia,$1$hour$without$

Maternal$distress$(underlying$cardiac$disease,$HPT$crisis,$etc)$ Presumed$fetal$compromise$ Maternal$exhaustion$

$Prerequisites$FT$Fully$dilated$cervix$OT$OP/OA$position$RT$Ruptured$membrane$CT$Cephalic$ET$Empty$bladder$(to$catheterize$first)$PT$Pain$relief$(adequate$analgesia)$ST$Skills,$Station$low$$Complications$The$relative$merits$of$vacuum$extraction$and$forceps$have$been$evaluated$in$a$Cochrane$Systematic$Review$of$ten$randomized$controlled$trials$involving$2923$primiparous$and$multiparous$women$$Compared$with$forceps,$vacuum$extraction$is:$ more$likely$to$fail$delivery$with$the$selected$instrument$(OR:$1.7;$95%$CI:$1.32.2)$ more$likely$to$be$associated$with$cephalohaematoma$(OR:$2.4;$95%$CI:$1.73.4)$ more$likely$to$be$associated$with$retinal$haemorrhage$(OR:$2.0;$95%$CI:$1.33.0)$ more$likely$to$be$associated$with$maternal$worries$about$baby$(OR:$2.2;$95%$CI:$1.2

3.9)$ less$likely$to$be$associated$with$significant$maternal$perineal$and$vaginal$trauma$(OR:$

0.4;$95%$CI:$0.30.5)$ no$more$likely$to$be$associated$with$delivery$by$caesarean$section$(OR:$0.6;$95%$CI:$

0.31.0)$ no$more$likely$to$be$associated$with$low$5Tminute$Apgar$scores$(OR:$1.7;$95%$CI:$1.0

2.8)$ no$more$likely$to$be$associated$with$the$need$for$phototherapy$(OR:$1.1;$95%$CI:$0.7

1.8).$$$$$$$$$


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FORCEPS$DELIVERY$$$

$$Conditions$when$forceps$are$preferable:$ Poor$maternal$effort$ Operator$or$maternal$preference,$when$either$instrument$would$be$suitable$ Large$amount$of$caput$ Gestation$of$less$than$34$weeks$ Marked$active$bleeding$from$a$fetal$bloodTsampling$site$ AfterTcoming$head$of$the$breech$ Face$presentation$

$Types$of$forceps:$$

1. Wrigleys$$for$liftTout$deliveries$and$Caesarean$section$

$2. Neville$Barnes$

$$$$$$$$$$

3. Rotational$forceps$(Kiellands$forceps)$$

The$blade$has$two$curves:$Cephalic$curve$$relates$to$fetal$head$Pelvic$curve$$relates$to$maternal$pelvis$!


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Classification$of$forceps$delivery:$$

OUTLET$$

Fetal$head$is$at$or$on$the$perineum$ Scalp$is$visible$at$the$introitus$without$separating$the$labia$ Fetal$skull$has$reached$the$pelvic$floor$ Sagittal$suture$is$in$the$AP$diameter$or$right$OA$or$OP$ Rotation$does$not$exceed$45$degrees$

LOW$ Leading$point$of$the$fetal$skull$is$at$the$station$+2$cm$or$more$ Rotation$$45$degrees$from$OA$position$ Rotation$>$45$degrees$including$OP$position$

$MID$ Leading$point$of$the$fetal$skull$is$above$station$+2$cm$but$

not$above$the$ischial$spines$ Rotation$$45$degrees$from$OA$position$ Rotation$>$45$degrees$including$OP$position$

Head$is$engaged$$Technique:$ Procedure$explained$to$patient$ Lithotomy$position$ Clean,$drape$and$catheterize$ Assemble$the$blades$ Left$blade$applied$first$(hold$like$a$pencil)$ Right$blade$follows$ Proper$application$and$positioning$of$forceps$will$bring$the$blades$together$and$locks$

easily$ If$fail,$to$proceed$with$LSCS$

$Clinical$checks$for$forceps$application:$ Sagittal$suture$lies$in$the$midline$of$the$shanks$ Operator$is$unable$to$place$more$than$a$fingertip$between$the$fenestration$of$the$

blade$and$the$fetal$head$on$either$side$ Posterior$fontanelle$is$no$more$than$a$finger$breadth$above$the$plane$of$the$shanks$of$

the$forceps$ Apply$traction$intermittently$and$synchronously$with$uterine$contraction$ Direction$of$traction$should$be$in$the$axis$of$the$birth$canal$ Head$descent$must$be$present$during$each$contraction$

$$VENTOUSE$DELIVERY$$ Risk$of$damage$to$the$maternal$tissue$is$considerable$ Preterm$pregnancy$(


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Advantages$ Disadvantages$Avoid$marked$compression$of$the$fetal$head$by$the$forceps$

Injuries$to$the$fetal$scalp$

Forceps$occupies$a$space$and$may$injure$the$vagina$

Cephalohematoma$

Forceps$carries$the$infection$in$the$genital$tract$

Intracranial$hemorrhage$

$Types$of$cup:$$

1. Silastic$cup$

$2. Metal$cup$

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3. Kiwi$cup$$

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Conditions$when$ventouse$is$preferable:$ Urgent$low$liftTout$delivery$with$no$previous$analgesia$ Rotational$delivery$ Operator$or$maternal$preference,$when$either$instrument$is$suitable$

$Technique:$ Cup$must$be$directed$to$the$occiput$in$the$midline$of$the$head$application$diameter$at$

the$flexion$point$ Ensure$that$maternal$tissue$have$not$caught$in$the$cup$ Increase$the$pressure$to$0.2$kg/cm2,$check$for$maternal$tissue$entrapment$between$

the$cup$and$the$fetal$head,$then$increase$to$0.8$kg/cm2.$Recheck$for$any$maternal$tissue$entrapment$prior$to$applying$traction$

With$contraction,$apply$traction$downward$and$backward$with$one$hand$while$the$other$hand$applied$to$steady$the$cup$on$the$head$

Head$should$descend$with$each$pull$ Delivery$should$be$completed$within$3$pulls$ Cup$should$be$reapplied$no$more$than$twice$ If$fail,$do$not$try$forceps$$

$$$$$$$$$$$$$$$References:$

1. HTAR$protocol$2. Royal$College$of$Obstetricians$&$Gynaecologists$$Instrumental$Delivery$

The$flexion+point$is$located$on$the$sagital$suture$3+cm+in+front$of$the$posterior$fontanelle$and$+6+cm+posterior$to$the$anterior$fontanelle$

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CAESAREAN'SECTION'$2$types$of$Caesarean$section:$

Lower$segment$section$ Classical$section$(Upper$segment)$ Transverse$ incision$ made$ ~2cm$ above$

symphysis$pubis$(Pfannenstiel)$ Advantages:$

!$adhesion$formation$ !$blood$loss$ !$ incidence$ of$ scar$ dehiscence$ in$

subsequent$pregnancies$ scar$heals$well$ short$duration$of$hospital$stay$

Midline$ longitudinal$ incision$ made$ in$uterine$upper$segment$

Indications:$ Fibroid$distorting$the$uterus$ Anterior$ PP$ with$ abnormally$

vascular$lower$uterine$segment$ Poorly$formed$lower$segment$

Advantages:$ Rapid$delivery$ !$risk$of$bladder$injury$

$Layers$cut$in$CS:$ Skin$ Subcutaneous$layer$(Camper$&$Scarpa$fascia)$ Rectus$sheath$(aponeuroses$of$the$external$oblique,$ internal$oblique,$and$tranversus$

abdominis$muscles$ Rectus$abdominis$muscle$ Transversalis$fascia$ Peritoneum$$

$PreQOp$

Keep$patient$NBM$with$IV$Drip$5$pints$(3$pints$NS$+$2$pints$D5%)$ If$patient$planned$for$elective$CS,$to$keep$NBM$at$12am$

Consent$form,$blood$transfusion$form$signed$ For$baseline$blood$investigations$$FBC,$GSH$ Prepare$GXM$2$units$packed$cells$ Shave$the$pubic$area$ Bladder$catheterization$ Prophylactic$antibiotic$$IV$Cefuroxime$1.5g$stat$&$IV$Flagyl$500mg$stat$ Pre$med$$IV$Ranitidine$50mg,$IV$Maxolon$10mg,$Oral$Sodium$citrate$30ml$given$stat$ Presence$of$Anaes$and$Paeds$ Regional$block$$spinal$intrathecal$morphine$

$Post$Op$

CRIB$for$6$hours$ Monitor$BP/PR$$15mins$x$4,$30mins$x$4,$1$hrly$x$4,$2$hrly$x$4,$then$4$hrly$if$stable$ Allow$orally$as$tolerated$ IV$drip$5$pints$(3$pints$NS$+$2$pints$D5%)$until$tolerating$orally$ Strict$IO$charting$ Wound$inspection$Day$2,$no$need$for$STO$ FBC$6$hours$post$op$ To$start$S/C$Heparin$5000$U$BD$for$1/52$after$review$FBC$post$op$ Keep$CBD$for$1/7,$to$inform$if$bloodQstained$urine$ Strict$pad$chart$monitoring,$to$inform$if$more$than$2$pads$soaked$ IV$Pitocin$40$U$in$1$pint$NS$for$4Q6$hours$ Analgesia$as$per$Anaes$order$

OnG$ $ HPT$IN$PREGNANCY$$

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HYPERTENSION+IN+PREGNANCY+

BP$of$140/90$mmHg$or$more$on$2$occasions$at$least$4$hours$apart$

Definition$

1. PregnancyHinduced$HPT$$HPT$after$20$weeks$of$gestation$in$a$previously$normotensive$woman$with$no$significant$proteinuria,$usually$condition$returns$to$normal$within$6$weeks$postpartum$

2. Chronic$HPT$$HPT$that$is$present$at$the$booking$visit$of$before$20$weeks$of$gestation$or$if$the$woman$ is$ already$ taking$ antiHPT$ medication$ when$ referred$ to$ maternity$ services.$ (NICE$guidelines)$

3. PreHEclampsia$ $BP$of$ $ 140/90$mmHg$with$ significant$proteinuria$ ($ 300$mg/24hrs)$ after$ 20$weeks$of$gestation$

4. Chronic$ HPT$ with$ superimposed$ preHeclampsia$ $ PreHeclampsia$ in$ patient$ with$ preHexisting$hypertension$

5. Eclampsia$$preHeclampsia$with$convulsion$6. Severe$ PreHEclampsia$ (Impending$ Eclampsia)$ $ PreHEclampsia$with$ severe$HPT$ $ symptoms,$ $

biochemical$$haematological$impairment$

$Pathophysiology$of$preHeclampsia$H Failure$ of$ normal$ invasion$ of$ trophoblast$ cells$ leading$ to$ maladaptation$ of$ maternal$ spiral$

arterioles$H The$cytotrophoblast$infiltrates$the$decidual$portion$of$the$spiral$arteries,$but$fails$to$penetrate$

the$myometrial$portion,$thus$the$large,$tortuous$vascular$channels$characteristic$of$the$normal$placenta$do$not$develop,$instead,$the$vessels$remain$narrow,$resulting$in$hypoperfusion$

H Abnormalities$of$spiral$artery$adaptation$are$immunologically$based,$with$genetic$influences$H The$ ischemic$placenta$appears$ to$alter$maternal$endothelial$ cell$ function$and$ leads$ to$ signs$

and$symptoms$of$preHeclampsia$H Many$of$the$clinical$features$can$be$explained$as$clinical$response$to$generalized$endothelial$

dysfunction$$

Risk$factors:$H Family$history$H Multiple$gestation$H PreHexisting$HPT,$DM,$renal$disease$or$vascular$disease$H Previous$severe/early$onset$PE$H Previous$SGA$H Age$$40$y/o$H Primigravida$H Obesity$(BMI$$30)$

$Symptoms$of$impending$eclampsia$(severe$PE):$H Severe$headache$H Vomiting$H Blurring$of$vision$H Epigastric$or$RUQ$abdominal$pain$(due$to$liver$capsule$distention)$H Sudden$onset$of$swelling$of$the$face,$hands,$feet$

$Systemic$involvement$H CVS:$generalised$vasospasm,$$peripheral$resistance$H Haematological:$thrombocytopenia$


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H CNS:$cerebral$edema,$cerebral$haemorrhage$H Renal:$proteinuria,$$GFR$H Hepatic:$subcapsular$hematoma$(which$gives$rise$to$epigastric$pain),$generalised$edema$

$AIM$TO$KEEP$BP$


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H Watch$out$for$signs$&$symptoms$of$impending$eclampsia$H Fetal$surveillance$$FKC,$CTG,$USG$(for$fetal$growth,$AFI,$Doppler)$

$$$$$$$$$$$Timing$of$delivery$$$$$$$$$$Uncomplicated$PIH$not$on$treatment$$40$weeks$$$$$$$$$$PIH$on$treatment/$complicated$PIH$$~36$to$38$weeks$$

$Intrapartum$management$$H BP/PR$half$hourly$H If$patient$is$on$medication,$to$continue$meds$H Strict$I/O$chart$H Adequate$analgesia$H CTG$monitoring$H NOT$for$syntometrine/ergometrine!$H To$give$Syntocinon$10$U$

$Postpartum$management$H Watch$ out$ for$ signs$ &$ symptoms$ of$ impending$ eclampsia$ and$ pulmonary$ edema$ (fluid$

overload)$H BP$monitoring$

$hourly$monitoring$for$at$least$2H4$hours$before$sending$to$postnatal$ward$ 4$hourly$monitoring$in$the$ward$for$24H48$hours$before$discharge$

H Continue$with$antihypertensive$meds$ (if$patient$ is$on$methyldopa$$discontinue,$ in$view$of$postpartum$depression)$

H Strict$I/O$chart$H Daily$urine$albumin$&$PE$profile$H If$discharge,$$

EOD$BP$monitoring$at$KK$for$2$weeks$and$to$review$BP$in$2$weeks$by$MO$ Continue$antihypertensive$meds$

$The$use$of$antihypertensive$medications$in$pregnancy$H Mild$PIH$usually$do$not$require$antiHPT$H Consider$antiHPT$if$diastolic$BP$above$100mmHg$H Pregnant$women$with$chronic$HPT$who$take$ACEi,$ARBs$or$thiazide$diuretics$preHpregnancy$

To$ discontinue$ the$ meds$ in$ view$ of$ increased$ risk$ of$ congenital$ abnormalities$ during$pregnancy$

H Indications$of$IV$antiHPT:$(as$per$protocol)$ When$BP$>$160/110$mmHg$sustained$for$more$than$30$minutes$ MAP$>$125$mmHg$$

$$$$$$$$*Mean$Arterial$Pressure$(MAP)$=$DBP$+$1/3$(SBPHDBP)$$$$$

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$$$$Source:$HTAR$protocol$

MAP+>+125mmHg+ MAP+$125mmHg$and$HR$>$120$bpm$or$15mg$Hydralazine$given$

IV$Labetolol$20mg$(at$least$1$min)$followed$at$$10$mins$intervals$by$40,$80,$80,$160$H each$ml$contains$

5mg$(1$ampoule$=$25mg$in$5ml$

Maintenance$therapy$

Hydralazine$infusion$(if$HR$$120$bpm$or$side$effects$of$hydralazine)$H 200mg$in$50cc$normal$

saline$H start$at$5ml/hour$

(20mg/hour)$and$double$every$30$minutes$by$10,$20,$40$

MAP+>+125mmHg+

IV$bolus$5mg$(2.5cc)$Hydralazine$over$1$min$H 1$ampoule$contains$

20mg$in$1$ml$H add$9cc$of$normal$

saline$in$10cc$syringe$(0.5mg/ml)$

$

Recheck$MAP$after$15$mins$


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H AntiHPT:$$

AntiHPT$ MOA$ Starting$dosage$ Max.$dosage$ Side$effects$Methyldopa$ Centrally$acting$ 250mg$TDS$ 3000mg/day$ PostHpartum$

depression$Labetolol$ ,$$blockers$ 100mg$TDS$ 2000mg/day$ Bronchoconstriction,$

IUGR,$heart$block$Nifedipine$ CCB$ 15mg$TDS$ 60mg/day$ Headache,$flushing$Hydralazine$(only$IV)$

Vasodilator$ 25mg/day$ 300mg/day$ Tachycardia,$hypotension$

$H Role$of$Aspirin$in$PIH$and$PE$

Women$at$high$risk$of$PE$are$advised$to$take$low$dose$aspirin$75mg$daily$starting$from$12$weeks$

High$risk:$previous$PIH,$chronic$hypertension,$chronic$kidney$disease,$autoimmune$disease,$DM$

$$Management$of$Eclampsia$H Obstetrical$emergency!$H Put$on$left$lateral$position$with$head$slightly$lowered$H Maintain$airway$H Give$O2$by$ventimask$H Set$2$IV$lines$(large$bore$branula)$H Abort$fit$by$MgSO4$

1$ampoule$contains$2.47gm$(~2.5$gm)$of$50%$MgSO4$in$5ml$ IV$regime$

! LOADING$dose:$4gm$MgSO4$H 8ml$=$4gm$(need$2$ampoules),$then$mixed$with$12ml$normal$saline$in$20cc$

syringe$H Give$20ml$slow$bolus$IV$over$10H15$minutes$

! Followed$by$MAINTENANCE$dose$1gm/hour$for$at$least$24$HOURS$after$last$fit$H 5gm$of$MgSO4$(2$ampoules$=$10ml)$mixed$with$40ml$normal$saline$in$50cc$

syringe$using$infusion$pump$titrating$at$10ml/hour$! Recurrent$seizure$$repeat$IV$MgSO4$but$at$a$lower$strength$dose;$2gm$given$slow$

bolus$over$10H15$minutes$ IM$regime$(usually$given$at$KK)$

! LOADING$dose:$10gm$MgSO4$! 4$ampoules$H$2$ampoules$of$10ml$(5gm)$with$1ml$lignocaine$2%$for$each$buttock$into$

upper$outer$quadrant$of$the$buttock$in$zigzag$manner$! MAINTENANCE$therapy$with$further$IM$5gm$MgSO4$(2$ampoules)$every$4$hours$

(alternate$buttocks)$! Recurrent$seizure$$IM$5gm$MgSO4$

H After$fit$aborted,$to$take$GXM$and$PE$profile$H Assess$GCS$level$and$neurological$status$H Close$monitoring$of$vital$signs$H Monitoring$during$MgSO4$therapy$

Clinical$signs$of$MgSO4$toxicity$! Loss$of$deep$tendon$reflexes$(knee$jerk)$! Respiratory$depression$


farehatta$$ $

How$to$manage:$! STOP$the$infusion$! Give$ANTIDOTE$$IV$Calcium$Gluconate$10%$10mls$over$10$minutes$! Oxygen$and$maintain$the$airway$if$respiration$is$depressed$! If$knee$jerk$absent$but$normal$respiration$$withhold$further$doses$of$MgSO4$until$

reflexes$return$! If$urine$output$

!OnG!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!GDM!

farehatta! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ! ! ! ! ! ! ! !

GESTATIONAL*DIABETES*MELLITUS*

Increase!in!blood!glucose!level!>!7.0mmol/L!or!>!11.1!mmol/L!2!hrs!post!prandial!(2HPP)!in!MGTT!

Physiology!!hPL!and!cortisol!!insulin!antagonists!!relative!insulin!resistance!(most!marked!during!3rd!trimester,!from!28!weeks!onwards)!!Risk!factors!(indication!for!MGTT,!to!be!documented!in!pink!book)!P Obesity!(BMI!>30)!P Age!>35!y/o!P Family!history!of!DM!P Prev.!big!baby!(>4.0!kg)!P Prev.!unexplained!stillbirth!P Prev.!congenital!abnormalities!P Prev.!GDM!P PCOS!P Polyhydramnios!P Presence!of!glycosuria!in!>2!occasions!

!MGTT!!!done!at!around!12P14!weeks!!!!!!!!!!!!!!!if!normal!but!have!significant!risk!factors,!to!repeat!at!28P32!!!!!!!!!!!!!!!!!!!weeks!and!again!at!32P34!weeks!!!!!!!!!!!!!!!if!high!risk,!to!repeat!as!early!as!24!weeks!!!!!!!!!!!!!!!!!!!!!Normal!range!MGTT:!!!!!!!!!!!!!!!!!!!!FBS!P! Done!4!times!(fasting,!postPbreakfast,!postPlunch,!postPdinner)!!!!!!!!!!!!!!!!!!!!!!Fasting:!3.5P5.2!

PrePmeal:!3.5P5.9!2HPP:!4.4P6.7!!

Admission!for!BSP!stabilisation!! FBS!!8!and!2HPP!!12!in!MGTT!! Deranged!BSP,!at!least!2!point!!8!mmol/L!

BSP!monitoring!in!ward!! On!diet!control!!4!point!BSP!(fasting,!postPbreakfast,!postPlunch,!postPdinner/before!

bed)!! On!insulin!!7!point!BSP!(fasting,!pre!&!post!meals)!! Investigations:!FBC,!BUSE,!HbA1C,!UFEME!

If!patient!is!given!IM!Dexamethasone,!BSP!reading!might!be!off!because!of!the!steroid!effect!(!glucose)!

!OnG!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!GDM!

farehatta! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ! ! ! ! ! ! ! !

! Advise!patient!to!repeat!BSP!after!72hrs!of!IM!Dexa!administration!P HbA1c!! Ultrasound!(macrosomia,!polyhydramnios)! Biophysical!profile! Fetal!kick!chart! CTG!

P Insulin!therapy! Actrapid!(short!acting,!given!before!meal)! Insulatard!(long!acting,!given!before!bed)!

P Refer!pharmacist!for!insulin!injection!technique!P Timing!of!delivery!(do!NOT!exceed!post!date!)!

On!diet!control!!40!weeks! On!insulin!!38!weeks!

!Management!of!GDM!in!active!labour!*!applicable!to!all!diabetic!mothers!with!insulin!therapy!only!P Keep!NBM!P Omit!morning!!dose!of!insulin!injection!if!SI!!20U!P Hourly!DXT!monitoring!P Start!sliding!scale!(depend!on!DXT!reading)!P 4!hourly!BUSE,!RBS!P Take!GSH!P Pain!relief!P Hourly!CTG!monitoring!P Urine!ketone!2!hourly!if!labour!>!8!hours!(to!look!for!dehydration)!

!Sliding!scale!regime:!

DXT! Insulin!infusion!

6.1P9! 2U/hr!(10U!insulin!in!500mls!D5%!+!1gm!KCl)!





!!DIK!regime!P A!constant!infusion!of!500!ml!of!D5%!dextrose!water!at!100mls/hr!P Preparation!of!soluble!insulin:!50U!Actrapid!in!50!ml!NS!(1U/ml)!P Baseline!BUSE,!check!K+!prior!to!KCl!infusion!P Separate!infusion!from!Syntocinon!infusion!(in!this!case,!patient!may!need!2!lines)!P Insulin!causes!potassium!shift!from!extracellular!into!intracellular!environment,!can!lead!to!!

K+!in!the!bloodstream!!hypokalemia!(the!reason!we!add!on!KCl)!

!OnG!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!GDM!

farehatta! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ! ! ! ! ! ! ! !

P Insulin!also!can!cause!hypoglycaemia!and!we!dont!want!our!patients!to!go!into!hypoglycaemic!state!so!we!give!dextrose!solution!

P DXT!monitoring!is!important!and!sliding!scale!is!adjusted!according!to!serial!DXT!reading!!PostPpartum!P Delivery!of!baby!!!insulin!requirement!!off!insulin!P Monitor!DXT!in!baby!and!mother!prior!to!discharge!P Repeat!MGTT!in!6!weeks!post!delivery!to!check!if!GDM!has!resolved!P If!patient!is!a!known!case!of!DM,!start!back!their!prePpregnancy!dose!and!regime!P Encourage!breastfeeding!P Advice!for!contraception!!!

Complications!of!GDM!!

Mother! Fetal!Nephropathy! Neural!tube!defect,!sacral!

agenesis*!Retinopathy! Macrosomia!Coronary!artery!disease! Hypoglycaemia!Hyperglycemia/hypoglycaemia! Polycythemia!PrePeclampsia! Polyhydramnios!(fetal!polyuria)!Infection!!UTI,!vaginal!candidiasis!

Unexplained!IUD!

Thromboembolism! RDS!DKA! Cardiac!anomalies!! Hyperbilirubinemia!! Preterm!labour!! Birth!trauma:!shoulder!dystocia,!

Erbs!palsy!!!

!References:!

1. HTAR!OnG!protocol!2. Oxford!handbook!3. Ten!teachers!

OnG! ! ! !!!!!!!!!PPROM,(PROM!!

farehatta((

PRETERM&PRELABOUR&RUPTURE&OF&MEMBRANE&(Spontaneous(rupture(of(membrane(at(LESS(THAN(37(weeks(of(gestation(before(onset(of(labour(i.e(the(onset(of(regular(uterine(contractions.(( Complicates(2%(of(pregnancies(but(associated(with(40%(of(preterm(deliveries(and(can(

result(in(significant(neonatal(morbidity(and(mortality((

ALWAYS(CONFIRM(THE(GESTATION!!!((History(( Sudden(gush(of(fluid(*( Clear(fluid,(not(foul(smelling(*( No(history(of(recent(trauma,(fall(or(abdominal(massage( Last(sexual(intercourse?( History(of(fever,(URTI(or(UTI(symptoms(

(Differential(diagnosis( UTI( Urinary(incontinence( Vaginal(candidiasis(!(may(have(thick(curdy(discharge(

(Risk(factors(

(((((((((

Investigations( Nitrazine(testing(

Based(on(testing(the(vaginal(fluid(pH((pH:(4.5]6.0)( Amniotic(fluid(pH:(7.1]7.3((alkaline)( Nitrazine(paper(will(turn(blue(if(pH(>(6.0(

Microscopic(examination(of(vaginal(fluid( Characteristic(ferning(of(the(crystalline(pattern(of(dried(amniotic(fluid(owing(to(its(

sodium(chloride(and(protein(content(( Litmus(test((red(to(blue)( Amniocater( High(vaginal(swab( Ultrasound(to(look(for(oligohydramnios((

Management(of(PPROM( Assess(for(signs(of(infection,(watch(out(for(signs(of(chorioamnionitis( FBC,(CRP( Sterile(speculum(examination(

Look(for(POOLING(of(fluid(in(the(posterior(fornix(

Maternal( Fetal(Infection((commonest)( Congenital(anomaly(Cervical(incompetence( Multiple(gestation(Multiparity( (Low(socioeconomic(class( (Poor(nutrition( (Previous(scars( (

OnG! ! ! !!!!!!!!!PPROM,(PROM!!

farehatta((

Cough(reflex((fluid(leaking(out(of(cervix( Os(open(or(close?( Litmus(test( Amniocater(if(in(doubt( Take(sample(of(HVS(for(culture(

CTG((for(>30(weeks)( Steroids(administration(for(fetal(lung(maturity((IM(Dexamethasone(12mg(BD)(for(24]

36(weeks(of(gestation( Start(prophylactic(antibiotic((T.(EES(250mg(QID(for(10(days)( Strict(pad(chart(monitoring( Avoid(digital(VE(unless(contraction(is(stronger( Ultrasound(scan(for(fetal(assessment( Inform(Paeds(for(neonatal(support(especially(ventilator(booking( Monitor(vital(signs,(look(for(temperature(spike( EXPECTANT(management:(

(Maternal( Fetal(

Temperature( Fetal(movement(FKC(FBC(and(CRP(biweekly( Growth(scan(biweekly(Pad(chart((change(of(liquor(colour( Daily(fetal(heart(monitoring(Uterine(assessment(](clinical( ((

Expectant(management(is(the(preferred(management(provided(there(is(no(fetal(or(maternal(contraindication(till(34]36(weeks(of(gestation(depending(on(the(ventilator(support.((If(patient(is(in(labour,( >34(weeks(:(consider(steroids(and(allow(labour(to(progress(

OnG! ! ! !!!!!!!!!PPROM,(PROM!!

farehatta((

PRELABOUR&RUPTURE&OF&MEMBRANE&(Spontaneous(rupture(of(membrane(AFTER(37(weeks(of(gestation(before(the(onset(of(regular(uterine(contractions((PROM((SROM(SROM(=(spontaneous(rupture(of(membrane(after(regular(uterine(contractions((Management(of(PROM( Sterile(speculum(examination(to(confirm,(with(litmus(paper/(amniocater(as(an(adjunct(

to(diagnosis((when(rupture(of(membrane(is(not(obvious)( Avoid(digital(examination(as(it(can(introduce(infection(

If(per(speculum(shows(os(open,(to(proceed(with(VE(to(assess(os(dilatation( CTG(stat(( For(VE(upon(stronger(contractions((to(avoid(regular(VE(if(possible)( Strict(pad(charting(with(noting(of(liquor(colour( Monitor(vital(signs,(look(for(temperature(spike( Watch(out(for(signs(of(chorioamnionitis( Monitor(LPC/FKC/FHR( To(report(any(decrease(in(fetal(movement( IOL(if(not(delivered(within(24(hours( Expectant(management(criteria((for(IOL(24(hours(later):(

Normal(pregnancy( Sterile(speculum(with(NO(prior(digital(examination( Reactive(CTG( No(antenatal(risk(factors( No(meconium(stained(liquor( No(malpresentation(

Daily(CTG( If(patient(is(in(labour,(to(commence(intrapartum(antibiotics(

To(start(IV(Benzylpenicillin(3gm(stat(and(1.5gm(TDS(if(leaking(>(18(hours((for(GBS(prophyaxis)(

Alternative:(IV(Ampicilin(2gm(stat(and(1gm(QID((((((References:(

1. HTAR(OnG(protocol(2. Royal(College(of(Obstetricians(&(Gynaecologists((Preterm(Prelabour(Rupture(of(

Membranes(3. Ten(Teachers(Obstetrics(

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$PPH! !!

farehatta! ! !

POSTPARTUM)HEMORRHAGE)$Primary$PPH$0$Blood$loss$of$$500$ml$from$genital$tract$within$24$hours$after$delivery$Secondary$PPH$0$Abnormal$or$excessive$bleeding$from$the$birth$canal$between$24$hours$and$6$weeks$postnatally$$Priorities$ Call$for$help$(to$assist$in$controlling$bleeding)$ Assess$the$patients$condition$ Find$the$cause$of$bleeding$ Stabilize$or$resuscitate$the$patient$ Prevent$further$bleeding$

$Causes$of$PPH$4$T$$tone,$trauma,$tissue,$thrombin$

$Risk$factors$ Prolonged$3rd$stage$of$labour$ Multiple$pregnancy$ Caesarean$section$ Episiotomy$ Antepartum$hemorrhage$ History$of$PPH$ History$of$retained$placenta$ Fetal$macrosomia$ Polyhydramnios$ Grandmultipara$ Anemia$$

$GENERAL$measures$in$managing$PPH$ ABC$ Set$2$IV$lines$(large$bore$branula)$and$take$blood$for$FBC,$GXM$(4$units),$PT,$aPTT$ Stabilize$ patient$ with$ crystalloids$ (Hartmanns$ or$ normal$ saline)$ or$ colloids$

(Gelafundin,$Hemacel)$and$run$fast$ High$flow$oxygen$ Monitor$parameters$closely$

General$condition$ Level$of$consciousness$ BP,$PR$ Pad$chart$ Strict$I/O$charting$

Abdominal$palpation$ If$the$uterus$is$not$contracting$and$soft$(boggy)$!$atony$

" Perform$uterine$massage$to$stimulate$contraction$

Tone$ Uterine$atony$(most$common$cause)$Trauma$ Genital$ tract$ trauma,$ laceration,$ hematoma,$ uterine$ inversion,$ uterine$

rupture$Tissue$ Retained$placenta$Thrombin$ Coagulation$disorder$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$PPH! !!

farehatta! ! !

" Empty$bladder$" Give$uterotonic$drugs$

If$the$uterus$is$well$contracted,$the$cause$of$bleeding$is$likely$to$be$genital$tract$trauma$

Careful$inspection$of$cervix,$vagina,$vulva,$perianal$area$for$lacerations,$hematoma$ Manual$exploration$of$uterine$cavity$$remove$clots,$retained$tissue$ Consider$coagulopathy$if$no$other$cause$identified$

$SPECIFIC$measures$in$managing$PPH$$

1. Uterine$atony$ Initially$ treated$ with$ bimanual$ uterine$ compression$ and$ massage$ to$ produce$

contraction$$

$$$$$$$$$$$$$$$$$$$$$

Medical$treatment:$ IM$ Syntometrine$ 1ml$ (Syntocinon$ 5U$ +$ Ergometrine$ 0.5mg)$ $

contraindicated$in$HPT,$heart$disease$ IM/IV$Syntocinon$5U$if$Syntometrine$is$contraindicated$ IV$Pitocin$40U$in$500mls$normal$saline$at$40dpm$$may$increase$up$to$80U$ IM$Carboprost$(Hemabate)$250mcg$$dose$can$be$repeated$every$15$mins$

up$to$a$maximum$of$2mg$*$Carboprost$is$150methyl$prostaglandin$F2a$

Insert$Foleys$catheter$to$empty$bladder! Check$the$placenta$for$completeness$to$rule$out$retained$placenta$and$look$for$

cervical$lacerations$to$rule$out$genital$tract$trauma! If$bleeding$persists$!$surgical$intervention!

Balloon$tamponade! Hemostatic$brace$suturing$(B0Lynch$compression$sutures)! Bilateral$ligation$of$uterine$arteries!

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$PPH! !!

farehatta! ! !

Selective$arterial$embolization! Hysterectomy$(last$resort$if$everything$fails)!!

2. Retained$placenta! Assess$the$patients$condition$&$estimate$blood$loss! Empty$the$bladder! Attempt$controlled$cord$traction$!

If$ successful,$examine$the$placenta$to$ensure$completeness.$Maintain$the$uterine$ contractions$ by$ massaging$ the$ fundus$ of$ the$ uterus.$ Put$ up$ IV$Pitocin$40U$in$500mls$normal$saline$and$run$over$406$hours!

If$fails$!$manual$removal$of$placenta$under$anaesthesia! Cover$with$broad$spectrum$antibiotics$(IV$Cefuroxime$1.5gm$and$IV$Flagyl$

500mg)!!3. Genital$tract$trauma$

Stabilize$patient$first$ Put$patient$in$lithotomy$position$ Find$the$bleeding$point$if$visible$and$clamp$it$ Suture$tear$immediately$ Watch$out$for$further$bleeding$ For$examination$under$anaesthesia$(EUA)$if$

Failed$to$identify$the$source$of$bleeding$ Patient$restless$or$uncooperative$or$vital$signs$are$unstable$ Bleeding$continues$despite$repair$done$

Cover$with$broad$spectrum$antibiotics$$Prevention$of$PPH$ Active$management$of$the$third$stage$of$labour$lowers$maternal$blood$loss$and$reduces$

the$risk$of$PPH$ Prophylactic$oxytocics$should$be$offered$routinely$in$the$management$of$the$third$stage$

of$labour$in$all$women$as$they$reduce$the$risk$of$PPH$by$about$60%$ For$ women$ without$ risk$ factors$ for$ PPH$ delivering$ vaginally,$ oxytocin$ (10U$ by$ IM$

injection)$is$the$agent$of$choice$for$prophylaxis$in$the$third$stage$of$labour$ For$women$delivering$by$caesarean$section,$oxytocin$(5U$by$slow$IV$injection)$should$be$

used$to$encourage$contraction$of$the$uterus$and$to$decrease$blood$loss$$$References:$

1. HTAR$OnG$protocol$2. American$Family$Physician$$Prevention$&$Management$of$Postpartum$

Hemorrhage$3. Royal$College$of$Obstetricians$&$Gynaecologists$$Postpartum$Hemorrhage$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MISCARRIAGES$!

farehatta$

MISCARRIAGES))Spontaneous$loss$of$pregnancy$before$the$fetus$reaches$viability,$before$22$weeks$of$gestation$$Classification$of$miscarriage$

Types$ Description$Threatened$miscarriage$ PV$bleeding$or$spotting$that$may$persist$for$days$or$

weeks,$cramping$abdominal$pain$ Cervical$os:$Closed$ Uterus$$date$ USG:$IUGS$seen,$viable$fetus,$FH$+,$fetal$echo$+$ Plan:$Allow$discharge$with$reassurance;$TCA$2/52$to$

repeat$scan$to$confirm$fetal$viability;$TCA$stat$if$pass$out$POC,$PV$bleed,$abdominal$pain$

DDX:$ectopic$pregnancy,$twisted$ovarian$cyst$Inevitable$miscarriage$ Bleeding$is$heavy$or$increasing,$and$abdominal$cramping$

is$present$but$NO$passing$out$POC$ Cervical$os:$Open$ Uterus$$date$ USG:$IUGS,$no$fetal$heart$beat$ Plan:$

Counseling$ Keep$patient$in$ward$until$expulsion$has$occurred$

completely$ Monitor$VS$and$pad$chart$ Analgesics$ Repeat$per$speculum$if$PV$bleeding$and$abdominal$

pain$increasing$ If$expulsion$has$not$occurred$within$12$hours$for$

Cervagem$1mg$to$hasten$the$process$Incomplete$miscarriage$ Pass$out$parts$of$POC$but$some$remains$in$the$uterus,$PV$

bleeding$(may$be$heavy$bleeding),$abdominal$pain$ Cervical$os:$Open$ Uterus$


farehatta$

Missed$miscarriage$ Gestational$sac$containing$embryonic$death$but$no$passing$out$of$POC$

PV$bleeding,$pain,$loss$of$pregnancy$symptoms$ Cervical$os:$Closed$ Uterus$20mm$with$no$fetal$pole,$no$FH$activity$ Plan:$conservative$vs$active$management$

Allow$discharge,$TCA$2/52$to$repeat$scan$to$confirm$$ Conservative$$let$POC$comes$out$naturally$ Active$$ERPOC$(S+C,$D+C)$ FBC,$GSH,$screening$for$coagulopathy$

DDX:$TRO$wrong$date,$early$pregnancy$Complete$miscarriage$ All$POC$have$been$expelled$

Commonly$occurs$before$12$weeks$of$pregnancy$ After$the$miscarriage$there$is$a$period$of$bleeding$and$

cramping,$which$resolves$without$treatment$ Cervix$os:$Closed$ USG:$empty$uterus$with$no$sign$of$gestational$sac$or$

embryo$seen,$endometrial$thickness$


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Diagnosis$ In$some$cases,$miscarriage$can$be$diagnosed$based$upon$the$woman's$symptoms$and$

the$physical$exam$ Ultrasound$

In$early$pregnancy$!$TVS$$ If$an$embryo$is$present,$its$size$is$measured$and$compared$to$the$size$that$is$

expected$at$the$woman's$stage$of$pregnancy$ The$sac$and$other$materials$surrounding$the$embryo$are$also$examined$to$look$for$

abnormalities$in$these$structures$ Fetal$heart$beat$

At$about$6$weeks$after$the$LMP,$the$motion$of$the$fetal$heart$should$be$visible$on$ultrasound$

If$the$pregnancy$has$progressed$to$the$stage$where$a$heart$beat$should$be$present,$the$failure$to$detect$a$heart$beat$during$an$ultrasound$exam$indicates$that$the$pregnancy$has$likely$ended$

On$the$other$hand,$the$presence$of$a$fetal$heart$beat$(in$the$absence$of$other$abnormalities$in$the$pregnancy)$indicates$the$pregnancy$may$still$be$viable$and$that$miscarriage$may$not$occur$

$$Counselling$before$discharge$ Cause$of$miscarriage$ Avoid$sexual$intercourse$for$2^3$weeks$ Contraception$for$3$months$(incomplete$miscarriage)$ TCA$stat$if$"$PV$bleeding,$severe$abdominal$pain,$or$pass$out$POC$ TCA$gynae$clinic$for$assessment$$$$$$$$References:$

1. Ten$Teachers$Gynaecology$2. Kedah$Hospital$Protocol$

$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ECTOPIC$PREGNANCY$!

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ECTOPIC'PREGNANCY'$Definition:$Implantation$of$conceptus$outside$the$uterine$cavity$$ A$potentially$lifeAthreatening$condition$ Ruptured$ectopic$pregnancy$is$a$gynaecological$emergency$ Recurrence:$10%$ 95A98%$of$ectopic$pregnancies$occur$in$Fallopian$tube$with$ampulla$is$the$most$

common$site$for$tubal$pregnancies$$Risk$factors$ Advanced$maternal$age$(>$35$years$old)$ Previous$history$of$PID$and$tubal$surgery$ Previous$history$of$ectopic$pregnancy$ Pregnancy$with$IUCD$in$situ$ Infertility$ Congenital$abnormality$of$Fallopian$tube$ Assisted$reproductive$technique$ Smoking$$

$History$ PV$bleeding$ Severe$abdominal$pain$$ UPT$positive$ Shoulder$tip$pain$(blood$irritating$the$diaphragm)$ Fainting$spells,$dizziness$

$Physical$examination$ Pale,$hypotension,$tachycardia$ Abdominal$tenderness$if$intraperitoneal$bleeding$ Pelvic$examination:$bluish$cervix$with$os$closed,$+$cervical$excitation,$adnexal/POD$

tenderness/mass$$TVS$(must$be$interpreted$together$with$serum$AhCG)$ Empty$uterus$(no$IUGS$seen)$ Free$fluid$in$POD$(nonAspecific)$ Ectopic$gestational$sac$(extrauterine$sac$with$an$embryo$or$embryonic$remnants)$ Presence$of$adnexal$mass/sac$$free$fluid$

$Investigations$ UPT$to$confirm$pregnancy$ FBC$ Coagulation$profile$if$signs$of$coagulopathy$present$$ GXM$4$pints$packed$cell$ Ultrasound$ Serial$serum$AhCG$if$diagnosis$in$doubt$$

In$99%$of$viable$intrauterine$pregnancies$A$!$hCG$levels$of$at$least$53%$(doubling)$in$48$hours$

When$level$is$above$discriminatory$level$(>$1000$U/L)$&$no$sign$intrauterine$gestation$on$TVS$$viable$intrauterine$gestation$is$extremely$unlikely$

Ruptured$ectopic$"$intraperitoneal$bleeding$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ECTOPIC$PREGNANCY$!

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Serum$quantitative$hCG$can$be$used$to$differentiate$between$an$ectopic$pregnancy$&$a$failing$intrauterine$gestation$

$$$$$$$

$$$$$$$$$General$management$ Resuscitation$ Arrange$for$surgical$intervention$ Counseling$regarding$the$diagnosis$and$plan$ To$give$IM$Rhogam$500$IU$if$mother$is$Rhesus$negative$

$Definitive$management$"$Surgery!$ Laparoscopy$is$the$gold$standard$of$treatment$to$establish$the$diagnosis$and$should$

be$considered$in$women$with$hCG$above$the$discriminatory$level$and$absence$of$IUGS$on$ultrasound$

Laparoscopy/laparotomy$with$salphingectomy/salphingostomy$$Criteria$for$IM$Methotrexate$50mg/m2$single$dose$ Unruptured$ectopic$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$GESTATIONAL$TROPHOBLASTIC$DISORDERS$!

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GESTATIONAL*TROPHOBLASTIC*DISORDERS*$ Arise$from$placental$trophoblasts$ Syncytiotrophoblasts$secrete$hCG$!$used$as$tumour$marker$$$Molar$Pregnancy$$

Complete*hydatidiform*mole* Partial*hydatidiform*mole*Generalized$swelling$of$the$villous$tissue$ Focal$swelling$of$the$villous$tissue$Diffuse$trophoblastic$hyperplasia$ Focal$trophoblastic$hyperplasia$No$embryonic$or$fetal$tissue$ Presence$of$embryonic$or$fetal$tissue$Diploid$chromosomal$constitution$derived$from$paternal$genome$&$usually$ resulting$from$ the$ fertilization$ of$ an$ oocyte$ by$ a$diploid$spermatozoon$

Usually$ triploid$ and$ of$ diandric$ origin,$having$ 2$ sets$ of$ chromosomes$ from$paternal$origin$&$1$from$maternal$origin$O$ most$ have$ a$ 69XXX$ or$ 69XXY$ genotype$derived$ from$a$haploid$ovum,$with$either$reduplication$ of$ the$ paternal$ haploid$ set$from$ a$ single$ sperm,$ or$ from$ dispermic$fertilization$

$Risk$factors$

Advanced$maternal$age$(>35$years$old)$ Previous$history$of$molar$pregnancy$ Blood$group$A$(assoc.$with$choriocarcinoma)$

$Signs$&$symptoms$

PV$bleeding$ Uterus$larger$than$dates$ Abnormally$high$serum$hCG$for$gestational$age$ Medical$ complications:$ PIH,$ hyperthyroidism,$ hyperemesis,$ anemia,$ ovarian$ theca$

lutein$cysts$$Ultrasound$

Uterine$cavity$ filled$with$multiple$ sonolucent$areas$of$varying$ size$&$shape$ (snowOstorm$appearance)$with$no$embryonic$or$fetal$tissue$

$$$$$$$$$$$$$$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$GESTATIONAL$TROPHOBLASTIC$DISORDERS$!

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Investigations$ Serial$serum$beta$hCG$ HPE$of$placental$ tissue$ :$placental$villi$with$ irregular$architecture,$edema$with$true$

villous$cavitation,$and$trophoblast$hyperplasia$$Management$

Uterine$evacuation$(S&C)$ Serial$measurement$ of$ hCG$ levels$ is$ the$ gold$ standard$ for$ diagnosis$&$monitoring$$

the$therapeutic$response$of$GTD$ After$ evacuation,$ hCG$ level$ should$ be$ monitored$ weekly$ until$ detectable,$

followed$by$monthly$monitoring$for$6O24$months$$$Choriocarcinoma$$ A$highly$malignant$tumour$that$arises$from$trophoblastic$epithelium$ Rapidly$metastasizes$to$the$lungs,$liver$and$brain$ Following$ uterine$ evacuation,$ molar$ pregnancy$ can$ progress$ to$ develop$

choriocarcinoma$ Many$patients$will$present$with$SOB,$neurological$symptoms$&$abdominal$pain$for$few$

weeks$or$months$$$$$$References:$

1. Ten$Teachers$Gynaecology$2. BMJ$Practice$$Molar$Pregnancy$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MENORRHAGIA$!

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MENORRHAGIA*$Heavy$cyclical$menstrual$blood$loss$over$several$consecutive$menstrual$cycles$in$a$woman$of$reproductive$years,$or$more$objectively,$a$total$menstrual$blood$loss$of$more$than$80$ml$per$menstruation$(Hallberg$et$al,$1966).$$Causes:$

1. Idiopathic$$Dysfunctional$uterine$bleeding$(DUB)$2. Secondary$$

Uterine$fibroid$ Endometrial$polyp$ Endometriosis$ Coagulopathy$ Drug$therapy$(warfarin,$IUCD)$ Hypothyroidism$

$Dysfunctional$uterine$bleeding$

A$diagnosis$of$exclusion$ Abnormal$uterine$bleeding$in$the$absence$of$pregnancy,$genital$tract$pathology,$or$

systemic$disease$ Mechanisms$of$DUB$

Abnormal$ prostaglandin$ ratios$ and$ other$ inflammatory$ mediators$ !$vasodilatation$&$platelet$nonTaggregation$

Excessive$fibrinolysis$$$

Management$of$Menorrhagia$ Full$history$

Pattern$of$menstrual$blood$loss$ Association$with$dysmenorrhea$ Symptoms$of$anemia$ Symptoms$of$hypothyroidism$ Bleeding$tendencies$ Risk$ factors$ for$ endometrial$ disease$ (age$ >40,$ obesity,$ nulliparity,$ infertility,$

tamoxifen$therapy,$underlying$DM,$PCOS)$ Smear$history$ Use$of$contraception$ History$of$drug$therapy$

Physical$examination$ Abdominal$examination$ Per$speculum$examination$ Bimanual$examination$

Investigations$ FBC,$GXM$ TFT$and$coagulation$profile$if$clinically$indicated$ Pap$smear$if$indicated$ Ultrasound$$ TVS$to$identify$fibroids$&$polyps,$measure$endometrial$thickness$(ET)$$usually$

indicated$if$age$>40,$failed$medical$therapy,$presence$of$risk$factors$ Pipelle$ sampling$ to$ exclude$ endometrial$ hyperplasia$ or$ cancer$ $ indicated$ if$

bleeding$persists,$presence$of$risk$factors$and$ET$>$12mm$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MENORRHAGIA$!

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Hysteroscopy$$ Medical$treatment$

Tranexamic$acid$500mgT1g$TDS$(antifibrinolytic$agent)$ Mefenamic$acid$500mg$TDS$(NSAIDs)$$can$relieve$dysmenorrhea$ T.$Provera$10mg$OD$for$21$days$from$D5$for$3$cycles$(medroxyprogesterone)$or$

T.$Duphaston$10mg$BD$for$21$days$from$D5$(dydrogesterone)$or$COCP$ Levonorgestrel$intrauterine$system$(Mirena)$ GnRH$analogues$ T.$Danazol$100mg$BD$for$3T6$months$ Hematinics$$

Surgical$treatment$(if$failed$medical$therapy)$ Endometrial$ablation$ Hysterectomy$$

$$$$$$$$References:$

1. Kedah$Hospital$Protocol$2. Oxford$Handbook$of$Obstetrics$&$Gynaecology$3. CPG$Menorrhagia$(2004)$

$$$$$$$$$

If$bleeding$persists$for$more$than$6$months$

HO SHORT NOTES O&GTOPICSDEFINITION IN OBSTETRICSIOL AND AUGMENTATION OF LABOURINSTRUMENTAL DELIVERYCAESAREAN SECTIONHYPERTENSION IN PREGNANCYGESTATIONAL DIABETES MELLITUSPPROM AND PROMPOSTPARTUM HEMORRHAGEMISCARRIAGESECTOPIC PREGNANCYGESTATIONAL TROPHOBLASTIC DISORDERSMENORRHAGIA

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HO OnG Notes