Department of Obstetrics and Gynecology

Protocol Handbook

January 2008
 Contents

Antenatal Care

Management of Premature Rupture of Membranes (PROM) and

Preterm Premature Rupture of Membranes (P-PROM)

Management of Preterm Labour

Management of Breech Presentations

External Cephalic Version - Proforma

Management of Antepartum and Postpartum Haemorrhage

Management of Diabetes in Pregnancy

Management of Hypertension in Pregnancy

Anticoagulation during Pregnancy and the Puerperium

Management of UTI during Pregnancy

Management of the Rhesus Negative Mother during Pregnancy and Delivery

Management of Multiple Pregnancies

Management of Post-term Pregnancy

Induction of Labour

Management of Meconium Stained Liquor

Management of Vaginal Birth after Cesarean Section

Management of Postpartum Fever

Misoprostol Use in OBGYN

Blood Transfusion Protocol

Management of First Trimester Bleeding

Preoperative Preparation and Evaluation of Women for Gynecological Surgery

Protocol for diagnosis and management of Amenorrhea

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 Antenatal Care

The main goal of antenatal care is to ensure the birth of a healthy baby with minimal risk for the
mother. Antenatal care undoubtedly contributed to the dramatic decline in maternal mortality in the
USA from 690/100,000 births in 1920 to 50/100,000 by 1955. Timing of visits is traditionally monthly
until 32 weeks, then every 2 weeks until 36 weeks then weekly until delivery. There is evidence to
suggest that less frequent visits may not be associated with any adverse outcome, but these are
preliminary findings.

Antenatal care allows for the following:

 Maternal health checks
 Evaluation of fetal health and development
 Disease screening
 Analysis of risk for the development of complications
 Provision of advice and education

1. Maternal health:

 Social circumstances – evidence shows that women with poor social circumstances have much
higher risk pregnancies than those in more comfortable circumstances. These women have
poorer nutrition and have more difficulty accessing health care. These are therefore the women
who should have more of our attention.
 Tobacco and Alcohol – good evidence shows that use of tobacco during pregnancy is
associated with placental abruption, preterm delivery, LBW and cleft lip/palate. Women should
therefore be advised to stop use when pregnant. Alcohol in small amounts does not cause harm
but the ‘safe’ level of alcohol in pregnancy is unknown. Women should therefore be advised to
limit or stop alcohol consumption in pregnancy.
 Supplements and Vitamins - Folate supplementation (0.5mg daily, starting up to 3 months
before conception) is advised because good evidence shows that this reduces neural tube
defects. Vitamin A supplements and liver products are not advised. At present there is insufficient
evidence for the routine use of vitamin D supplements in pregnancy although it is known that
Asian women are deficient in vitamin D so this may also be recommended in Afghanistan.
 Food hygiene - attention to food hygiene is recommended. Washing of salads and fruits (to avoid
toxoplasma), thorough cooking of meat (to avoid listeria and salmonella) and avoiding
unpasteurized milk, soft cheese, pate (listeria) and raw eggs (salmonella).
 Physical exertion – physically demanding work has been associated with poor pregnancy
outcome such as preterm birth, pre-eclampsia and LBW. Women should be advised to exercise
‘normally’ not to become over-tired
 Sexual intercourse – there is no evidence to associate sexual intercourse with poor outcome.
 Pre-existing medical disease – women with diabetes, thyroid disorders, asthma, epilepsy,
tuberculosis, renal, liver or cardiac disease all need specialist care and follow-up in a high-risk
clinic where medical and obstetric services are combined.

2. First Antenatal Visit (Booking Visit)

Most tests during pregnancy are considered screening tests. Remember that for a screening test to
be effective, it should lead to identification of a problem in order to allow appropriate intervention. Be
aware or false positives and false negatives.

 History and risk assessment – a thorough history is important to identify any risk factors in the
pregnancy and to determine a management plan
 Determining the EDD – this is one of the most important aspects to antenatal care and can be
calculated from the LMP (if known) by Naegele’s rule (adding 7 days and subtracting 3 months). If
the LMP is not known or not sure an ultrasound towards the end of the first trimester, before 14
weeks is the most accurate time for dating the pregnancy. However, if only one screening
ultrasound is possible in the pregnancy, the best time is between 16-20 weeks (fetal anomaly
scan).

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 Maternal examination – height and weight should be got at the initial visit to determine BMI in
order to provide dietary advice. There is no evidence that repeated measurement of weight is of
any value during pregnancy. Auscultation of the heart and lungs, breast and abdominal
examination are useful on booking. Pelvic examination is not recommended routinely – only if
there is an indication. A history of preterm labour or previous genital infection is an indication to
swab the vagina and culture for pathogens. As culture is difficult in Afghanistan, we should
consider at least performing a wet prep after swabbing the vagina to identify common vaginal
pathogens.
 Urine examination – if bacteria are present, the urine should be sent for culture as treatment of
asymptomatic bacteriuria is effective. Proteinuria and glycosuria should be tested for at every visit
using the dipsticks.
 Blood Pressure (BP) – anything over 140/90 needs careful follow-up at every visit.
 Booking blood tests
o Hematocrit: should be ordered to screen for anemia (WHO define anaemia as < 11g/dl
and severe anaemia as < 7g/dl).
o Blood Group and Rhesus: must give prophylactic anti-D to Rhesus negative mothers
(who are non-sensitized, that is their indirect coombs test is negative) after potential
sensitizing events and routinely at 28 weeks gestation (see Rhesus Negative protocol)
o Maternal infection screening: Rubella antibodies indicate immunity and sero-negative
women should be offered vaccination after delivery. Syphilis, HBV and HIV screening
should be offered because effective treatments are available. There is no evidence to
support routine screening for toxoplasma, varicella or human parvovirus B19.
o Glucose tolerance testing: see Diabetes Protocol
 Fetal growth monitoring – the aim is to detect small or large for gestational age babies.
Consistent measurement of symphiseal-fundal height is effective. Measurements of 3cm or more
above or below the calculated gestational age warrant referral to ultrasound for assessment of
fetal growth. There is no evidence for routine ultrasound in the third trimester.
 Anomaly screening – doctors should be aware of the possibilities of both biochemical and
invasive screening for chromosomal and genetic anomalies although this is currently unavailable
in Afghanistan.

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Management of Premature Rupture of Membranes (PROM) and Preterm Premature
Rupture of Membranes (P-PROM)

Definitions:
 PROM: Rupture of amniotic membrane more than 1 hour prior to the onset of labor.
 P-PROM: Rupture of amniotic membrane more than 1 hour prior to the onset of labor and before
37 weeks gestation.

Symptoms and signs:

 Leakage of clear fluid from the vagina (40% of patients who complain of fluid leakage do not have
ruptured membrane)
 50% of women will deliver in 5 hours and 95% within 28 hours.

Management:
 Detailed history and physical examination
 Accurate assessment of gestational age and fetal wellbeing including presentation.
 Examine the woman in lithotomy position with a sterile vaginal speculum and look for the following
signs.
1. A pool of fluid in the posterior fornix
2. A flow of amniotic fluid from the cervical os when the woman coughs or with fundal
pressure
3. Positive nitrazine paper (turns blue with pH of 7.1-7.3)
4. A positive Fern test (use a swab to plate the fluid onto a slide, let it dry and look at it
under the microscope)
 Avoid digital examination unless already in labor.
 In P-PROMs start Erythromycin 250mg orally qds and give for 10 days for prevention of neonatal
infection including group B streptococcus.
 In PROMs after 18 hours at term, start Ampicillin 2g IV and 6 hourly until delivery.
 Term babies should be delivered within 24 - 72 hours of ruptured membranes.
 In P-PROM patients, the risk of prematurity and RDS should be weighed against the risk of
intrauterine infection. Steroids should be given if gestation less than 34 weeks.
 Tocolytic should only be used to postpone the delivery for 24 - 48 hours to allow the steroids time
to take effect (Nifedipine 20mg orally every 4 hours if still contracting).

Diagnosis and Management of Chorioamnionitis

 The first indication of intrauterine infection is usually fetal tachycardia >160 bpm
 Maternal temperature of >38 degree C
 Maternal tachycardia >100 bpm
 Elevated white count or CRP
 Uterine tenderness
 Offensive vaginal discharge
 Amniotic fluid studies: Gram stain, WCC, culture (need microbiology service)

When a diagnosis of chorioamnionitis is made, antibiotics can be started (Metronidazole and

Erythromycin or Ampicillin +/- Gentamicin depending on severity) but these are rarely curative, the
correct management is to arrange delivery. Consultation with the Attending doctor is necessary.

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 Management of Preterm Labour

Definition of labor: Uterine contractions that cause anatomical changes in the cervix
(dilatation and effacement)

Initial assessment:

 History: including detailed history of contractions, symptoms of urinary tract infection, other
illnesses, fevers, previous history of preterm labor, nicotine or drug use and leaking amniotic
fluid.
 Physical: including evaluation of uterine size and contractions, gestational age, and cervical
evaluation – sterile speculum, try to avoid digital exams.
 Fetal assessment: CTG recording for uterine activity and fetal wellbeing, US.
 Laboratory: urinalysis should be requested in every patient with preterm labor. Consider other
lab tests as indicated by the history and examination.

Management:

 Correct dehydration by oral and / or IV fluid.

 Treat UTI with appropriate antibiotics.
 Treat other illnesses appropriately eg malaria, pneumonia, other causes of fever.
 Monitor uterine contractions and fetal heart rate.
 If gestational age is less then 34 weeks give dexamethsone 8mg IM every six hours for four
doses or betamethasone 12mg every 12 hours for two doses.
 Use Tocolytics under the supervision of the doctor: Start an IV infusion of 1000ml Ringers and
give Nifedipine 20mg orally (avoid sublingual), monitor BP initially after 15 mins and then
every 30 mins. Repeat the dose after 4 hours if still contracting and BP stable. Tocolytics
are contraindicated in preeclampsia, placental abruption, intrauterine infection, lethal
fetal abnormalities, advanced cervical dilatation and where there is evidence of fetal
compromise or placental insufficiency. In all these cases, it is safer for the mother (and
baby) to deliver.
 Give prophylactic treatment for group B Streptococcus (Ampicillin 2g IV initially and then 1g
every 6 hours until the birth of the baby) in patients with the following conditions:
a. Maternal temperature of >38 degree C.
b. Premature rupture of membranes for 18 hours or more.
c. Premature labor.
d. History of previous newborn with GBS (early neonatal death with sepsis or
pneumonia)
e. UTI caused by GBS.
 Inform pediatrician, as neonatal support is essential to neonatal morbidity and mortality.

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 Management of Breech Presentations

Frank (Extended) Breech:

Buttocks presenting with legs flexed over the body (knees extended).
Can be allowed to deliver vaginally if the following conditions are met:
1. No hyperextension of the head. (ultrasound is the best mode for assessing head extension)
2. No evidence or suspicion of macrosomia
3. Normal progress of labor in terms of partogram
4. Adequate help is available, including experienced obstetrician and or midwife, second assistant,
adequate anesthesia, neonatal support and availability of performing C/Section.
5. Adequate clinical Pelvimetry
6. Availability of Piper forceps for the after coming head is desirable.
7. An obstetrician should be called for all breech presentations during labor.

Complete (Flexed) Breech:

Buttocks and legs are presenting at the same time.
Should be evaluated by an obstetrician for possible vaginal delivery. If delivering vaginally, the
conditions above also need to be met.

Double-footing Breech:
Both legs are extended at hip and knee so that both feet are presenting.
High risk of cord prolapse and CPD. Must have C/Section if it is not too late.

Footing Breech:
Single leg is extended at hip and knee so that one foot is presenting.
High risk of cord prolapse and CPD. Must have C/Section if it is not too late.

 Consider C/Section in patients with premature breech presentations in labor. Each case
needs to be assessed individually and the risks and benefits discussed with the parents.
 All patients with breech presentation should be given the option of external cephalic version
(ECV) at 38 weeks. If patients accept, Dr Jacqui should be contacted and a time will be
arranged for them to attend labor ward for this procedure. See also ECV proforma.
 All patients with breech presentation should have adequate counseling by an obstetrician or
experienced midwife in terms of risk benefit of vaginal delivery verses C/Section regarding
infant and maternal morbidity and mortality.
 The decision of the rout of delivery should be left to the patient as long as she understands all
aspects of the procedure and has signed an informed consent.

Evidence from research:

Recently, researchers conducted a large international multi-centre randomized clinical trial (the
Term Breech Trial) comparing a policy of planned cesarean birth with planned vaginal birth.
Following the results of this trial, both the American College of Obstetricians and Gynecologists
and the UK’s Royal College of Obstetricians and Gynecologists recommended that obstetricians
continue their efforts to reduce breech presentation in singleton gestations through the application
of external cephalic version whenever possible.

In the USA, if a breech presentation is not converted to cephalic presentation by version,

according to ACOG standards they will have C/Section unless the patient refuses. C/Section in
the modern world is extremely safe, but in Afghanistan the selective delivery of breech is probably
safer than C/Section.

Any mother admitted to the ward for c-section because of breech presentation, must have an
USS on the morning of the c-section to confirm that the baby is in fact still breech.

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 Algorithm for the management of breech presentation at term:

Medical or Breech presentation at term

obstetric
contraindications See after one
to labor and Repeat week to confirm
vaginal delivery procedure ECV offered cephalic
may be
offered
Unsuccessful
/ unwanted Successful

Counselling of patient re:

risks/benefits of vaginal Book elective
breech delivery C/Section if wishes

Wishes trial of vaginal delivery

Footling breech Arrange USS

Macrosomic fetus
Abnormal fetus or
hyperextension of No placenta praevia Trial of vaginal
head Extended or flexed breech <3.8kg breech delivery
Flexed fetal head

Clinical pelvimetry
Obvious pelvic
Advise C/Section abnormality

Any mother admitted to the ward for c-section because of breech presentation, must have an
USS on the morning of the c-section to confirm that the baby is in fact still breech.

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 External Cephalic Version - Proforma

Date:

Name: Hospital No.:

Parity: Gestation by scan:

Exclude the Following (tick):

□ Multiple pregnancy
□ Previous Caesarean section
□ Antepartum haemorrhage after 20weeks
□ Need for CS regardless of presentation
□ Ruptured membranes
□ IUGR / oligohydramnios
□ Fetal abnormality

Explain the procedure and the following risks:

 Need for immediate CS if signs of fetal distress on CTG following procedure
 Small risk of feto-maternal haemorrhage – anti-D needed if Rhesus negative
 Need to return for check of presentation next week
 Very small risk that baby can turn back (approx 2%)

Procedure:
Ultrasound findings:
1. Presentation Breech extended □ Flexed □ footling □ Cephalic □
2. Nuchal cord No □ Yes □
3. Liquor volume Normal □ Increased □ Decreased □
4. Placental site Anterior □ Posterior □

Pre ECV CTG satisfactory: Yes □ No □

Fetal head easy to feel: Yes □ No □
Breech deep in the pelvis: Yes □ No □

Procedure carried out by: (Name) …………………… (Signature)…………………….

Successful: Yes □ No □
Post ECV CTG satisfactory: Yes □ No □

Blood group:……………… Kleihauer:………………. Anti-D given (date)….……………

Outcome: Home (without ECV) □ Home after ECV □ Immediate CS □

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 Management of Antepartum and Postpartum Haemorrhage

The blood flow in the uterine arteries at term pregnancy is 800 cc/minute

 Never examine a patient with third trimester bleeding unless you know the location of the
placenta or the patient is on the operating table for a double sit up examination.
 Third trimester bleeding is most commonly caused by placental abruption or placenta praevia.
 Postpartum bleeding is caused mainly by uterine atony, but retained products, uterine rupture,
cervical, vaginal or perineal lacerations can also cause serious bleeding.

Management:

During an obstetric emergency someone must take charge, preferably an obstetrician,

who should direct the rest of the team, allocating responsibility for the following
procedures that need to take place simultaneously.

 Shout for help – get someone to start phoning to inform obstetrician, lab tech,
anaesthetist, pediatrician as needed
 Stay calm - Understand the level of emergency
 Allocate specific tasks to the members of the team
 Take a brief history and physical. Assess the patient’s condition and plan your
management accordingly – know the protocols.
 Start two IVs with large cannulae, 16 or 14 gage
 Start crystalloid IV solution and run it fast, 2000ml immediately
 Get blood drawn for QBC, bleeding time and Blood type and XM 4 units. Arrange for
transfusion of 0Rh –ve blood in acute emergency if needed.
 Catheterise the bladder and start monitoring input and output.
 Keep the patient warm
 Treat specific problems:
o Placenta praevia: Commonly delivered by C/Section, according the patient’s
condition and location of the placenta
o Placental abruption: The patient needs to be delivered vaginally or by C/Section
within 4-6 hours depending on the condition of the mother and the baby
o Postpartum bleeding: active management of the third stage and further use of
oxytocic drugs (40iu oxytocin in 1000ml N/Saline over 4 hours plus 0.5microgram
ergometrine IM), direct injection of prostaglandin (haemabate) into the
myometrium, manual removal of placenta, manual exploration of the uterus,
possibly uterine packing or tamponade with large Foley balloon, suturing of
cervical, vaginal or perineal lacerations, exploration of the abdomen and ligation
of internal iliac and ovarian arteries, finally - abdominal hysterectomy.

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 Management of Diabetes in Pregnancy

Definitions:

Gestational diabetes mellitus (GDM) has been defined as carbohydrate intolerance that begins, or
is first recognized, during pregnancy. GDM results from insulin resistance due to the physiologic
changes of pregnancy and affects 2-5% of the pregnant population.
More than 50% of women with GDM will develop overt diabetes over the next 20 years.

Pre-existing diabetes:
Type 1 diabetes is absolute insulin deficiency due to pancreatic B-cell destruction. B-cell destruction
can be immune-mediated or idiopathic.

Type 2 diabetes results from defective insulin secretion or insulin resistance. Type 2 diabetes has a
strong relationship with obesity.

Classification of Diabetes Complicating Pregnancy:

Class Onset Fasting Plasma 2-hour Therapy

Glucose Post-Prandial Glucose
A1 Gestational <105 mg/dL <120 mg/dL Diet
A2 Gestational >105 mg/dL >120 mg/dL Hypoglycemic
agent
Class Age of Onset (yr) Duration (yr) Vascular Disease Therapy
B Over 20 <10 None Insulin
C 10 to 19 10 to 19 None Insulin
D Before 10 >20 Benign retinopathy Insulin
F Any Any Nephropathy* Insulin
R Any Any Proliferative retinopathy Insulin
H Any Any Heart Insulin
*When diagnosed during pregnancy: proteinuria of 500mg or more per 24h before 20 weeks
gestation.

Screening and Diagnosis of Gestational diabetes:

Despite much research, there remains a lack of consensus regarding the optimal approach to
screening pregnant women for GDM. Although it is agreed that all pregnant patients should be
screened in some way, using:
1. Patient history
2. Clinical risk factors
3. Laboratory screening

There are 2 approaches to screening:

Universal screening: All patients are screened between 24 and 28 weeks.

Selective screening: Uses a screening strategy based on a risk assessment for GDM.

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Selective screening based on risk assessment:

Risk Category Recommendations for Screening

High risk (one or more of the following): Screen at initial antenatal visit or as soon as
-Marked obesity possible: repeat at 24-28 weeks gestation if
-Diabetes in first degree relative initial screening negative for gestational
-History of glucose intolerance diabetes
-Previous infant with macrosomia
-Previous unexplained stillbirth
-Current glycosuria
Average risk: Screen between 24 and 28 weeks gestation.
Patient fits neither high-risk nor low-risk
Low risk (patient must have all of the Screening not required
following):
-Age < 25
-Belongs to a low risk ethnic group§
-No diabetes in first degree relative
-Normal pre-pregnancy weight (BMI <25) and
normal weight gain during pregnancy
-No history of abnormal blood glucose levels
-No prior poor obstetrical outcomes
§ Low- risk races and ethnic groups are those other than Hispanic, black, Native American, South or
East Asian, Pacific Islander, or Indigenous Australian.
Source: Kjos SL and Buchanan TA. Gestational Diabetes Melllitus. N Engl J Med 1999; 341:1749-
1756

Procedure for screening and diagnosis:

Screening test: Result of serum glucose: Next step:

50g oral glucose challenge 140 mg/dL or less -No further testing required
test. Plasma glucose is >140 mg/dL -Proceed with 3-hour GTT
measured 1 hour after the >190 mg/dL -GDM is diagnosed. No
glucose load, no matter time of further testing needed
day or time of last meal.
Diagnostic test: Interpreting the 3-hour GTT Next step:
(National Diabetes Plasma
Data Group):
100g oral glucose tolerance Fasting 105 mg/dL Two or more abnormal
test (3-hour GTT). Test should 1 hour 109 mg/dL values= Gestational diabetes
be performed after overnight fast. 2 hour 165 mg/dL (GDM)
Venous plasma glucose is 3 hour 145 mg/dL
measured at fasting, 1 hour, 2
hour and 3 hours.

Treatment and Management for Gestational and Pre-existing Diabetes

Goals of treatment include: 1. Fetal surveillance to decrease excess perinatal mortality.
2. Prevention of adverse pregnancy outcomes, such as macrosomia, which can lead to operative
delivery, shoulder dystocia, and birth trauma.
Management and treatment is best achieved by a team consisting of obstetrician, diabetic
midwife/nurse, and medical physician/family medicine practitioner.

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Diet: Ideal body weight (IBW) = 100 pounds @ 5 feet, plus 5 pounds/inch > 5 feet
Daily kcal: 36 kcal/kg or 15 kcal/lb of IBW + 100 kcal/trimester
Nutrients:
- 40-50% carbohydrate
- 12-20% protein
- 30-35% fat

Plasma glucose control: Recommend checking plasma glucose levels for morning fasting value and
2 hours after each meal (post-prandial).
Desired ranges:
Fasting 70-105 mg/dL
2-hr post prandial 100-140 mg/dL

Insulin: Usually begun for fasting blood glucose levels > 105 mg/dL consistently.
Most individuals require a combination of short acting insulin (Regular) to cover each meal, and long
acting insulin (NPH), to provide baseline coverage throughout the day.

Insulin types and duration:

Type of Insulin Onset of Action Maximum Effect Duration
Regular 1 hour 2-3 hours 4-5 hours
NPH 2 hours 8 hours 24 hours

Distribution of insulin: A.M. 2/3→2/3 NPH, 1/3 Regular P.M. 1/3→½ NPH, ½ Regular

Anticipated eventual insulin requirements for gestational diabetic by gestational age:

Gestational age (weeks) Anticipated insulin dose
6-18 0.7 Units/kg
18-26 0.8 Units/kg
26-26 0.9 Units/kg
36-40 1.0 Units/kg

Oral hypoglycemic agents: Can be used instead of or prior to starting insulin if fasting glucose levels
are less than 110 mg/dL. Glyburide has been studied and found to be safe and effective for some
women with only mild hypoglycemic requirements.
Glyburide 2.5mg can be given as once daily dose initially in p.m.
- If inadequately controlled, second dose of 2.5mg orally can be added in a.m.
- Can increase dose to 5mg and if not controlled with 5mg twice daily, need to switch to insulin for
glucose control.

Insulin Dependent Diabetes and Pregnancy: Special considerations

- Check Hemoglobin A1C preconception and during 1 st trimester. Rate of malformations 22% for
HgB A1C > 8.5
- Arrange fetal cardiac echocardiogram at 22 weeks
- Ophthalmology evaluation during 1st and 3rd trimesters for progressive retinopathy
- 24-hour urine for creatinine clearance, total protein
- Fetal ultrasound for growth at 18, 22, 26, 38 weeks
- Insulin requirements will increase throughout pregnancy.
- Recommend plasma glucose levels be checked at fasting, 2-hours post-prandial (breakfast,
lunch, dinner) and at bedtime.

Fetal monitoring
- Ultrasound at 18-24 weeks (dating, growth, anatomy)
- Kick counts starting at 28 weeks (10 movements over a 2 hour time period daily)
- Twice weekly fetal testing (weekly AFI and twice weekly NST) starting at 32 weeks

Delivery recommendations
- In general, women with GDM do not require early delivery or other interventions.
- Women with pre-existing diabetes should have elective inductions 39-40 wks gestation.

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- Elective c-section should be considered in women with an EFW by USS of 4500g or more. It is
controversial whether elective c-section has any effect on the incidence of brachial plexus injury.

Insulin use during labor

- Check blood sugars every 2 hours in labor
- If blood sugars >120 mg/dL, begin insulin infusion via IV pump (10 units regular insulin in 1000cc
normal saline, therefore 1 unit = 10 cc)
- If patient is having labor induced, give only morning NPH (long acting) insulin dose.

Insulin infusion sliding scale:

o <100 no insulin
o 100-120 at doctor’s discretion
o 120-140 1 unit/hour
o 141-180 1.5 units/hour
o 181-200 2 units/hour
o 201-220 2.5 units/hour
o >220 call doctor on duty

- If patient is on an insulin infusion, blood sugar should be checked hourly

- Urine should be dipped after each void and checked for ketones
- Turn insulin infusion off after delivery
- Post-partum, blood sugar can be checked fasting and before meals, or per doctor instructions.
Sliding scale can be used if necessary.

Note: If steroids are given for a preterm patient with diabetes, monitor glucose carefully for 48 hours,
as blood sugars will increase and insulin requirement will be greater. May need to start insulin
infusion.

Post-partum:
Women diagnosed with GDM should have a 75g OGTT at 6 to 12 weeks after delivery and be
reassessed every 3 years. These women are also at risk of developing GDM in a subsequent
pregnancy.

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 Management of Hypertension in Pregnancy

Any patient who comes to the maternity ward with any of the following diagnoses should be
assessed by the midwife and seen by the resident doctor.

Classification

 Chronic hypertension (Presence of hypertension before pregnancy)

 Coincidental hypertension (Hypertension is discovered for the first time during pregnancy)
 Gestational hypertension / Pregnancy Induced Hypertension (PIH) (Pregnancy related
hypertension without protienuria or edema)
 Preeclampsia (hypertension 140/90, protienuria >300mg/24h, edema of upper body)
 Eclampsia (preeclampsia + convulsion)
 Chronic hypertension with superimposed Preeclampsia / Eclampsia

Initial evaluation

1. Brief history and physical

a. Patient’s conscious level
b. Heart and lungs auscultation
c. Abdominal examination
d. Upper body edema
e. Deep tendon reflex (DTR)
f. Fundoscopy
g. Pelvic examination for cervical evaluation and fetal presentation
h. Determination of gestational age (history and abdominal exam, US)
i. Fetal well-being (biophysical profile BPP) - CTG, US

2. Laboratory (Call the results to the doctor)

a. Blood for QBC inc platelets, LFTs, Bleeding time, Blood Group & Save
b. Urine for dipstix (protein and leucocytes)

3. Tentative diagnosis - Plan management according to diagnosis

Chronic hypertension (most favorable prognosis)

 Continue to treat BP with anti-hypertensive drugs as necessary (BP >/= 160/110) May be
treated as outpatient if mother and baby otherwise normal.

Coincidental hypertension is difficult to distinguish from gestational hypertension

 Treat with anti-hypertensive drugs only if BP > 160/110.

May be treated as outpatient if mother and baby otherwise normal.

Severe Preeclampsia (BP >/= 160/110, proteinuria ++, symptomatic) and Eclampsia

 Admit and call the doctor immediately

 If unconscious or fitting, place in recovery position and check:
Airway assess, maintain patency, give oxygen
Breathing assess, protect airway, ventilate if required
Circulation evaluate pulse and BP, if absent start CPR, left lateral tilt, deliver
immediately.
 Start IV fluid (RL or NS) slowly (85ml/hour = 1000ml over 12 hours)
 Insert Foley catheter and monitor output every hour (aim for 30ml/hour)
 Keep accurate fluid input/output record. Start eclampsia observation sheet.
 Give MgSO4 to prevent or to stop convulsions. See protocol below. (If the convulsion is not
stopping, consider adding diazepam, consider other diagnoses eg meningitis, epilepsy,
intracerebral bleed)

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  Treat hypertension only if it is over 160/110 (Hydralazine, Nifedipine, Labetalol – see protocol
below). Aim for BP around 130-140/90-100.
 Start steroids if gestation less than 34 weeks (8mg Dexamethasone IM every 8 hours for 4
doses or 12mg Betamethasone every 12 hours for 2 doses)
 Plan delivery: aim for vaginal delivery where possible and start induction of labour with
misoprostol 25 micrograms PV (see Induction protocol).
 Continue close observation for 48 hours after delivery (Convulsions may take place for the
first time after delivery).

Magnesium Sulfate Protocol

1. Give 4g IV slowly over 15 minutes.

2. Start IV infusion by adding 20g MgSO4 to 1000ml Ringers and give 2g/h (100ml/h). Watch for
symptoms and signs of fluid over load (Regular chest auscultation for pulmonary oedema,
fluid input/output charting).
3. If unable to site IV, or unable to monitor IV, give 5g MgSO4 (plus 1ml lignocaine 2%) by deep
IM injection into each buttock and then 5g (with lignocaine) into alternative buttocks every 4
hours.
4. Watch and monitor DTR (should be weakly present) and Respiratory Rate.
5. MgSO4 may be given in much larger doses, until patient convulsion, agitation and
hyperreflexia is under control.
6. Side effects of MgSO4 are hypotension, flushing, nausea/vomiting, respiratory depression,
arrhythmias, slurred speech, drowsiness – DO NOT Give MgSO4 if
1. DTR becomes absent
2. Respiratory Rate less than 15 breaths per minute
3. Urine Output less than 30ml/hour
7. If there are symptoms and signs of MgSO4 toxicity, the antidote is Calcium Gluconate. Give
1g (10ml of 10%) IV over 10mins.
8. Continue MgSO4 for 24 hours after delivery.

Hydralazine Protocol

 Give 5mg IV over 10 mins and wait 30 mins before repeating the dose if needed.
Further 5mg boluses can be given IV, up to 15mg.
 Once BP stable, consider an infusion of 10mg/hour.

Nifedipine Protocol

 Give 10mg orally (avoid sublingual) every 8 hours.

Labetolol Protocol

 Give 20mg IV over 10 mins and wait 30 mins before giving a further dose of 20mg or
40mg as necessary.
 Once BP stable, consider an infusion at 40mg/hour.

16
 Anticoagulation during Pregnancy and Puerperium

Recent studies using objective criteria for the diagnosis of venous thromboembolism (VTE) have
found that ante-partum deep vein thrombosis is at least as common as post-partum thrombosis and
occurs with equal frequency in all three trimesters. However, pulmonary embolus is more common
post-partum.

Some of the factors associated with changes in coagulation during pregnancy and puerperium
include: Increased clotting factors (I, VII, VIII, IX, X), decreased protein S, decreased fibrinolytic
activity, increased venous stasis, increased activation of platelets, resistance to activated protein C
and vascular injury associated with delivery.

1.The following are risk factors for VTE in pregnancy and the puerperium:

Pre-existing
 Previous VTE
 Congenital
 Antithrombin deficiency
 Protein C or S deficiency
 Factor V Leiden mutation
 Prothrombin gene variant
 Acquired (antiphospholipid syndrome, APS)
 Age >35 years
 Obesity (BMI >30 kg/m2) either pre-pregnancy or in early pregnancy
 Parity >4
 Gross varicose veins
 Paraplegia/prolonged immobility
 Sickle cell disease
 Inflammatory disorders
 Valvular heart disease
 Myeloproliferative disorders (polycythemia vera)

New-onset or transient
 Surgical procedures in pregnancy or puerperium (e.g. ERPC, postpartum sterilization)
 Hyperemesis, dehydration
 Ovarian hyperstimulation syndrome
 Severe infection, e.g. pyelonephritis
 Immobility (>4 days bedrest)
 Pre-eclampsia
 Excessive blood loss
 Long-haul travel
 Prolonged labor
 Midcavity instrumental delivery
 Immobility after delivery

Some of these risk factors confer more risk on a patient for VTE than others.
Treatment should be individualized based on risk.

17
2. The following patients should receive thromboprophylaxis (low-dose prophylaxis)
during the ante-partum and/or post-partum period:

Condition Ante-partum Post-partum

Previous VTE but no thrombophilia No (if VTE associated with 6 weeks
resolved temporary risk factor)

> 1 previous VTE or Yes 6 weeks

1 VTE + family h/o VTE or
unusual site of VTE

Thrombophilia (factor V Leiden, Yes 6 weeks

prothrombin mutation, antithrombin
deficiency, APS) AND prior VTE

Antithrombin deficiency (RCOG) Yes 6 weeks

Other thrombophilias but no prior VTE ? 6 weeks

APS with recurrent miscarriage No 3-5 days

> 3 persistent risk factors Yes 3-5 days

3. The following patients should receive adjusted-dose heparin prophylaxis

(full anticoagulation) during ante-partum AND post-partum period:

 Mechanical prosthetic heart valve

 Valvular heart disease WITH atrial fibrillation
 APS with history of VTE (ACOG recommendation)
 Patients receiving chronic anticoagulation for recurrent VTE
 Homozygous for Factor V Leiden mutation
 Homozygous for prothrombin G20210A mutation
 Severe heart failure, particularly in the presence of a ventricular thrombus
 Eisenmenger syndrome

In general warfarin should be avoided in pregnancy. However it is sometimes required and if so

heparin should be used in the first trimester to avoid the risk of teratogenicity and warfarin can be
started around week 13 or 14. Warfarin should be stopped again around 34 weeks gestation because
of risk of haemorrhage at time of delivery and heparin again used until delivery. Warfarin should only
be started when the prothombin time is known and following discussion with the medical team. Dose
is calculated on body weight and approximately 3mg will be required daily. Frequent INR checks are
necessary to maintain the INR between 3 – 3.5. Vitamin K can be given to reverse the effects of
warfarin.

18
4. Heparin dosing should be as follows:

a) Low-dose prophylaxis
 First trimester – 5,000 to 7,500 Units sc every 12 hours
 Second trimester – 7,500 to 10,000 Units sc every 12 hours
 Third trimester – 10,000 Units every 12 hours – check aPTT near term and decrease
dose if elevated

b) Adjusted-dose prophylaxis (therapeutic)

 >10,000 Units sc bid to tid to achieve an aPTT of 1.5 – 2.5 times control. Once achieved,
check aPTT weekly.
 If changing to warfarin, do so after the 13th week and overlap with heparin for 2-3 days. In
mid-third trimester, should transition back to sc heparin until delivery.

c) Treatment of acute thrombosis or embolism

 IV heparin bolus of 5000 units (80 IU/kg), then continuous infusion of at least 30,000 IU
for 24 hours titrated to achieve full anticoagulation
 Maintain IV anticoagulation for 5-7 days and then change to subcutaneous adjusted-dose
heparin therapy
 Give subcutaneous heparin every 8 hours to prolong aPTT to at least 1.5 – 2.5 times
control
 Continue for at least 3 months after event

5. Intrapartum Management

 For patients requiring full anticoagulation – switch to IV heparin at the time of labor and
delivery (short half-life). Heparin infusion should be stopped approximately 4 hours prior
to cesarean delivery, as C-section in heparinized patients is accompanied by a
significantly increased blood loss. This is not the case with vaginal deliveries.
 For patients receiving low-dose prophylaxis – stop injections at onset of labor
 May resume heparin 4-8 hours after an uncomplicated delivery and 12 hours after
cesarean delivery if stable and no signs of bleeding. Warfarin may be started the following
day.
 Protamine sulfate may be used to urgently reverse heparin effects. 1mg by IV injection
will neutralize 80-100 units heparin when given within 15 minutes of heparin injection. If
longer time, less protamine is required. Maximum dose of protamine is 50mg.

19
 Management of UTI During Pregnancy

Lower UTI: Cystitis

Symptoms: Dysuria, urgency, frequency, nocturia and possible fever and chills.
Signs: Supra-pubic tenderness and retro-pubic tenderness on vaginal exam.

Upper UTI: Pyelonephritis

Symptoms: Fever and chills, costo-vertebral angle (CVA) pain, dysuria, frequency,
urgency

Signs: CVA, supra-pubic and retro-pubic tenderness, fever, toxic appearance.

Asymptomatic bacteriuria:
Refers to persistent, actively multiplying bacteria within the urinary tract without symptoms.
(Significant bacteriuria is diagnosed as greater than 100,000 colony-forming units (cfu) per ml in a
midstream clean catch urine specimen and 50,000 cfu/ml in catheterized urine. In pregnant women, if
asymptomatic bacteriuria is not treated 47% will develop pyelonephritis. Treatment of asymptomatic
bacteriuria has also been shown to reduce the incidence of preterm delivery. Women should be
treated with either nitrofurantoin 100mg qid for ten days, or amoxycillin 500mg tid for 7 days and the
urine culture repeated. (Unfortunately at Cure Hospital at present we are not able to culture urine or
do colony counts)

Recurrent UTI:
This is the term used to describe a symptomatic infection that follows the resolution of a previous UTI
and can be due to relapse of the original organism or re-infection (80-90%) with the same or different
organism. Recurrent UTI may benefit from the use of prophylactic antibiotics such as nitrofurantoin
100mg or cephalexin 500mg at night.

Management of Pregnant Women with UTI:

All women attending the antenatal clinic or being checked on labor and delivery should have a mid
stream clean catch urinalysis (and ideally, culture and sensitivity and colony count) to screen for
bacteriuria and UTI.
 If the woman has symptoms and signs of recent duration (over a few days), treatment should be
given irregardless of the result of the urinalysis.
 If urinalysis is positive for UTI, treatment should be given irregardless of the women’s symptoms.
 The commonest uropathogen is E.coli and the drug of choice for lower UTI in pregnancy is
Nitrofurantoin 100mg qid for 10 days. Amoxicillin 500mg tid for 7 days can also be given but has
been shown to be less effective.
 Women should be told to increase their fluid intake to 10-12 glasses a day. Potassium citrate
preparations can also give symptomatic relief.
 Mild pyelonehpritis (low grade temperature, mild to moderate CVA pain and tenderness,
moderately elevated white count and not systemically toxic) can be treated with an initial dose of
ceftriaxone 1g IV or IM and discharged on cephalexin 500mg tid for 10 days.
 Severe pyelonephritis (high temperature, moderate to severe CVA pain and tenderness, high
white count and systemically toxic) should be hospitalized as IV and oral hydration is essential.
Ceftriaxone 2g / 24hours should be administered IV for 7 days. If there is no response in 24 hours
add gentamicin 80mg IV tid.
All women with recurrent or complicated UTI such as severe pyelonephritis should have their renal
function determined by checking serum creatinine, urea and electrolytes. Renal ultrasound should
also be performed to evaluate possible urinary tract obstruction.

20
 Management of the Rhesus Negative Mother
Antenatal

 At the first antenatal visit, all mothers should have their blood group and Rh factor determined. If
they are Rh negative they should also have an indirect Coombs test. If the indirect Coombs test is
negative, the mother has not been sensitized (anti-D isoimmunisation has not taken place).
 In order to prevent sensitization taking place, the UK RCOG Guidelines for Rh negative mothers
state that the indirect Coombs test should be repeated routinely at 28 weeks and again at 34
weeks gestation and if still negative at these visits, RhoGam (anti-D immunoglobulin) should be
offered in a dose of 500iu IM.
 The recommendations for specific sensitizing events are as follows:
In Rh negative mothers, RhoGam does not need to be routinely given with threatened or
spontaneous abortions at less than 12 weeks gestations. However, if curettage is performed or if
there is antepartum haemorrhage or abortion between 12 and 20 weeks gestation, 250iu
RhoGam IM should be given. If abortion or haemorrhage occurs after 20 weeks gestation, 500iu
RhoGam IM should be given.
Following these potentially sensitizing events RhoGam should ideally be given within 72hours but
can be given up to 10 days after the event.
 If at any time the indirect Coombs test is positive, this suggests that sensitization has taken place.
A senior obstetrician must be informed and the pregnancy evaluated for isoimmunisation. This
involves checking the type of antibody found (only IgG is important as it crosses the placenta, IgM
does not) and measuring antibody titres every four weeks to determine when to deliver. If
however the mother already has a history of a previous affected baby, antibody titres are
unnecessary and amniotic fluid spectrophotometry should be performed from 28 weeks (Liley
Method) to determine how affected the fetus is.

Labour and Delivery

 All mothers admitted to labor and delivery should have their blood group and Rh factor checked if
this has not already been done during their antenatal care. If they are Rh negative, they should
have an indirect Coombs test.
 If the indirect Coombs test is negative, the mother has not been sensitized (anti-D
isoimmunisation has not taken place) and the newborn should be checked at birth for its Rh
factor. If the baby is also Rh negative, the mother does not need RhoGam.
 All Rh negative mothers who are indirect Coombs test negative with Rh positive infants should
receive Rho-Gam (anti-D immunoglobulin) 500iu IM within 72 hours of delivery.
 Notify the obstetrician and the pediatrician if the indirect Combs test is positive. This means that
the mother has been sensitized and the baby could be at risk of haemolytic disease. It also
means that Rhogam should not be given as it is not useful once sensitization has taken place.

21
 Management of Multiple Pregnancy
Risks to the mother with multiple pregnancy:

1. Miscarriage
2. Hyperemesis
3. Premature labour and delivery
4. Anaemia
5. Pre-eclampsia
6. Antepartum and postpartum haemorrhage
7. Polyhydramnios
8. Operative delivery

Risks to the fetus with multiple pregnancy:

1. Preterm birth
2. Intra-uterine growth restriction
3. Intra-uterine fetal death
4. Twin-twin transfusion syndrome (TTTS) in monochorionic twins
5. Increased risk of congenital abnormality

Ultrasound in multiple pregnancy:

If a twin or triplet pregnancy is diagnosed in the ante-natal clinic, an USS should be performed and an
attempt made to discover whether the twins are monochorionic or dichorionic. During antenatal care,
dichorionic twins should have US every 4 weeks from 24 weeks gestation to look for evidence of
growth restriction. In monochorionic twins or in triplets, growth scans should be every two weeks from
24 weeks.

For multiple pregnancies in labor the following measures should be taken:

 The obstetrician, pediatrician and anaesthetist should be notified as soon as possible.

 Start two IVs with large cannulae.
 Presentation and gestational age should be determined by ultrasound.
 Obstetrician and pediatrician must be present during the delivery.
 Be prepared for possibility of postpartum bleeding.

Management on the labor ward:

1. Twins with Vtx/Vtx presentation can be safely delivered vaginally.

2. If the first twin is breech, no matter what the presentation of the second twin is, C/Section delivery
should be the method of choice. Mother’s who want to continue with vaginal delivery should
understand the risks involved.
3. Twins with Vtx/breech presentation should be individualized.
4. Premature twins should be managed like premature singletons (see protocol).
5. For twins being delivered vaginally, after the birth of the first twin, an oxytocin infusion should be
started immediately with 10iu in 1000ml RL. Once the contractions restart, the midwife should
stabilize the lie and if longitudinal, the doctor should rupture the membranes and allow normal
delivery of the second twin. Aim for delivery of the second twin within 30mins of the first.
Continuously monitor FHR.

22
 Management of Post-term Pregnancy
Post-term Pregnancy Definition: 42 weeks or more from the last menstrual period (294 days or
estimated date of delivery [EDD] +14 days)

Accurate pregnancy dating is therefore critical to the diagnosis.

Incidence: from 4 to 14 %, an average of about 10% of pregnancies.

Although some cases of post term pregnancies likely result from an inability to accurately define the
EDD, many cases result from a true prolongation of gestation.

Risks to the fetus: post term pregnancy is associated with significant risks to the fetus. The perinatal
mortality rate (PMR = stillbirths plus early neonatal deaths) at greater than 42 weeks of gestation is
twice that at term (4-7 deaths versus 2-3 deaths per 1,000 deliveries) and increases 6-fold and higher
at 43 weeks of gestation and beyond.

Diagnosis: over 50% of PTP is due to miscalculation.

Accurate calculation requires LMP plus:
1. Auscultated FHR 17-20 weeks or
2. Fundal height between18-30 weeks +/- 2cm to LMP weeks or
3. Ultrasound before 26 weeks

Management: Fetal assessment should be twice weekly to include:

1. Activity (kick) count – should be more than 10 kicks during the day.
2. NST
3. Biophysical profile (BPP) or modified BPP (NST plus AFI)
4. Amniotic fluid volume (this is abnormal if there is no vertical pocket of AF greater than 2cm or
if the AFI is 5cm or less)

Other factors to consider include gestational age, results of antenatal fetal testing (eg fetal anomaly),
the condition of the cervix and maternal preference after discussion of the risks/ benefits of expectant
management with fetal monitoring versus induction of labour.

When gestational age is known:

 Membrane stripping at 38 to 40 weeks decreases the frequency of post-term pregnancy.
 It is reasonable to initiate antenatal surveillance of pregnancies between 41weeks (EDD+7 days)
and 42 weeks (EDD+14 days) of gestation because of evidence that perinatal morbidity and
mortality increases as gestational age advances.
 Deliver at term if inducible.
 Deliver at 42 weeks regardless of fetal assessment
 Consider C/S if EFW>4500g.

When gestational age is not known:

 Postpone induction unless there is evidence of fetal jeopardy (requires fetal assessment twice
weekly.)

Intrapartum management:
 As soon as labour begins, monitor fetal heart and uterine contractions with the CTG.
 Amniotomy causes further reduction of AF and may enhance the possibility of cord compression
but can reveal the presence of meconium (see management of meconium)
 Presence of meconium: when the woman is remote from delivery consider C/S, especially when
CPD is suspected or when hypotonic or hyper tonic dysfunctional labor is evident.
 An obstetrician experienced in managing shoulder dystocia should be present at delivery.
 Pediatric support should also be requested for the delivery.

23
 Induction of Labour
Definition: To induce or enhance uterine contractions with medication.

Indications:
1. Maternal APH, Preeclampsia / Eclampsia, Diabetes, PROMs, Chorioamnionitis,
Failure to Progress (FTP) in labor due to poor contractions
(Augmentation)
2. Fetal Intra Uterine Growth Retardation (IUGR), Oligohydramnios, Major fetal
abnormality, Multiple Pregnancy, Isoimmunization, Post Maturity
(confirmed over 42 weeks gestation), Intra Uterine Death (IUD)

Contraindications:
Any woman with a history of previous caesarean section or uterine scar due to other surgery is at risk
of scar rupture and should not be induced or augmented unless this is discussed with either the
OBGYN training program director or head of department.

Cervical assessment:
The success or failure of induction is directly related to the extent of cervical ripening.
Cervical ripening is measured using the Bishop Score (0 – 13).

Score Dilatation Effacement Station Cervical Cervical

(cm) (%) Consistency Position

0 Closed 0-30 -3 Firm Posterior

1 1-2 40-50 -2 Medium Midposition
2 3-4 60-70 -1 Soft Anterior
3 >5 > 80 0 -- --

Methods of Induction:

1. Membrane Sweeping:
It is recommended that all women be offered membrane sweeping prior to induction of
labor as it is associated with an increased likelihood of spontaneous labor within 48 hours and a
decreased incidence of prolonged pregnancy of more than 41weeks.

Preinduction cervical ripening:

2. Misoprostol:
Insert 1 tablet (25 micrograms) vaginally into the posterior fornix and repeat every 3 hours (up to 4
tablets in 24 hours) until contractions start or membranes can be ruptured.

3. Extra-Amniotic Infusion:
When misoprostol is unavailable and the cervix is unfavourable an infusion of Normal Saline into the
extra-amniotic space using a Foley catheter has been shown to be effective. This should be
performed by the obstetrician.

4. Amniotomy (Artificial Rupture of Membranes – ARM):

With a favourable cervix, ARM alone can induce labor in 88% women within 24 hours. When possible
therefore, perform ARM and start an oxytocin infusion after 2 hours.

5. Oxytocin:
Use with great caution, especially in multiparous women.
Remember oxytocin can cause:

a) Hyperstimulation: any contraction lasting longer than 60 seconds OR more than 4

contractions in 10 minutes.
b) Fetal distress: fetal heart rate less than 100 beats per minute.
c) Uterine rupture: constant pain, loss of contractions, bleeding, shock, fetal distress.

24
d) Water intoxication: nausea, vomiting, confusion, convulsion and coma

If any of the above occur, STOP THE INFUSION IMMEDIATELY, turn the woman onto her side and
give oxygen.

Women receiving oxytocin should NEVER be left alone. Monitoring of contractions and fetal heart rate
should be performed regularly for 10mins every 30 mins.

Oxytocin Regime: Aim for 3 contractions lasting for 40 seconds every 10 minutes.

1. Start with 10 iu oxytocin in 1000ml of NS or Ringers at 10 dpm.

2. Increase by 10 dpm every 30 minutes until a good contraction pattern is established.

3. If no good contraction pattern is established after giving 60 dpm and the patient is
multiparous, discuss with the obstetrician on-call and consider caesarean section for failed induction.

4. If no good contraction pattern is established after giving 60 dpm and the patient is
primiparous, discuss with the obstetrician on-call and if there is no evidence of obstructed labor or
fetal distress change the infusion to: 20 iu oxytocin in 1000ml NS and start at 30 dpm. Increase by 10
dpm every 30 minutes until a good contraction pattern is established. If no good contraction pattern is
established after giving 60 dpm consider caesarean section for failed induction.

25
 Management of Meconium Stained Liquor

Incidence of Meconium Stained Liquor:

 Less then 5% in preterm pregnancies

(may be associated with infection and chorioamnionitis)
 12-15% in term pregnancies
 Up to 50% in post-mature pregnancies

Diagnosis:

When the amniotic membrane is ruptured spontaneously or artificially, green stained amniotic fluid
with or without particles is diagnostic. Meconium stained fluid may thin or thick. Infrequently the
meconium in the amniotic fluid indicates fetal stress.

Management Antenatal and Intrapartum:

Thin meconium stained amniotic fluid is benign and does not require any special care.

Thick meconium stained amniotic fluid will require the following procedures:

1. An obstetrician should be called when thick meconium is diagnosed.

2. Amnioinfusion: An intra-uterine pressure catheter is introduced to the endometrial cavity
posterior to the presenting part. 800-1000 cc of warmed Ringers or Normal Saline is infused
rapidly in to the amniotic cavity and then 250-300cc of fluid is infused every hour until the
baby is born. (The idea is to dilute the meconium and prevent meconoum aspiration and
meconium pneumonitis)
3. Cesarean Section is not necessary unless fetal distress occurs.

Management Postnatal:

1. Call the paediatrician to attend the delivery

2. Suction the mouth first and the nose second (naso-pharynx) on the perineum before the
delivery of the shoulders.
3. If baby is depressed and or premature it is recommended to suction the trachea via
endotracheal intubations and or manually (this should only be performed by a qualified
physician).
4. Term and vigorous babies only need naso-pharynx suction.
5. Term depressed babies need tracheal suction and resuscitation.

26
 Meconium stained amniotic fluid

Thick Thin

Suction on perineum - mouth, nose and

posterior pharynx before the delivery of Suction on perineum – mouth and nose.
the shoulder. Continue with resuscitation if needed.
Continue with resuscitation if needed. Dry, Dry, stimulate and reposition baby
stimulate and reposition baby

Is the baby vigorous?

Yes No Suction mouth and trachea

Continue resuscitation

Continue with resuscitation

If needed

27
 Management of Vaginal Birth After Caesarean Section

The main risk of VBAC is of uterine scar rupture leading to the death of the baby (usually within
10 minutes of scar rupture) and endangering the life of the mother.

 Women who have had a classical uterine incision instead of the more common lower segment
(LS) incision have a much higher risk of uterine rupture. Therefore we need to be certain of
the type of previous C/Section she had. Women with previous classical C/Section must not be
allowed to labor and should have repeat C/Section at 38-39 weeks of gestation.
 The obstetrician, anesthetist and the operating room team must be immediately available
when VBAC is in progress, in case an emergency caesarean section is necessary.
 Women with previous LSCS need to be evaluated for risk factors and properly counseled and
informed regarding the risks and benefits of VBAC vs Elective CS.

Management on Admission:

1 Start an IV with a 16 or 18 gage cannula on admission.

2 Take blood for HB and type and cross-match two units of blood.
3 Monitor uterine contractions and fetal heart rate closely, preferably by electronic method
(CTG).
4 Watch for symptoms and signs of uterine rupture (cessation of contractions, mild bleeding,
fetal distress, constant pain, shock) and notify the obstetrician immediately if any warning
signs occur during the course of labor.
5 Use of oxytocin for augmentation (see oxytocin protocol) may be acceptable under close
observation but requires discussion and agreement by a senior obstetrician.
6 Induction of labor for maternal and or fetal indications is controversial; it could be performed in
selective cases under close observation by the senior obstetrician and with CTG monitoring.

28
 Management of Postpartum Fever

Definition of Postpartum Fever:

 Oral temperature of 38oC or more is considered to be febrile morbidity in the postpartum

period and needs to be investigated.
 If a woman develops a fever the doctor must be notified and a complete history and physical
should be performed along with a UA and a QBC.
 If H&P, UA and QBC are all normal, the woman should be hydrated, 1g paracetamol given
and the woman observed over the next 12 hours. 3% of these women will become afebrile
within 8-12 hours (this condition is called febrile inflammatory response or benign fever and is
common after delivery).
 If the temperature remains above 38oC after two consecutive checks 4 hours apart, the doctor
must be called again and after thorough examination and laboratory tests, antibiotics may be
used at the discretion of the doctor.

Causes of postpartum fever:

 Benign fever (as discussed above)

 Engorgement of the breast (milk fever), should not last more then 24 hour
 Infections of the urogenital tract: Endometritis
Urinary tract infection
Infected perineal tears/repairs
 Distant infections: Wound infection (CS)
Thrombophlebitis
Chest infection
Other disease (malaria, TB, etc)

If any of these conditions are diagnosed, appropriate treatment should be started immediately.

Remember, postpartum fever due to genital tract infection (Puerperal Sepsis) is an important
cause of maternal death and should be diagnosed early and treated appropriately.

29
 Misoprostol Use in OBGYN

An extensive list of references for the dosages below can be found on www.misoprostol.org

Indication Dosage Notes

Induction of labour for live 25 - 50ug PV 6 hourly until Effective

baby > 28 weeks onset of contractions. First line treatment in many
centres
After third dose wait until next Caution with previous
day before restarting C-section scar
induction. Beware of hyperstimulation

Induction of labour for an IUFD 100ug PO/PV 4 hourly until Good

of > 28 weeks delivery First line treatment in many
centres
Caution with previous
C-section scar

Missed abortion 12 – 28 400ug PO/PV 4 hourly until More effective than oxytocin
weeks expulsion

Missed abortion 4 – 12 weeks 400ug PO/PV 4 hourly OR 95% effective

800ug PV 24 hourly until
expulsion

Incomplete abortion 4 – 12 600ug PO single dose > 95% effective

weeks (open os and bleeding) Standard regime in Europe

Postpartum haemorrhage Not as effective as injectible

-Prevention 600ug PO oxytocics but useful second
-Treatment 1000ug PR / 600ug SL line
-During C-section 400ug SL

Cervical ripening prior to 400ug PO/PV stat 2 hours Reduces perforation and
instrumentation before procedure failure rates

30
 Blood Transfusion Protocol
Requesting Blood
When a patient is being scheduled for major surgery, or is likely to need blood, a Blood Request Form
should be filled out by the doctor and given to the lab to find blood
1. A doctor must be involved in requesting blood.
2. Before requesting blood, patient consent should obtained. The patient should be educated on the
process, risks and benefits of the transfusion, as well as any alternatives. Family and attendants
should be involved in the discussion.
 The doctor should record the discussion in the patients’ medical record and obtain the
signature (thumb print) of the patient if possible.
 If the patient refuses, this should be documented
 If the patient is not conscious, and no relative is available to give consent, blood may be
transfused based on two doctor’s assessment of need.
 If the patient is under 17 yrs, parents or guardians will sign the consent form
 Warning Signs that the patient should be made aware of are:
pain at IV site, breathing difficulties, back or chest pain, chills/flush/fever, nausea,
dizziness, rash/ urticaria, dark or red urine
3. Blood Request Form should be filled out on the ward by the doctor and the patients’ name, CURE
number, and Blood Group and Type double-checked.
4. The Lab should be notified of the need for blood.

If the blood is not used within one week of requesting, the Lab will communicate with the doctor for
permission to release the blood to be used for other emergencies.

Finding Blood
1. If the patient has relatives accompanying them, they should be sent to the Lab for Blood Group
and Type testing and Cross-matching
2. If there are no relatives; none of them are a match; or the blood is needed urgently, the Lab tech
should check the Blood Bank Refrigerator for compatible blood
3. If there is no compatible blood for the patient
 During office hours, check the Blood Donor List for volunteers who have not donated within the
last 12 weeks
 If there are no compatible donors, or it is after hours, call the Medical Director to contact an
expatriate donor
4. If a prospective donor tests positive for Hepatitis B, Hepatitis C, HIV or syphilis, they should be
notified with a Lab Slip which has information about further testing.
5. If the CURE Blood Bank does not have compatible blood, and a suitable donor cannot be found,
the Central Blood Bank, Ibn Sina or other Blood Bank should be notified.
 The Lab Tech should call the Blood Banks to find the needed blood
 The Lab Tech should fill out an Outside Blood Request Form (in Dari)
 The patient’s relative should take the Outside Blood Request Form and go to the Blood
Bank to collect the blood.
 If the patient’s relative does not have money to obtain the blood, they should speak with a
CURE business office representative
6. Lab Techs and other CURE Hospital Personnel should actively encourage others to voluntarily
donate blood. To get onto the Volunteer Donor list, hospital staff or outside donors should contact
the Lab for testing and to be added to the Donor List.

Collecting Blood Sample for Cross-matching

1. When the Lab Tech arrives on the ward, the Blood Request Form should be given to him/her.
2. The Lab Tech will then fill out a red ID band with the Patient’s Name, CURE number, and Blood
Group and Type. The Lab Tech will attach the identification band to the wrist of the patient who is
to receive the transfusion
3. The Lab Tech will then obtain a sample of the patient’s blood for testing:
 If the patient is conscious, the Lab tech should ask them “What is your name?” and
recheck with a nurse or doctor, the Blood Request Form, patient’s chart and the patients’
wrist band for correct identification

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  If the patient is not conscious, a relative who is present should be asked the name of the
patient
 If there are ANY discrepancies in the identification process, these should be addressed
before taking the patients’ blood sample
 The Lab tech should label the blood sample tube with the patients’ name, Family name,
CURE # and date before taking the sample, and after taking the sample should recheck
that it is correct.
 The Lab Tech should take the blood sample and the Blood Request Form to the Lab for
Typing and cross-matching. (See Finding Blood)

Cross-matching
1. The blood sample from the patient should be rechecked against the Blood Request Form before
starting the cross-match
2. The results of the cross-match, and donor blood screening tests should be recorded on the bag of
blood, Blood Request Form, and in the Lab Notebook.
3. The ward should be notified when the successful cross-match has been completed.
4. If the cross-match is unsuccessful, the blood should be returned to the lab fridge with only donor
information on the bag.

Collection and Storage of Donated Blood

1. All donor blood must undergo screening tests by CIH lab to rule out Hepatitis B, Hepatitis C, HIV,
and syphilis.
2. Donated blood that is acceptable should have the name of the donor, the Blood Group, Rhesus
type, and the date of donation and expiration written on the bag.
3. All blood will be stored in the laboratory fridge until it is requested. Blood should not be stored
anywhere else in the hospital.
4. Requests for donation should be recorded in the laboratory transfusion log book.

Preparation for Blood Transfusion

1. Blood should only be started by a doctor, a nurse anesthetist or a nurse.
2. Baseline vital signs should be checked and charted
3. The patient should be assisted to use the bathroom before the transfusion (since they should be
stationary during the transfusion).
4. Venous access should be adequate:
 A large gauge cannula should be used (at least 18 gauge)
 In infants, umbilical catheters are desirable, cannulas of at least 22 gauge can be used
peripherally
5. Only blood transfusion tubing, with a filter should be used for transfusion.
 The tubing should be primed with normal saline
 Normal saline should be the only solution used during blood administration
 Drugs should not be administered in the same IV line as blood or blood components. If IV
drugs need to be given, a second IV line should be started

Receiving Blood at the Wards

1. The porter/cleaner from the lab will transport the blood and Blood Request Form to the where the
patient to receive the transfusion is.
2. The donated unit of blood, the Blood Request Form, the patient’s chart and the patient’s wrist
band should be checked by at least two people after asking the patient for his/her name.
3. The Group and Type of the donated unit should be checked against the Blood Request Form, and
the Group and Type of the patient.
4. The blood bag should be inspected for leaks, clots, abnormal color, excessive air or air bubbles.
The results of this inspection should be noted on the Blood Request Form
5. Transfusion must begin within 30 minutes of receiving the blood from the Blood Bank. If the
transfusion is not started within 30 minutes, or the blood is not needed, it should be returned
immediately to the Blood Bank.

Returning Unused Blood

1. If cross-matched blood is not used, it should be returned to the lab with its forms and the bag
marked NOT USED. This must be done in less than 30 minutes.

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2. Any blood that has been connected to a transfusion set is considered USED and cannot be
returned to the lab.
3. Returned blood should be returned to the fridge as soon as possible.
4. The lab should write BLOOD NOT GIVEN on the request and return it to the patient’s file.

Blood Transfusion
1. Once the blood transfusion has been started, the patient must be monitored closely and vital
signs charted on the Blood Request Form. For the first hour vital signs should be monitored every
15 minutes, and then every 30 minutes for the second hour. After the first two hours, the vitals
should be monitored hourly throughout the duration of the transfusion, which should never be
longer than 4 hours.
2. If the patient complains of feeling unwell or any transfusion reaction signs are noted, the doctor
should be immediately notified and the nurse should stop the transfusion.
 The nurse should remove the tubing and replace it with new tubing
 The nurse should flush the IV cannula with normal saline and start a slow infusion of
normal saline .
 The doctor should prescribe and the nurse give appropriate meds (paracetamol,
antihistamines).
 Vital signs should be monitored every 15 mins
 If the reaction was severe, the Lab tech should be called to take two blood samples from
the opposite arm to the one the blood transfusion is in order to check the cross match
again (was the correct blood given?) and to look for signs of haemolysis. If possible urine
should also be collected to look for signs of haemolysis (haematuria).

Transfusion Reaction Signs:

 Rapid, thready pulse
 Decreased blood pressure
 Hematuria (red/black urine)
• Tightness or pain in chest
• Severe lumbar (back) pain
• Dyspnea
• Skin rash / urticaria or facial edema
• Chills
• Increase in patient’s temperature ≥1° C (common, mild reaction)
 Increase to a reaction temp of at least 38°C (more serious)

Blood Storage and Supply

There should always be at least 4 units of blood in the Blood Bank Refrigerator
 Requested units are not included, and will have a removable label attached to them with the
name, CURE number, Blood Group and Type of the patient for whom they were ordered
 When a Holding Order expires (when the patient is no longer at CURE Hospital and has not
required the blood being held for them), the blood that was being held can be added to the
general pool of blood for emergencies
 There should always be at least one unit of O negative blood for emergencies
 Blood will not be stored for more than 30 days after donation. After 30 days, or if clots,
discoloration or leaks become apparent, the unit of blood will be discarded
 Once a unit of blood has been used, it should promptly be replaced by donation by family
members of the patient (see Finding Blood)

Quality Assurance
1. All blood transfusions will be reviewed on a regular basis by the medical staff
2. When there are any adverse reactions to blood, the Medical Director should be notified.

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 Management of First Trimester Bleeding

Uterine bleeding during the first trimester of pregnancy requires a thorough history and examination. It
is caused by one of the following:

1. Ectopic Pregnancy:

A ruptured ectopic pregnancy can lead to life-threatening hemorrhage. Therefore, it is

important to make the diagnosis and inform the doctor early, before rupture.
If a woman complains of abdominal pain and irregular uterine bleeding, consider ectopic
pregnancy and order a pregnancy test. If negative, there is no ectopic pregnancy. If positive,
immediately refer for USS and if the uterus is empty, arrange for surgery. Risk factors for ectopic:
history of infertility, tubal surgery, PID, pelvic surgery, adhesions.

2. Abortion (miscarriage):

Threatened abortion: The product of conception is intact, but there is uterine bleeding from
minimal separation of the gestation sac from the decidua. On vaginal examination, the cervix is
closed and on ultrasound examination the embryo intact. No treatment is needed for these
patients; bed rest has been shown to have no effect one way or the other.
Inevitable abortion: The product of conception is detached from the decidua. On vaginal
examination the cervix is open and tissue may be protruding from the cervical os. Treatment is to
evacuate the endometrial cavity by MVA and / or D&C. Unless the woman is obviously infected,
antibiotics are unnecessary.
Incomplete abortion: The product of conception is partially expelled; the retained portion needs
to be evacuated. Usually on vaginal examination the cervix is open. Women can present with
prolonged vaginal bleeding and lower abdominal cramps. Treatment is as for inevitable abortion.
Missed abortion: The product of conception is detached from the decidua and demised, but still
totally retained. 85% of these cases will have spontaneous abortion within 4-6 weeks. Evacuation
of the uterus is thought safer than waiting for spontaneous abortion to take place when the
amount of blood loss cannot be predicted.

In all the above cases of abortion, the mother’s blood group and haemoglobin should be
determined. If the mother is Rhesus negative and her uterus is instrumented and a MVA or D&C
performed, she should be offered RhoGam 250iu IM within 72 hours of the procedure.

3. Incidental bleeding:

Rarely, bleeding can occur from trauma to the vagina, for example after forced sexual intercourse,
or from a cervical lesion such as a polyp or a carcinoma.

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 Preoperative Preparation and Evaluation of Women for Gynecological Surgery
A. The Preoperative Evaluation:

A carefully constructed preoperative evaluation with emphasis on patient preparation and close
postoperative observation will elevate the good surgeon to a great one. For all surgical procedures, whether
major or minor, the evaluation should be individualized and never routine. The preoperative evaluation
should include the following:

1. History and physical examination, including review of systems and vital signs

2. Investigations:
 Pregnancy test to rule out unexpected early gestation
 Urea and creatinine if major surgery or hypotension likely, if nephrotoxic drugs may be used, or if over
age 50
 ECG per recommendations: over age 55, known cardiac disease or at increased risk of cardiac
disease because of medical history or symptoms, at risk of electrolyte abnormalities, planned major
surgical procedure (unless one present from within the last 1 month and no new symptoms)
 Chest x-ray if over age 60, or suspected cardiac or pulmonary disease (unless one present from
within the past 6 months and no new symptoms)
 QBC, RBG, Na, K, U/A, Group & X-match 2 units for all major surgery
 Other tests only if clinical evaluation suggests likelihood of disease.
 Occasionally, the gynecologic surgeon runs the risk of both small and large bowel injuries because of
the presence of pelvic adhesions resulting from either previous surgery or an inflammatory process,
such as PID or endometriosis. In these cases, it is reasonable to consider preparing the bowel for
surgery with a mechanical bowel preparation and using a parenteral antibiotic regimen that is effective
in preventing infection among patients undergoing elective bowel surgery.

3. Consent: explain the operation procedure and risks and get consent from the patient and
husband (or other close relative). Instruct the patient to come for admission the day before
surgery and must be NPO from midnight. For patients needing minor (day case) surgery e.g.
BTL, biopsy, D&C, instruct the patient to come for admission at 7 am on the day of surgery and
insist that she must be NPO from midnight. Identifying patients at risk, and recognizing potential
complications associated with specific surgical procedures can allow interventions that aim to
eliminate, or at least minimize, surgical complications and improve patient outcome.

4. Book Date: write the name, hospital number, age and procedure in the operating book under the
correct date.

5. Inform theatres: on the afternoon before the day of surgery give the operation list to the Operating
Theatre Nurse Supervisor. Specify which ward the patient will be on.

6. Inform reception: send the patient’s file back to reception with a note that they will come for
admission to a certain ward on a certain date. Do not keep the file with you.

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B. Prevention of venous thromboembolism (VTE) for women undergoing surgery:

Post-op DVT ranges from 7% to 29% in general gynecologic surgery and up to 45% in patients with
malignant disease. Pulmonary embolism (PE) occurs in 0.1-5% cases depending on level of risk.
Unfortunately, PE occurs without clinical evidence of DVT in 50-80% of cases and is fatal in
approximately 10-20%. Most events occur within 7 days postop in gynecologic surgical patients;
however, patients continue to be at risk for 3 weeks after discharge, probably secondary to decreased
ambulation.

Classification of risk levels for VTE among gynecologic surgery patients:

Classification Definition
Low risk (< 3% risk of DVT) Age < 40y and surgery lasting < 30 mins

Moderate risk Age > 40y and surgery of any duration

(10-40% risk of DVT) No other clinical risk factors

High risk Age > 40y plus risk factors:

(40-70% risk of DVT, 1-5% risk of PE)  Prior DVT or pulmonary embolism
 Varicose veins
 Infection
 Malignancy
 Estrogen therapy
 Obesity
 Prolonged surgery

Prophylaxis for low-risk patients: None required but ensure early ambulation

Prophylaxis for moderate-risk patients: (no 1. and no 3. should be used)

1. Thigh-high graduated compression stockings placed pre-op until fully ambulatory.

2. Pneumatic compression placed intra-op untilpatient fully ambulatory.
3. Unfractionated heparin (5000iU) administered at least 2 hours before surgery and
continued post-op every 12 hours until discharge.
4. LMWH (dalteparin 2500 iU, or enoxaparin 40mg) administered 12 hour before surgery and
once a day postoperatively until discharge.

Prophylaxis for high-risk patients: (no.2 should be used)

1. Pneumatic compression placed intra-op until patient fully ambulatory.

2. Unfractionated heparin (5000iU) administered 2 hours before surgery and continued every 12
hours for 7 days or until discharge.
3. LMWH: Dalteparin (5000iU) or Enoxaparin (40mg) administered 12 hours before surgery and
then once a day for 7 days or until discharge.

Intra-op or post-op anticoagulation after regional anesthesia is safe but regional anesthesia should not
be used nor should an epidural catheter be removed within 12 hours of an injection of LMWH.

36
C. Antibiotic prophylaxis for gynecologic procedures

Up to 5% of operative patients will develop a surgical site infection leading to a longer hospital stay
and increased cost. One of the advances in infection control practices has been the selective use of
antibiotic prophylaxis. Systemic antibiotic prophylaxis is based on the belief that antibiotics in the host
tissues can augment natural immune-defense mechanisms and help to kill bacteria that are inoculated
in the wound. The induction of anesthesia represents a convenient time (before the incision) for
initiating antibiotic prophylaxis in major gynecologic procedures. A second or third dose of the
prophylactic antibiotic should be repeated to maintain tissue levels if the procedure extends beyond
three hours or in surgical cases with an increased blood loss (> 1500 ml).

During a procedure where a patient is thought to be at greater risk for infection, use of therapeutic
antibiotics should be considered.

Antimicrobial Prophylactic Regiments by Procedure

Procedure Antibiotic Dose
Vaginal/abdominal Cefazolin 1 or 2g single dose IV
Hysterectomy* Cefoxitin 2g single dose IV

Metronidazole 1g single dose IV

Tinidazole 2g single oral dose

(4-12hours before surgery)
Laparoscopy None
Laparotomy None
Hysteroscopy None
Hysterosalpingogram Doxycycline 100mg orally, twice daily for
5days
IUD insertion None
Endometrial biopsy None
Induced Abortion/D&C Doxycycline 100mg orally 1hour before
procedure and 200mg orally
after procedure

Metronidazole 500mg orally twice daily for

5days
Urodynamics None
*A convenient time to administer antibiotic prophylaxis is at induction of anesthesia.
Antimicrobial agents of choice in women with a history of hypersensitivity to penicillin
If HSG demonstrates dilated fallopian tubes. No prophylaxis is indicated without dilated tubes.

Preop and postop treatment of bacterial vaginosis with metronidazole for at least 4 days prior to
surgery reduces vaginal cuff infection among women with abnormal flora.

37
Endocarditis prophylaxis recommended in:
1. High-Risk Category: Prosthetic cardiac valves, previous bacterial endocarditis,
complex cyanotic CHD (eg single-ventricle states, TGA, TOF), surgically constructed
systemic pulmonary shunts or conduits

2. Moderate-risk Category: Most other congenital cardiac malformations, acquired valvular

dysfunction (eg RHD), hypertrophic cardiomyopathy, mitral valve prolapse with valvular
regurgitation, thickened leaflets, or both

Endocarditis prophylaxis not recommended in:

3. Negligible-risk category: (ie risk no greater than that of the general population)
Isolated secundum ASD, surgical repair of ASD, VSD, or PDA (without residua beyond 6
months), previous coronary artery bypass graft surgery, mitral valve prolapse without
valvular regurgitation, physiologic, functional, or innocent heart murmurs, previous
Kawasaki syndrome without valvular dysfunction, previous rheumatic fever without
valvular dysfunction, cardiac pacemakers (intravascular and epicardial) and implanted
defibrillators

Antibiotics given for prevention of surgical site infection are not sufficient for endocarditis prophylaxis.
However, prophylactic agents for endocarditis will provide sufficient coverage against surgical site
infection. The following are prophylactic regimes for prevention of endocarditis in susceptible patients
undergoing GU or GI procedures:

Situation Agents Regimen*

High-risk patients Ampicillin plus Gentamicin Ampicillin 2g IV plus
gentamicin 1.5mg/kg (not to
exceed 120mg) IV within 30
mins of starting procedure. 6
hours later, ampicillin 1g IV or
amoxicillin 1g PO
High-risk patients allergic to Vancomycin plus Gentamicin Vancomycin 1g IV over 1-2
penicillins hours plus gentamicin 1.5
mg/kg IV (not to exceed
120mg). Complete infusion
within 30 mins of starting
procedure
Moderate-risk patients Amoxicillin or Ampicillin Amoxicillin 2g PO 1hour before
procedure or Ampicillin 2g IV
within 30 mins of starting
procedure
Moderate-risk patients allergic Vancomycin Vancomycin 1g IV over 1-2
to penicillin hours; complete infusion within
30 mins of starting procedure
* No second dose of vancomycin or gentamicin is recommended.

38
 Protocol for diagnosis and management of Amenorrhea
Definitions:
 Primary Amenorrhea:
 No period by age 14 years and no growth and development of secondary sexually
characteristics.
 No period by age 16 years regardless of presence of normal development and secondary
Sexually characteristics
 Secondary Amenorrhea: Cessation of regular menstruation for more than three cycle interval or
more than six months total.

Evaluation of the amenorrheic patient.

Menstrual function involves a four step interrelated system with negative feedback to higher centers
from Axes 2 and 3. Disorders are divided into four axes, depending on the step that fails to function
properly.

Axis 1: Disorders of the outflow tract, patency and continuity (endometerium, cervix and vagina).
Axis 2: Disorders of the ovary
Axis 3: Disorders of the anterior pituitary
Axis 4: Disorders of the CNS/ hypothalamus

First step:
 H&P
 Pregnancy test
 TSH level
 Progesterone challenge test (PCT):
o 10 mg progesterone daily for7 days
o If the patient bleeds within one week after completing the progesterone challenge, this
means that endogenous estrogen is available and the out flow tract is normal.
Anovulation, an axis 2 disorder, is established.
o If the patient does not bleed, then further investigation is necessary to determine if an
Axis 1, 3, or 4 disorder is present.

Second step:
Necessary if tests administered in first step are negative. .
 Estrogen and progesterone challenge test:
o 1.25mg estrogen daily for 21 days with the addition of 10 mg progesterone for the last
5 days
o If the patient does not bleed within 2 days after completing the progesterone, an outflow
tract problem is present.
o If the patient bleeds, disorder may be axis 2, 3 or 4.

Third step:
Determine reason for lack of estrogen production. Follicle problem (axis 2) or gonadotropine problem
(axis 3 or 4) can be present. FSH and LH assay is recommended.
Key point: When gonadotropins (FSH or LH) are low, the problem is at the higher centres
(hypothalamic/pituitary); when the gonadotropins are high, the problem is in the ovary/follicle.

Fourth step:
Determine the cause of hypogonadotropic or hypergonadotropic state.
If the patient is hypogonadotropic, axis 3 and 4 are involved. If the patient is hyperganadotropic and
younger than 30 years karyotype determination is necessary. The presence of Y chromosome is
indication for gonadectomy.

39
Specific diagnostic evaluation for primary amenorrhea:
 If there is no breast and FSH level is elevated probable diagnosis is gonadal dysgenisis,
karyotype should be obtained. With 46 xy gonadectomy is mandatory.
 If the uterus is absent. FSH is normal and testosterone is within normal range, the probable
diagnosis is mullarian agenesis (Mayer-Rokitansky-Kuster-Hoauser syndrome).
If testosterone is in the male range the probable diagnosis is androgen insensivity syndrome
(testicular feminization). Will need karyotype determination. If there is Y chromosome material
gonadectomy is mandatory.
 If FSH is normal and both uterus and breast are present, than the work up should focus on the
secondary amenorrhea.
 Hyperprolactinemia and PCOS are the rare causes of primary amenorrhea, will discuss in
evaluation of secondary amenorrhea.

Specific diagnostic evaluation for secondary amenorrhea:

 Hyperprolactinemia is the cause of amenorrhea- galactorrhea syndrome.
Serum prolactin level above 15 to20 ng/ml is considered abnormality high in women in
reproductive age.
Serum prolactin level should be measured at least twice before MRI particularly in women with
borderline high level (<50ng/ml). All patients with hyperprolactinemia should be screened for
thyroid disease because hypothyroidism can cause hyperprolactinemia.
 PCOS is a common etiologic factor for amenorrhea; the minimal criteria for the diagnosis are two
out of three of the following:
1- Hyperandrogenisim
2-Oligomenorrhea or amenorrhea
3-Polycystic ovaries on ultrasound
 A high level of testosterone or DHEA-S may solidify the diagnosis of PCOS or may rise question
of an androgen secreting tumor of ovary or adrenal gland.CT imaging or ultrasonography of the
ovaries can be helpful.
 Asherman syndrome should be suspected in women with secondary amenorrhea and history of
uterine infection or D&C for an obstetrical complication. Hysterosalpingography or ideally
Hysteroscopy will confirm the diagnosis.

40
Management:
 All women with primary amenorrhea should be counselled regarding its cause treatment, and their
reproductive potential.
 Psychological counselling is important in patients with absent mullarian structure or a Y
chromosome.
 Presence of Y chromosome is indication for gonadectomy.
 HRT is considered in women with gonadal failure.
 In functional hypothalamic amenorrhea cause correction is recommended.
 An advance in assisted reproductive technology has now made it possible for many women with
primary amenorrhea to participate in reproduction.
 A dopamine agonist Bromocriptine will correct hyperprolactinemia.
 Treatment of hyperandrogenisim is directed toward patient’s goal (eg, relief of hirsutism,
resumption of menses, fertility).
 Asher man’s syndrome needs hysteroscopic lyses of adhesions followed by long term oestrogen
administration to stimulate regrowth of endometrial tissue.

Summary of Treatment

 If galactorrhea/ hyperprolactinemia

 Most common lesion is micro adenoma of the pituitary, R/O drug cause and hypothyroidism.
 May have headache or visual symptoms.
 High resolution CT or MRI of sella turcica are studies of choice.
 Refer appropriate if abnormal, if normal follow prolactin levels every six months and CT and
MRI every 1-2 years.
 Can treat with bromocriptine to suppress prolactin and shrink adenomas.

 If no galactorrhea, positive PCT and normal prolactin

 Treat underlying cause if identified : PCOS (elevated LH, normal or low FSH, possibly
mildly elevated androgens) and ovarian/adrenal tumour if hirsute
 Combined OCPs or q1-2 months provera, 10mg daily for 10 days to prevent endometrial
hyperplasia.
 If fertility is desired, clomophene citrate can be used in PODS at 50 mg/day orally for 5
days.

 If no glactorrhea, negative PCT, normal prolactin

 Determine the FSH level.

 Consider Asherman’s disease, if there is history of D&C, normal FSH, and luck of
bleeding after Oestrogen /progestin challenge.
 FSH level greater than 40mIU/mL indicate gonadal failure including menopause.
 FSH level less than 40mIU/mL, suggest sever hypothalamic disorder.
 Treat hypooestrogenism to maintain bone density and prevent genital atrophy with
combined OCPs or one of HRT regimens.
 If fertility is desired, refer to combined Clomophene/ human menopausal
gonadotropin therapy.

By dr. Allah Noor sahak

41