HOSPITAL MUHIMBILI

I YA TAIFA
HUDUMA UTAFITI
ELIMU

TREATMENT GUIDELINES
Obstetric and
Gynaecological
Disorders
 AUGUST, 2019

Department of Obstetrics and Gynaecology

Obstetric and Gynaecological Disorders

CONTENTS
FOREWORD.................................................................................................................................................................ix
ACKNOWLEDGEMENT ...........................................................................................................................................
x

PART 1: OBSTETRIC CONDITIONS ....................................................................................................... 1

ANTENATAL CARE ............................................................................................................................................1

Definition...............................................................................................................................................................
1
Goals........................................................................................................................................................................
1 First visit antenatal care
visit........................................................................................................................1
Antenatal prophylaxis and treatment schedules............................................................................. 2
Identification of high risk pregnancy:.................................................................................................. 3
Follow up
visit......................................................................................................................................................4

INTRAPARTUM CARE ......................................................................................................................................4

Definitions.............................................................................................................................................................
4 Clinical
presentation.........................................................................................................................................4
Management........................................................................................................................................................5
Initial evaluation.......................................................................................................................................
5 Laboratory
tests........................................................................................................................................ 5 Treatment
................................................................................................................................................... 5
Monitoring............................................................................................................................................................6
Second stage of labor...............................................................................................................................6
Third stage of labor ..................................................................................................................................
7

INDUCTION OF LABOUR ...............................................................................................................................7

Definition...............................................................................................................................................................
7 Indications of Induction of Labour
..............................................................................................................7 Contraindications of induction of
labour .................................................................................................8 Pre-induction
assessment..............................................................................................................................8
Modified Bishop Scoring System ..........................................................................................................9
 Methods of induction of labour....................................................................................................................9
Complications of induction of labour......................................................................................................11

AUGMENTATION OF LABOR ..................................................................................................................... 11

Definition............................................................................................................................................................1
1 Methods of augmentation of labor
..........................................................................................................11

TRIAL OF LABOR AFTER CAESAREAN SECTION............................................................................... 12

Optimal candidates for TOLAC.................................................................................................................12
Management.....................................................................................................................................................12

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TREATMENT GUIDELINES

POSTNATAL CARE.......................................................................................................................................... 13
Definition............................................................................................................................................................1
3 Management
....................................................................................................................................................13

PERIOPERATIVE CARE IN OBSTETRICS ................................................................................................ 14

Definition............................................................................................................................................................1
4

OBSTETRIC HAEMORRHAGE.................................................................................................................... 17
Antepartum haemorrhage...........................................................................................................................17
Placenta Praevia..............................................................................................................................................18
Placental Abruption.......................................................................................................................................20 Types
of placenta abruption: .............................................................................................................. 20

POSTPARTUM HAEMORRHAGE (PPH).................................................................................................. 22

Definition............................................................................................................................................................2
2 Etiology and risk
factors...............................................................................................................................22 Clinical
presentation......................................................................................................................................22
Management of primary PPH
....................................................................................................................22
Treatment ................................................................................................................................................
23 Treatment of Secondary
PPH.....................................................................................................................24 Prevention of
PPH..........................................................................................................................................24

PRETERM LABOR ........................................................................................................................................... 25

Definition............................................................................................................................................................25
Risk factors
........................................................................................................................................................25 Clinical
presentation......................................................................................................................................26
Management.....................................................................................................................................................26
PRE-LABOR RUPTURE OF MEMBRANES.............................................................................................. 27
Definition............................................................................................................................................................27
Clinical presentation......................................................................................................................................27
Investigations ...................................................................................................................................................27
Management of Term PROM......................................................................................................................28
Management of Preterm PROM...............................................................................................................28

RECURRENT PREGNANCY LOSS.............................................................................................................. 29

Definition............................................................................................................................................................29
Risk factors ......................................................................................................................................................29
Causes..................................................................................................................................................................29
Management.....................................................................................................................................................30
Work up.................................................................................................................................................... 30
Treatment plan....................................................................................................................................... 31

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Obstetric and Gynaecological Disorders

HYPERTENSIVE DISORDERS IN PREGNANCY.................................................................................... 33

Gestational Hypertension
...........................................................................................................................33
Pre-eclampsia...................................................................................................................................................34
Preeclampsia without severe features............................................................................................. 34
Preeclampsia with severe features:...................................................................................................
35 Management - Preeclampsia without severe features................................................................
35 Management - Pre-eclampsia with severe features.....................................................................
35
Eclampsia............................................................................................................................................................37
Chronic Hypertension...................................................................................................................................38
Definition ................................................................................................................................................. 38
Management........................................................................................................................................... 38
Chronic Hypertension with superimposed pre-eclampsia.............................................................39
Definition ................................................................................................................................................. 39
Management........................................................................................................................................... 39

PERIPARTUM CARDIOMYOPATHY......................................................................................................... 40
Clinical manifestations..................................................................................................................................40
Diagnosis
............................................................................................................................................................40
Management.....................................................................................................................................................41
Investigations..........................................................................................................................................
41 Treatment
................................................................................................................................................ 41 Delivery
.................................................................................................................................................... 42
Postnatal care......................................................................................................................................... 42
 ANAEMIA IN PREGNANCY......................................................................................................................... 43
Definition and
Classification.......................................................................................................................43 Causes of
anaemia ..........................................................................................................................................43 Clinical
features...............................................................................................................................................43
Management.....................................................................................................................................................43
Intrapartum care
.............................................................................................................................................45
Prevention..........................................................................................................................................................4
6

SICKLE CELL DISEASE AND PREGNANCY ............................................................................................ 46

Introduction
......................................................................................................................................................46 Clinical
features...............................................................................................................................................46
Management.....................................................................................................................................................47
Preconception care................................................................................................................................
47 Antenatal care
........................................................................................................................................ 47 Care during
delivery.............................................................................................................................. 47 Care during
pueperium ........................................................................................................................ 48

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TREATMENT GUIDELINES

MALARIA IN PREGNANCY.......................................................................................................................... 48
Introduction ......................................................................................................................................................48
Clinical presentation......................................................................................................................................48
Management.....................................................................................................................................................49
Complications...................................................................................................................................................50

DIABETES MELLITUS IN PREGNANCY................................................................................................... 51

Definitions..........................................................................................................................................................5
1 Risk factors
........................................................................................................................................................51 Diagnostic
criteria ..........................................................................................................................................51 Clinical
presentation......................................................................................................................................51
Management.....................................................................................................................................................52
Intrapartum glucose and insulin requirements..............................................................................
54 Postpartum
care..................................................................................................................................... 54

MANAGEMENT OF HIV IN PREGNANCY.............................................................................................. 55

Introduction
......................................................................................................................................................55 Clinical
presentation......................................................................................................................................55
 Management.....................................................................................................................................................55
Antiretroviral treatment (ART) in pregnant and breastfeeding women.................................. 56
Perinatal care..........................................................................................................................................
57 Infant
prophylaxis.................................................................................................................................. 57
Postpartum use of ART......................................................................................................................... 58

PART 2: GYNAECOLOGICAL CONDITIONS .....................................................................................59

GYNAECOLOGICAL TUMORS ...................................................................................................................

59

GYNAECOLOGICAL BENIGN TUMORS.................................................................................................. 59

Uterine Fibroids/myomas............................................................................................................................59 Risk
Factors............................................................................................................................................. 59 Clinical
features and work up............................................................................................................. 59 Medical
Treatments.............................................................................................................................. 60 Surgical
Management........................................................................................................................... 60 Uterine fibroids in
pregnancy.....................................................................................................................93 Ovarian cysts
....................................................................................................................................................94
Diagnosis.................................................................................................................................................. 95
Investigations.......................................................................................................................................... 95
Management........................................................................................................................................... 96 Vulva
warts ........................................................................................................................................................96
Diagnosis.................................................................................................................................................. 96
Management........................................................................................................................................... 96

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Obstetric and Gynaecological Disorders

Vulva skin problems and dysplasia...........................................................................................................97

Allergic vulvitis....................................................................................................................................... 97
Vulva dermatoses.................................................................................................................................. 97
Vulva dysplasia....................................................................................................................................... 97
Vulvodynia............................................................................................................................................... 98

GYNAECOLOGICAL MALIGNANCIES .................................................................................................... 65

Introduction
......................................................................................................................................................65 Cancer of
the cervix .......................................................................................................................................65
Cervical screening..................................................................................................................................
65 The Bethesda Classification of carcinoma of the cervix 2001..................................................
66 Management of abnormal smears....................................................................................................
67 Indication for colposcopy and associated ablative procedures.................................................
67 Clinical Presentation.............................................................................................................................
68 Principle of Management
.................................................................................................................... 68 FIGO staging of cancer
 of the cervix uteri (2018) ........................................................................ 69 Treatment based on
disease stage and desire for fertility........................................................... 70 Chemotherapy in
Cervical Cancer Treatment ............................................................................... 71 Management of
clinical complications of cervical cancer.......................................................... 71 Cervical Cancer
with Vesico-vaginal fistula ................................................................................... 71 Severe pain
realted to Cancer of Cervix........................................................................................... 72
Cervical cancer in pregnancy .....................................................................................................................72
Ovarian cancer.................................................................................................................................................72
Clinical Presentation............................................................................................................................. 73
Management........................................................................................................................................... 73
Staging of ovarian cancer.................................................................................................................... 74
Table. FIGO and TNM system staging of ovarian cancer............................................................ 74
Epithelial ovarian cancer..............................................................................................................................76
Endometrial cancer
........................................................................................................................................77 Clinical
presentation............................................................................................................................. 77 Treatment
................................................................................................................................................ 77 Stages of
endometrial cancer (FIGO 2009).................................................................................... 77 Follow
up.................................................................................................................................................. 77 Cancer of
the vulva.........................................................................................................................................78 Diagnosis
and work up......................................................................................................................... 78 Staging and
types of vulva cancer (FIGO 2009) ........................................................................... 78
Management........................................................................................................................................... 79
Follow-up ................................................................................................................................................. 79
Malignant Gestational trophoblastic disease......................................................................................79
Choriocarcinoma ................................................................................................................................... 79

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TREATMENT GUIDELINES

Scoring system based on the prognostic factors............................................................................ 80

FIGO Clinical staging f Malignant Gestational Trophoblastic Disease ...................................
80 Treatment based on clinical Stage based
Treatment.................................................................... 80
Management of cancer related pain........................................................................................................82
General measures.................................................................................................................................. 82
Steps of pain management.................................................................................................................. 82

INFERTILITY AND ENDOCRINOLOGICAL CONDITIONS ............................................................... 83

Infertility.............................................................................................................................................................83
History Taking of infertile couple....................................................................................................... 83 Causes of
Infertility: .............................................................................................................................. 83 Initial Infertile
couple screening......................................................................................................... 84 Treatment
................................................................................................................................................ 84 Polycystic ovarian
syndrome......................................................................................................................85 Diagnosis
criteria................................................................................................................................... 85
Management........................................................................................................................................... 85
 Endometriosis and Adenomyosis..............................................................................................................86
Management........................................................................................................................................... 86
Amenorrhoea....................................................................................................................................................87
Causes....................................................................................................................................................... 87 Clinical
assessment and work up....................................................................................................... 87
Investigations.......................................................................................................................................... 88
Premature menopause .................................................................................................................................89
Diagnosis.................................................................................................................................................. 89
Management........................................................................................................................................... 89
Prolactinoma.....................................................................................................................................................89
Other causes of amenorrhea......................................................................................................................90
Hirsutism............................................................................................................................................................90

PELVIC PAIN...................................................................................................................................................... 92
Differential diagnosis ....................................................................................................................................92
Pelvic Inflammatory.......................................................................................................................................92
Irritable bowel syndrome.............................................................................................................................94
Primary and secondary dysmenorrhea ..................................................................................................95
Urinary tract infection ..................................................................................................................................95
Clinical feature: ...................................................................................................................................... 95

GENITAL DISCHARGE SYNDROME AND STIs..................................................................................... 97

Vulvovaginal candidiasis (VVC).................................................................................................................97
Foreign body .....................................................................................................................................................98
Vulvovaginal trichomoniasis.......................................................................................................................98

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Obstetric and Gynaecological Disorders

Bacterial
vaginosis..........................................................................................................................................98
Mucopurulent cervicitis and gonococcal cervicitis
...........................................................................99

EARLY PREGNANCY DISORDERS...........................................................................................................100

Hyperemesis gravidarum..........................................................................................................................100
Ectopic pregnancy........................................................................................................................................101
Miscarriage.....................................................................................................................................................103
Hydatidiform Mole......................................................................................................................................105

ABNOMAL VAGINAL BLEEDING ............................................................................................................106

Abnormal uterine bleeding ......................................................................................................................106
Definitions.............................................................................................................................................106
Causes.....................................................................................................................................................106 The PALM
COEIN system for classifying abnormal uterine bleeding....................................106 Clinical
history......................................................................................................................................106 Physical
examination..........................................................................................................................107
Investigations........................................................................................................................................107 Treatment
..............................................................................................................................................107 Vaginal bleeding in a
child.........................................................................................................................108 Causes and
Management..................................................................................................................108

MENOPAUSE ..................................................................................................................................................109
Diagnosis .........................................................................................................................................................109
General Work up..........................................................................................................................................109
Management..................................................................................................................................................109
Postmenopausal osteoporosis................................................................................................................110
Postmenopausal bleeding (PMB)...........................................................................................................110

UROGYNAECOLOGICAL CONDITIONS...............................................................................................112
Urinary incontinence..................................................................................................................................112
Classification of urinary incontinence.....................................................................................................112
Genuine stress incontinence ...................................................................................................................114
Urge incontinence........................................................................................................................................115
Mixed Incontinence.....................................................................................................................................116
Sensory Urge incontinence......................................................................................................................116
Functional and Transient incontinence ...............................................................................................116
Bypass incontinence ...................................................................................................................................117
Urethral diverticulum.................................................................................................................................117
Genital Fistulas .............................................................................................................................................117
Clinical presentaion.......................................................................................................................................117
Examination finding:......................................................................................................................................117
Special tests......................................................................................................................................................118

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TREATMENT GUIDELINES

Complementary
examinations..................................................................................................................118 WHO
Classification of genital fistula......................................................................................................119
Treatment of obstetric vesical vaginal fistula
.......................................................................................119 Prevention of
VVFs........................................................................................................................................121
Disorder of Pelvic
support........................................................................................................................121
Causes............................................................................................................................................................
....121
Classification................................................................................................................................................
....121
Uterine prolapse or vault prolapse
.......................................................................................................122 Rectocele
...........................................................................................................................................................122
Enterocele
.........................................................................................................................................................122
Paravaginal
 prolapse.....................................................................................................................................123
Treatment
.........................................................................................................................................................124
Urethral Prolapse.........................................................................................................................................124
Iatrogenic injury to the Ureters..............................................................................................................126
Surgical Therapy...........................................................................................................................................127
Complications...............................................................................................................................................
...127 Urinary bladder
injury................................................................................................................................128 Urethral
injury...............................................................................................................................................129

AMBIGUOUS GENITALIA...........................................................................................................................130

SEXUAL ASSAULT .........................................................................................................................................132

Types of sexual assaults .............................................................................................................................132
Cause.................................................................................................................................................................132
Clinical presentation...................................................................................................................................132
Investigations ................................................................................................................................................133
Treatment........................................................................................................................................................134

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Obstetric and Gynaecological Disorders

FOREWORD
Clinical guidelines in medical discipline provide evidence based
recommendations that medical professions should follow during
cases management hence a tools that complete the function of
Standard Operating Procedures (SOP) that provide a guide that care
providers should follow in order to give services safely, effectively
and operationally efficiently. The Muhimbili National hospital (MNH)
is the highest referral health facility nationally; and therefore,
dependable for multidisciplinary advance clinical and diagnostic
services. In order to ensure our subspecialized services, align with
evidence based practice and national policy of disease management the established clinical
 guideline needed to under period review to keep up with evidence bases practice. Nonetheless,
the review process ought to align with SOP to guarantee safety and accelerated proficiency in
service provision. Thus, building a foundation for universal standards of structure and process
of clinical services at MNH that also carries the function of teaching activities, staff-led
collaborative research, supervisory role in clinical service in its catchment areas including but
not limited to, Pwani, Lindi, Mtwara and Morogoro regions.

Recently, MNH has made numerous structural changes in patients’ care and support services.
The upgraded structure of care includes establishment of subspecialty services in medical and
surgical disciplines and increased capacity of Radiological services, advancement of the Central
Pathology Laboratory investigations, increase range, availability and accessibility of medicines
from the hospital pharmacy and expansion of operating theaters including the obstetrics and
gynecological theaters. These changes and other quality improvement innovations necessitate
establishment of clinical guideline in all disciplines, so that the process of care aligns with the
new structure of care. Doing so, increase the efficiency and effectiveness of the health care and
administrative intervention that determines the outcome of patients care and impact of the
investment put into improving clinical services at MNH. Nonetheless, standardized clinical
guideline in our institution strengthen networking within and between different specialties.

These clinical guidelines address process of subspecialized obstetric and gynecological care and
at the same time fully utilize the opportunity of having other subspecialized disciplines and
supportive staff. As a complimentary tool to SOP in management of obstetric and gynecological
conditions, clinical management guidelines aligns with Treatment Guideline established by the
Ministry of Health, Community Development, Gender, Elderly and Children (MoHCGEC).

Standardizing and continuously updating the way clinical management of disease is performed
at MNH is a pre-requisite for strategic improvement of clinical care and subsequently, teaching
activities and staff led collaborative research. Thus, a potential enabler for success
accreditation of our institution to become a center of excellence by 2022, in accordance to the
MNH strategic plan.

Prof. Laurence Museru

Executive Director – Muhimbili National Hospital
June, 2020

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TREATMENT GUIDELINES

ACKNOWLEDGEMENT
The established clinical guideline of obstetrics and gynecological conditions was accomplished
by committed members of the obstetrics and gynecology department at Muhimbili National
Hospital (MNH) and Muhimbili University of Health and Allied Sciences (MUHAS) in their
tireless effort of standardizing and continuously improving clinical services at MNH. The
support of Units and Maternity Block One manager is well appreciated.

I would like to acknowledge the main contributors and those who organized the task force of
writing this clinical guideline namely:
1. Dr. Angela Thomas, MD, MMED, MPH
Consultant, Obstetrician gynecologist
Head of Gynaecology Oncology Unit (IV) – MNH

2. Prof. Charles Kilewo, MD, MMED, PHD

Professor, Obstetrician and Gynaecologist - MUHAS
 Consultant, Obstetrician Gynecologist – MNH

3. Dr. Matilda Ngarina, MD, MMED, PHD

Senior Specialist, Obstetrician gynaecologist
Head, Reproductive Endocrinology and infertility Unit (III) - MNH
Honorary Lecturer, Obstetrics and gynaecology – MUHAS

4. Dr. Vincent tarimo, MD, MMED, Cert. Minimum Invasive Gynecological Surgery
Senior Specialist, Obstetrician gynaecologist
Former, Head of Department of Obstetrics and Gynaecology

5. Dr. Furaha August, MD, MMED, PHD

Senior Lecturer, Obstetrics and Gynaecology - MUHAS
Senior Specialist, Obstetrician gynaecologist - MNH

6. Dr. Abidan Mganga, MD, MMED

Medical Specialist, Obstetrician and Gynaecologist
Member, maternal-fetal Medicine Unit (UNIT I) - MNH

7. Dr. Andrew Mgaya, MD, MMED, PHD

Senior Specialist, Obstetrician Gynaecologist
Head of Urogynaecology Unit (II)

Team work from all the Consultants, Specialists and Nurses/Midwives was the key for
successful revision of this manual.
Thank you.

Dr. Nathaniel L. Mtinangi

Head, Department of Obstetrics and gynaecology
Muhimbili National Hospital

x
Obstetric and Gynaecological Disorders

PART 1: OBSTETRIC CONDITIONS

ANTENATAL CARE

Definition
Antenatal care (ANC) refers to systematic supervision of a woman during pregnancy. The
supervision should be regular and periodic in nature according to the need of the
individual.

It comprises of a thorough history taking and physical examinations; identification of risk

factors, intervention and continuous counseling.

Goals
 The role for ANC is to ensure a safe delivery of a healthy baby while minimizing risk to the
mother by:
■ Early, accurate estimation of gestational age.
■ Identification of risk factors and possible intervention to prevent or minimize maternal
or fetal morbidity and mortality.
■ Ongoing evaluation of maternal and fetal health status.
■ Health promotion, education, support, and shared decision-making. ■ To advice on birth
preparedness, labour and delivery, care of the newborn and family planning.

First visit antenatal care visit

Components
■ Registration as pregnancy is confirmed
■ Appropriate history, physical examination, and laboratory studies to identify high risk
pregnancy
■ High risk pregnancy include pregnant women at increased risk of medical complications,
pregnancy complications, or fetal abnormalities.
■ Client education and counseling, preferably involving a partner

Investigations
■ Confirm pregnancy: UPT, Ultrasound, Beta hCG
■ Haemoglobin
■ ABO and Rh factor blood typing
■ VDRL/ RPR

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TREATMENT GUIDELINES

■ MRDT/ BS for malaria parasite

■ HIV testing; if positive, initiation of ART according to the national treatment protocol ■
Hepatitis B surface antigen
■ Random blood glucose/ Fasting blood glucose
■ Urine for protein, sugar, acetone
■ Other specific investigations depending on the pre-existing or per individual indication

Antenatal prophylaxis and treatment schedules

■ Intermittent Presumptive Treatment of Malaria parasites
IPTp regime should be given using pyrimethamine/sulphadoxine (SP) First single
dose after 14 week then continue every 4 weeks to at least 4 dose/ until delivery
th

Contraindicated for women who are allergic to Sulphur.

IPTp is an administration of antimalarial in full therapeutic doses at predetermined
intervals during pregnancy to individuals with no signs/symptoms of malaria. IPTp
clear placenta malaria infections to prevent maternal anaemia, low birth
weight, premature delivery, congenital infection and/or perinatal death. IPTp
should ideally be administered as directly observed therapy (DOT) with either on an
empty stomach or with food
Folic acid at a daily dose equal or above 5 mg should not be given together with SP
 as this counteracts its efficacy as an antimalarial.
SP should not be administered to women receiving Cotrimoxazole prophylaxis If
malaria is diagnosed to a scheduled pregnant woman for IPT with SP; SP should not be
given, instead a full treatment with antimalarial should be given.

■ Iron and Folic Acid supplements regime:

Prophylaxis: Give elemental Iron tablets 60mg daily.
Treatment: Give elemental Iron tablet 120mg daily until the Haemoglobin is ≥
12g/dl and continue as prophylactic dosage.
Folic acid (PO) 5mg once a day throughout the pregnancy

■ Anti-D (Anti RhIgG) prophylaxis for women with Rh –ve and negative Indirect Coomb’s
test
Give Inj Anti RhIgG 250-300mcg, when indicated.
Anti D prophylaxis is indicated at any gestation age following a threatened and
other types of abortion, chorionic villus sampling, amniocentesis, ectopic
pregnancy and episodes when a fetal-maternal hemorrhage, external cephalic
version, antepartum hemorrhage or abdominal trauma.
Routinely give Anti-D at gestation age between 28 and 34 weeks
For a multiple pregnancy give inj. Anti RhIgG 600 mcg

Note: For second and third trimester, a Kleihauer Batker test should be performed (1-24 hours
after the bleeding or sensitizing event) so additional anti-D may be given if required.

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Obstetric and Gynaecological Disorders

■ Tetanus Toxoid Immunization (TT) regime:

TT1 at 1st contact or as early as possible during pregnancy – No protection
TT2 at 4 weeks after TT1 - Protection duration of 3 years
TT3 at 6 months after TT2 or next pregnancy within 3 years – Protection duration 5
years
TT4 at 1 year after TT3 or next pregnancy within 5 years – Protection duration 10
years
TT5 at 1 year after TT4 or next pregnancy within 10 years – Protection duration 20
years.

■ Antiretroviral Treatment (ART)

All HIV infected pregnant women should receive ART irrespective of CD4 count.
ART should continue for life hence a need for proper counseling to ensure adherence
Currently, the recommended dosage is One Tab of TLE nocte.

Note: Details of ART to be followed according to the National Guidelines for HIV Treatment

Identification of high risk pregnancy:

■ Past obstetric history:
Previous Caesarean Section
Vacuum extraction and Forceps delivery
Symphisiotomy
 Laparotomy for ruptured uterus
Retained placenta
PPH
■ Recurrent abortions
■ Previous stillbirths and/or neonatal deaths
■ Grand multiparity (> 4)
■ History of 10 + years of involuntary infertility
■ Past gynaecological operation: Myomectomy, Repair of VVF, Repair of genital prolapse,
Repair of complete perineal tear and Repair of stress incontinence.
■ Primigravida Height ≤ 150cms
■ Age < 16 years or ≥ 35 years
■ Deformities of musculoskeletal system e.g. Kyphosis.
■ Maternal disease: PIH – Blood Pressure of ≥140/90 mmHg, Anaemia (Haemoglobin ≤
8g/dl), Sickle Cell Disease, Cardiac diseases, Pulmonary diseases, Renal diseases,
Diabetes mellitus, Syphilis and HIV infection.
■ Current obstetric factors: Abdominal pregnancy, multiple pregnancy, malpresentation of
fetus, Abnormal lie at term, Polyhydramnios, APH, IUGR.

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TREATMENT GUIDELINES

Follow up visit
■ Follow up visit should be individualized based on the clinical evaluation ■ At each visit a
thorough clinical assessment should be performed to evaluate pre existing or newly
identified pregnancy risks
■ Counseling in danger signs and the need for early intervention
■ Make a delivery plan

INTRAPARTUM CARE

Definitions

Intrapartum period
A period from the onset of labour to the end of third stage.

True labor
A process characterized by regular and progressive painful uterine contractions associated
with cervical changes leading to delivery of the fetus and placenta.

■ First stage of labour

Latent phase is a period of first stage of labor characterized by some degree of
cervical effacement and slower progression of dilatation up to 5 cm.
Active phase is a period of first stage of labor characterized by substantial degree of
cervical effacement and more rapid cervical dilatation from 5 cm until full
dilatation.
 Second stage of labour
A period of labor which begins with a complete cervical dilatation to a complete
delivery of the fetus.

■ Third stage
It is the period of labor between the delivery of the fetus and the delivery of the
placenta and fetal membranes.

Note: Precipitate or precipitous labor refers to expulsion of the fetus within two to three hours of
commencement of contractions with a risk of asphyxia, postpartum hemorrhage and
genital tract lacerations

Clinical presentation
■ Regular uterine contractions
■ Significant cervical changes: effacement (≥80 percent) and dilation

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Obstetric and Gynaecological Disorders

Management

Initial evaluation
■ Admission in labor ward should be considered in women in active phase of first stage of
labor.
■ Review antenatal visit records for medical or obstetrical conditions that need to be
addressed intrapartum
■ Check for development of new disorders since the last antenatal visit ■ Enquire for a
recent history of membrane rupture, vaginal bleeding or bloody show (vaginal discharge of a
small amount of blood and mucus)
■ Initial assessment should include general condition of the patient, check for vital signs; i.e.
pulse rate, blood pressure; heart and respiratory rates; temperature. ■ Obstetric assessment
should include; frequency, quality and duration of uterine contractions; fetal size estimation,
lie, presentation, and position; and fetal heart rate (FHR) should be performed.
■ Initial pelvic assessment to establish baseline cervical status so that subsequent progress
can be determined; fetal position and station; and assessment of adequacy of the pelvis
except for patients with placenta previa and PPROM for expectant management.

Laboratory tests
The following laboratory results should be available at the time of
delivery ■ Hemoglobin (recent within 2weeks)
■ ABO grouping and Rhesus (Rh) factor
■ Human immunodeficiency virus (HIV)
■ Hepatitis B surface antigen
■ Syphilis test

Treatment
■ Intrapartum care
 Allow oral fluids and food intake during labor
Give 5% dextrose in normal saline if oral intake is restricted or when dehydrated
Prophylactic antibiotics to prevent early-onset neonatal GBS infection should be given
in patients with PROM, positive GBS culture or in labour with membrane ruptured for
more than 6 hours
Pharmacological pain control should be considered on request during labor. Pain
medication during labor include: Epidural analgesia and Parenteral analgesia such as
Pethidine; Diamorphine; Fentanyl
Amniotomy procedure
□ Amniotomy should be considered in women undergoing augmentation or
induction of labor in combination with oxytocin administration.
□ Controlled amniotomy should be performed to minimizes the risk of abruption
placentae and umbilical cord prolapse
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TREATMENT GUIDELINES

□ Amniotomy should be avoided, if possible, in women with active hepatitis B,

hepatitis C or HIV infection to minimize mother to child transmission

Monitoring

First Stage of labour

■ Fetal heart rate:
Intermittent auscultation with Pinard fetal stethoscope or Doppler scan every 15-
30 minutes
Continuous electronic FHR monitoring e.g. MOYO and CTG in women with
pregnancies at increased risk of fetal compromise.
If FHR abnormalities occurs, evaluate for complications such as maternal
exhaustion and/or dehydration, cord presentation/prolapse/around the neck or
uterine dehiscence/rupture

■ Uterine contractions:
Uterine contractions should be monitored and documented by the duration of each
contraction (in sec) and number of contractions per 10 minutes.

■ Labor progress
Perform vaginal examinations on admission and subsequently at four-hour intervals
in the first stage
When the woman feels the urge to push to determine whether the cervix is fully
dilated

Second stage of labor

■ Monitoring
Fetal heart rate monitoring should be every five minutes
The maximum duration of the second stage of labour should be 2-3 hours, in the
absence of fetal distress
Shortening of the second stage should be considered based on the obstetric
indications including maternal illness (e.g. Severe anaemia, Cardiac diseases,
Eclampsia) and fetal distress, when appropriate with the use of vacuum
 extraction.

■ Pushing position and technique

Pushing is encouraged after confirmation a fully dilated cervix
A woman should bear down when she feels the need to do so.

■ Persistent anterior cervical lip

Perform expectant management and avoid manual reduction of the anterior lip to
avoid risk of cervical laceration and subsequent hemorrhage.

6
Obstetric and Gynaecological Disorders

Third stage of labor

■ This is a period between the delivery of the fetus and the delivery of the placenta and
fetal membranes

■ Active management of third stage of labour include:

Prophylactic administration of oxytocin or other uterotonics (prostaglandins or
ergot alkaloids)
Cord clamping/cutting
Controlled traction of the umbilical cord

■ Perineal care
Perineal massage should be performed during and between pushes with two fingers
of the lubricated gloved hand moving from side to side just inside the patient’s
vagina and exerting mild, downward pressure.
Perineal support should be performed during delivery of the fetus.

■ Delivery of the placenta often takes less than 10 minutes, but the third stage may last as
long as 30 minutes when active intervention should be done.

INDUCTION OF LABOUR

Definition
Induction of labour (IOL) refers to artificial techniques for initiation of uterine contractions
to accomplish vaginal delivery prior to the onset of spontaneous labor.

Indications of Induction of Labour

Induction of labor is indicated when the benefits to either mother or foetus outweigh those of
pregnancy continuation.
■ Eclampsia
■ Prelabour Rupture of Membranes (at ≥ 34 weeks)
■ Suspected Chorioamnionitis
■ Intrauterine fetal death (IUFD)*
 ■ Gestational / Unclassified Hypertension (at 38 weeks)**
■ Chronic Hypertension (at 38 weeks)**
■ Pre-eclampsia*
■ Post term / Prolonged Pregnancy
■ Diabetes in Pregnancy (at 38 weeks)**
■ Intrauterine Fetal growth restriction (IUGR)***
■ Oligohydramnios***
■ No reassuring fetal status***

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TREATMENT GUIDELINES

■ Previous documented abruptio placentae (at 38 weeks)

■ Fetal Anomalies***
■ Previous unexplored/unexplained IUFD in uncomplicated pregnancy (at 38 weeks) *
Gestation of induction dependent on severity of disease
**GA for all maternal indicated inductions is dependent on no organ dysfunction with
normal fetal Doppler and normal growth.
*** Indicated by the Maternal Fetal Medicine Unit

Contraindications of induction of labour

■ Any gynaecological, obstetrical or medical condition that precludes safe vaginal delivery ■
Malpresentation (e.g. transverse lie, footling breech)
■ Cord presentation
■ Contracted or abnormal pelvis
■ Active genital herpes
■ Placenta praevia; grade IIB/ III/ IV
■ Previous cesarean delivery
■ Macrosomic fetus (>4.0kg)
■ Previous major uterine surgery including previous myomectomy. ■ The preferred method
to induce labor is contraindicated by the preexisting maternal condition e.g. allergic to
prostaglandins
■ Cervical cancer
■ Severe hydrocephalus

Pre-induction assessment
■ All elective IOL must first be discussed with a specialist/ consultant/ panel discussion ■
The indication for all IOL should be a well-defined and documented ■ Exclude any
contraindications for IOL
■ Complete the informed consent form/ IOL Safety Check List before starting any IOL ■ In
the absence of medical indication for induction fetal maturity must be confirmed by either
dating or ultrasound measurement or amniotic fluid analysis when available ■ Confirm
gravidity and parity; gestation age, fetal size, presentation, uterine activities and fetal heart
beats
■ Assess the Bishop score to measure the likelihood of success and to select the appropriate
method of induction and should be well documented.
 8
Obstetric and Gynaecological Disorders

Modified Bishop Scoring System

Factor Score

0 1 2

Cervical dilatation (cm) 0 1-2 3-4

Cervical effacement (%) 0-30 40-50 60-70

Station of the presenting part −3 or -2 -1 or 0

above

Consistency of the cervix Firm Medium Soft

Position of the Cervix Posterior Mid Anterior

Methods of induction of labour

Unfavorable cervix (Bishop score ≤6)

Cervical ripening methods should be applied including mechanical and pharmacologic options,

■ Dinoprostone
Dinoprostone is a prostaglandin E2 analogue that is given vaginally as a vaginal
suppository (3mg) and endo-cervical gel (0.5mg in 2mls) for labor induction The dose
should depend on formulation: Vaginal tablet of 3g that is inserted in posterior fornix
6-12hourly (maximum 2 doses)
Oxytocin can only be used 8 hours after the last dose to avoid potential of uterine
tachysystole.
PGE2 should not be used to patients with history of glaucoma and myocardial
infarction

■ Misoprostol
Misoprostol is a prostaglandin E1 analogue that can be given vaginally or orally for
labor induction.
Give 25 mcg vaginally OR 25-50 mcg orally with a drink of water (ensure that it is
swallowed quickly to avoid sublingual absorption)
For vaginal regimen repeat every 6 hours as long as contractions are absent
(maximum 4 doses)
For oral regimen repeat 2hourly until contractions start to a maximum of 8 doses.
Oxytocin can only be used 6 hours after the last dose of Misoprostol Assess fetal
 heart rate 30minutes before each dose

■ Balloon Devices
Foley Catheter 18F introduced and inflated (with 30-60cc) under sterile technique
into the intra-cervical canal past the internal os.
Intra-cervical Foley catheters are acceptable and safe both in the setting of a normal
vaginal birth and in cases with IUFD after Caesarean section when induction of
labour is considered.

9
TREATMENT GUIDELINES

There is a need for oxytocin when Foley catheters are used

Foley catheters cause much less uterine tachysystole

Favourable cervix (Bishop score >6)

■ Amniotomy
Amniotomy is a simple and effective component of labour induction when the
membranes are accessible and the cervix is favourable and in the case of engaged
presentation part except for HIV infected women where it should be avoided until
6cm dilated.
After amniotomy, oxytocin should be commenced early in order to establish labour.

■ Oxytocin
Intravenous oxytocin is the most commonly used method of induction for women
with favourable cervix.
Oxytocin produce uterine contractions, but it has no direct effect on the cervix.
Initial dose of oxytocin is 5 mIU/min, with dose increments of 5 mIU/min every 30
minutes until the desirable uterine contraction is reached.
Maximum dose of IV Oxytocin infusion rate should not exceed 30 mIU/ minute.

Special considerations
■ For Multiparous
Initial dose of oxytocin is 2.5 mIU/min, with dose increments of 2.5 mIU/min every
30 minutes until the desirable uterine contraction is reached; aim for a maximum
of 3 – 4 contractions in ten minutes.
Maximum dose of IV Oxytocin infusion rate should not exceed 30 mIU/ minute.
For a prolonged oxytocin infusion, consider doubling the dose and running the infusion
at half the previous rate.
Delay commencement of oxytocin infusion by 6 hours following administration of
vaginal prostaglandins
Amniotomy should be performed prior to commencement of oxytocin infusion
Continuous CTG is required with oxytocin infusion
Observe for uterine hypercontractility and/or signs of fetal compromise

■ Post-Dates Induction
Women should be offered induction of labour between 41 and 42 weeks as this
intervention may reduce perinatal mortality and meconium aspiration syndrome
without increasing the caesarean section rate
 Women who choose to delay induction < 41 weeks should undergo twice-weekly
assessment for fetal well-being including Biophysical profile and fetal stress test

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Obstetric and Gynaecological Disorders

Complications of induction of labour

■ Failed induction
■ Prolonged labour
■ Tachysystole
■ Ruptured uterus
■ Postpartum Haemorrhage

AUGMENTATION OF LABOR

Definition
Augmentation of labor refers to enhancement of uterine contractions that are considered
inadequate after the onset of labor.

The aim of augmentation is to reach the adequate uterine contraction to facilitate vaginal
delivery.

Methods of augmentation of labor

Amniotomy
■ Amniotomy is the process performed to enhance progression of active phase of labor. ■
Assessment of uterine contractions and fetal heart rate has to be performed immediately
after amniotomy.
■ Cautions have to be taken as this may increase the risks of cord prolapse, early placental
separation and infection.

Oxytocin
■ Amniotomy should be performed prior to commencement of oxytocin infusion ■ Initial
dose of oxytocin is 5 mIU/min, with dose increments of 5 mIU/min every 30 minutes until the
desirable uterine contraction is reached.
■ Maximum dose of IV Oxytocin infusion rate should not exceed 30 mIU/ minute. ■
For Multiparous:
Initial dose of oxytocin is 2.5 mIU/min, with dose increments of 2.5 mIU/min every
30 minutes until the desirable uterine contraction is reached.
Maximum dose of IV Oxytocin infusion rate should not exceed 30 mIU/ minute. ■
Continuous CTG is required with oxytocin infusion and observe for uterine tachysystole. ■ If
augmentation of labor is required following induction with vaginal prostaglandins,
oxytocin infusion should be delayed for at least 6 hours following administration of the
last dose.
 ■ For a prolonged oxytocin infusion, consider doubling the previous dose and running the
infusion at half the previous rate.

11
TREATMENT GUIDELINES

TRIAL OF LABOR AFTER CAESAREAN SECTION

Definition
Trial of labor after caesarean section (TOLAC) refers to an attempt to achieve vaginal
delivery following a prior cesarean delivery.

The goal for TOLAC is achieving a successful vaginal birth after cesarean delivery (VBAC)

Optimal candidates for TOLAC

■ Previous vaginal delivery, whether before or following the cesarean delivery ■
Singleton pregnancy in cephalic presentation
■ Single previous low segment transverse caesarean section
■ Inter-delivery interval ≥18 months
■ Body mass index less than 30
■ Prior nonrecurring indication of CS
■ Spontaneous onset of labor at less than 41 weeks of gestation
■ Estimated fetal weight of less than 4 kg
■ Current preterm pregnancy
■ Intrauterine fetal death
■ No obstetric contraindication for vaginal delivery in the index pregnancy ■
Appropriate informed consent (no woman should be forced to undergo TOLAC)

Management

Antenatal care
■ Early obstetric ultrasound, preferably first trimester, for dating and number of fetuses. ■
All women who are eligible candidates for TOLAC should have a continuous counseling on
the mode of delivery; the risks and benefits regarding TOLAC versus elective repeat
cesarean delivery (ERCD).
■ The decision to attempt TOLAC should be made by the well informed woman in
conjunction with the health care provider; obtain a written consent.
■ At 37 weeks, assessment to determine the suitability of the woman who opted for TOLAC
should be done.
■ At > 40 weeks, ERCD should be performed for women who had opted for TOLAC but have
not gone into spontaneous labor.
■ Induction of labor can be attempted in some circumstances i.e. IUFD, early preterm
pregnancy but avoid misoprostol and/or sequential use of prostaglandins and oxytocin

Intrapartum care
■ Notify team on call and review the plan for TOLAC on admission in the labor ward ■
Provide intrapartum care as per guideline for normal vaginal delivery
 12
Obstetric and Gynaecological Disorders

■ All patients for TOLAC should be prepared as for cesarean delivery An

intravenous line placement and commence crystalloids solution
Blood investigation: Full blood picture, ABO grouping and retain
■ Clinical monitoring for scar dehiscence and fetal behavior
■ The planned TOLAC should be abandoned in patients who
Develop obstetric indication for caesarean delivery
Refuse to continue with TOLAC
■ Oxytocin for augmentation of labor may be used selectively and judiciously as increases
the risk of uterine scar rupture.

POSTNATAL CARE

Definition
Postnatal period refers to the time after delivery of the placenta to 42 days when maternal
physiological changes related to pregnancy return to the non-pregnant state.

■ Postnatal care involves proper assessment by skilled health provider for early recognition
of postpartum complications.
■ Following uncomplicated delivery, a woman should be observed for at least 24 hours after
vaginal delivery or 72 hours after cesarean delivery.
■ For complicated cases, the duration of hospital stay should be individualized depending on
the recovery status.

Management
■ The first 24 to 48 hours are the most critical time for the woman and the baby hence
individualized skilled care during the immediate postnatal period can be lifesaving. ■
Postnatal care includes
Assessment of maternal vital signs, lochia, uterine tonicity, urinary output, ability to
tolerate diet, adequate pain control, ability to ambulate and care for herself and
the newborn.
Check for evidence of infection or bleeding, and presence of any abnormal physical
or emotional evaluation findings.
Important laboratory results should be reviewed and addressed e.g. infant ABO
group/ Rh for Rhesus negative mothers, administer anti D immunoglobulin if
appropriate.
■ Health education prior to discharge
All women should be instructed on expected normal postpartum changes and care
of themselves and the newborn.
Normal postpartum activities/exercise and support resources for the new mother
should be identified

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TREATMENT GUIDELINES
 Danger signs of possible complications that should prompt medical review,
including but not limited to: Excessive postpartum bleeding, foul smelling, lochia,
headache, fever, new or worsening perineal or uterine pain, dysuria, Breast
problems, dyspnea, chest pain, cough, painful leg swelling, significant mood
disturbance
■ Iron and calcium supplements should be prescribed to all women upon discharge for 6
months.
■ Contraceptive plans should be discussed before the woman leaves the hospital. ■
Neonatal care/information should be provided to women, neonates with complications may
be referred to neonatologist.
■ Follow-up visits
Routine evaluation should be at one, two, four and six weeks.
Additional visits should be considered for women with complications that require
close follow-up.
A thorough clinical history and physical evaluation in every visit.
Patient should be assessed for vital signs, breasts (fissures, tenderness, lumps, skin
changes), abdomen (diastasis, hernias), external genitalia/perineum (wound
healing, fistulas), vagina (pelvic support), cervix, uterus/adnexa (size, tenderness,
masses), and extremities.

PERIOPERATIVE CARE IN OBSTETRICS

Definition
Perioperative care refers to the care given to the patient before, during and after surgery.

Components of preoperative care

■ This refers to the patient management period from the diagnosis and an accurate decision
of the planned surgical intervention is made; and necessary preoperative evaluation
and preparation is accomplished.
■ Duration of preoperative care varies widely extending from minutes to months depending
on the severity and nature of the condition and timing of the surgical procedure. ■ It consists
of the preoperative patient evaluation as well as intraoperative and postoperative patient
monitoring and care.

Preoperative investigation
■ Preoperative investigations should depend on the patient condition and timing. These
includes
Full blood picture
ABO grouping and retain; cross matching should be done for selected cases who are
more likely to require blood transfusion.
Serum creatinine, urea, sodium and potassium
Serology for HIV and Hepatitis B surface antigen

14
Obstetric and Gynaecological Disorders

Additional investigations to be considered in selected cases, including: Prothrombin

time, partial thrombin time, Electrocardiogram, Echocardiogram and Chest x-ray
Patient preparation
■ Anaesthesia consultation has to be done in all cases with increased risk above baseline
prior to transfer to operating theatre.
■ Nil by mouth for at least 6 hours prior to surgery
■ Commence or continue with intravenous fluids
■ Insert in-dwelling urinary catheter as time allows
■ Finger nail polish and hair clips removed
■ Rings and jewelry removed or taped
■ Continue with patients monitoring
■ Pre-operative checklist completed and signed
■ Surgical safety checklist should be completed
■ Antibiotic prophylaxis should be administered within 60 minutes before making the skin
incision to ensure adequate drug tissue levels.
Give a course of 3 doses (first dose prior to incision) of either
□ Ceftriaxone 1g IV for women ≤80 kg or 2 g for women >80 kg
□ Cefuroxime 1.5g IV
□ Amoxicillin clavulanic acid 1.2 g IV
▪ Alternatively, a single dose of antibiotics is as effective as multiple doses, if and
only if the following drugs are available:
□ Vancomycin 1g IV stat
□ Clindamycin 900 mg intravenously PLUS Gentamicin 5 mg/kg IV stat □ PLUS, a
single dose of azithromycin 500 mg IV before skin incision to those in labor or
with PROM or for women at high risk of post cesarean infection ▪ For woman on
antibiotic prophylaxis for GBS, add a single dose of azithromycin.

Special consideration:
■ High risk of infection
For a patient with increased risk above baseline of infection or with
chorioamnionitis Administer Ceftriaxone 1g IV plus either Clindamycin 900mg IV or
Metronidazole 500mg IV before skin incision
Continue with Ceftriaxone 1g IV once daily, plus either Clindamycin 900 mg IV
every 8 hours, or Metronidazole 500 mg IV every 8 hours for 5-7 days. ■ Thromboembolism
prophylaxis
For low risk women: encourage early ambulation postoperatively (8 hours) For
high risk women: Encourage early ambulation plus pharmacologic prophylaxis □
Previous venous thromboembolism (VTE)
□ Any thrombophilia (inherited or acquired)

15
TREATMENT GUIDELINES

□ For women with ≥ two less prominent risk factors for VTE such as body mass
index >35 kg/m2, obesity, hypertension, autoimmune disease, heart disease,
sickle cell disease, multiple gestation, preeclampsia, gross varicose veins,
paraplegia, preterm birth, postpartum hemorrhage >1000mls/requiring
transfusion, admission/immobility ≥three days, current systemic infection.
▪ If the risk of bleeding is low, pharmacological prophylaxis may be initiated
 within 2 to 12 hours preoperatively.
▪ If the risk of bleeding is high, pharmacologic prophylaxis can be added 2 to 12
hours postoperatively, and is continued until the woman is fully ambulating
or up to six days in women with significant risk factors.
□ Enoxaparin (Clexane) 40 mg subcutaneous injection daily (0.5 mg/kg every 12
hours for BMI>40; maximum single dose should not exceed 150 mg) OR □
Unfractionated heparin 5000 units subcutaneous injection daily (every eight
hours for BMI>40)
□ Patients who require prolonged anticoagulation can be switched over to an
oral agent i.e. warfarin

Intraoperative preparation
■ Skin preparation
For abdominal surgical site: scrub with a chlorhexidine-alcohol or with povidone
iodine-alcohol skin preparation
For vaginal preparation: scrub with povidone-iodine; avoid alcohol based in the
vagina because alcohol irritates mucous membranes
■ Drapes: The surgical site should be draped with non-adhesive drapes

Postoperative care
■ Patient monitoring:
Blood pressure, pulse rate, respiratory rate, uterine tone, vaginal and incisional site
bleeding, and urine output should be monitored closely.
■ Laboratory testing:
Postoperatively should be individualized depending on the anticipated complications
or complications noted upon evaluation
■ Analgesia:
Postoperative pain control after surgery should be employed to promote rapid
recovery. Either or in combination of Pethidine, Paracetamol, Diclofenac and Tramadol ■
Input and output monitoring
Bladder catheter removal should be as soon as possible after ambulation to minimize
the risk of infection except for specific indication.
■ Diet:
Oral intake is encouraged after 8 hours postoperatively; it may be delayed in some
specific condition.

16
Obstetric and Gynaecological Disorders

■ Lifting:
Patients can avoid lifting of heavy objects from the floor for four to six weeks following
abdominal surgery to minimize stress on the healing fascia.
■ Exercise:
Patient may start and slowly increase aerobic training activities, depending on their
level of discomfort and postoperative complications. Pelvic floor muscle exercises can
reduce urinary incontinence, if present.
■ Driving:
 Patient should avoid driving if they are taking opioids or other sedatives or if they have
pain with the normal activities required of a driver (e.g., turning the body or head,
stepping on the brake/accelerator, steering).
■ Breastfeeding
After caesarean section breast feeding can be initiated in the operating delivery room,
when appropriate
■ Wound care:
Stitch should be removed after seven days except for special indications e.g.
repaired burst abdomen, septic wound with pus discharge before seven days or in
cases where absorbable sutures were used.
Postoperative showering within 48 hours of surgery in patients with surgical
wounds dressed with water proof plaster.

OBSTETRIC HAEMORRHAGE

Antepartum haemorrhage

Definition
Antepartum Haemorrhage (APH) is defined as bleeding from the genital tract occurring
from 28 weeks of pregnancy and prior to delivery.

The bleeding can be spotting, minor, major or massive hemorrhage

■ Spotting – staining, streaking or blood spotting noted on underwear or sanitary
protection
■ Minor haemorrhage – blood loss less than 50 ml that has settled
■ Major haemorrhage – blood loss of 50–1000 mls, with no signs of clinical shock ■
Massive haemorrhage – blood loss greater than 1000 mls and/or signs of clinical shock

Etiology and Risk factors

■ The main causes are bleeding from the placenta site including placenta praevia and
abruption placenta.
■ Other causes of APH includes vasa praevia and local causes such as bleeding from the
vulva, vagina and cervix. These include cervical polyp, dysplasia, cervicitis, cervical
carcinoma, varicose vein and local trauma.
17
TREATMENT GUIDELINES

Placenta Praevia
It is an obstetric complication in which the placenta embeds itself partially or wholly in the
lower segment of the uterus.

Risk factors
■ Previous placenta praevia
■ Previous caesarean sections
■ Previous termination of pregnancy
■ Increasing parity
■ Advanced maternal age (>40 years)
■ Multiple pregnancy
■ Smoking (Active or Passive)
■ Assisted conception
■ Deficient endometrium due to presence or history of:
Previous uterine surgical procedure
Endometritis
Previous Manual removal of placenta
Submucosal fibroids

Clinical presentation
■ Sudden onset of bright red fresh painless unprovoked bleeding after 28 weeks of
gestation but it may be an incidental sonographic finding
■ Foetal heart tone usually heard
■ Foetus often presents high, pushed up by the placenta, uterus is soft

Investigation
■ Full blood picture
■ Blood group and Rh
■ Blood coagulation tests
■ Ultrasound for fetal wellbeing and localization of the placenta and grading

Treatment
■ If asymptomatic
Bed rest and follow up every 2 weeks until ≥ 37 weeks
Give 60 mg of elemental iron and 400 micrograms (0.4mg) of folic acid supplements
Follow up ultrasound for fetal wellbeing and localization of the placenta ■ For minor
hemorrhage:
Admit for expectant management
Avoid vaginal examination
Blood grouping and retain in case of need.

18
Obstetric and Gynaecological Disorders

Ensure that the patient has hemoglobin level above 11.7g/dl

Give prophylaxis anti-D immunoglobulin 300mcg if the patient is Rh negative Give
Dexamethasone 6 mg IM every 12 hours for 48 hourly to enhance fetal lung
maturation if <34 weeks of gestation
Provide Tocolytics if there are uterine contractions for allowing lung maturation: □
Magnesium Sulphate 4-6gm (IV) loading dose and maintenance 1-2gms per hour
for 48hours
OR
□ Nifedipine short acting 20mg (PO) start, then continue with long acting
Nifedipine 20mg every 8 hourly for 48hours.
Follow up ultrasound for fetal wellbeing and localization of the placenta every 2
weeks
Delivery should be aimed after completed 37 weeks
 Reassess for mode of delivery at 37 completed weeks
Vaginal delivery may be indicated for grade I and IIA
Carefully perform amniotomy for vaginal delivery, if the head is engaged Deliver
by caesarean section for placenta praevia grade IIB and grade III In case of any
hemorrhage, the patient should report to the health provider for immediate
assessment and action
■ For major and massive bleeding
Assess for airway, breathing and circulation
Give Oxygen if required
Obtain intravenous access, two large borehole cannular
Give 3000 mls of Crystalloids – fast and then reassess. Aim to replace 1.5 to 3
times of the blood loss until blood is secured.
Insert a urethral catheter and monitor urine output aiming at 30ml/hour
ABO grouping and cross match
Give blood transfusion depending on the amount of blood loss
Deliver by emergency caesarean section

Follow up
Follow post-operative and postnatal guideline below

19
TREATMENT GUIDELINES

Placental Abruption
It is one form of antepartum haemorrhage where the bleeding occurs due to partial or complete
premature separation of a normally situated placenta.

Types of placenta abruption:

■ Revealed: This is the most common type whereby the blood comes out of the cervical
canal to be visible externally.
■ Concealed: The blood is collected and prevented from coming out of the cervix. At times
the blood may percolate into the amniotic sac after rupturing the membranes. ■ Mixed: This
is also quite common whereby some part of the blood collects inside (concealed) and a part
is expelled out (revealed).

Risk Factors
■ Abruption in previous pregnancy
■ Chronic hypertension and pre-eclampsia
■ Fetal growth restriction
■ Non vertex presentation
■ Multiple pregnancy
■ Polyhydramnios
■ Intrauterine infection
■ Premature rupture of membranes
■ Multiparity
■ Low body mass index (<18.5).
■ External cephalic version
■ Uterine defects e.g. Myoma
■ Pregnancy following assisted reproductive techniques
■ Advanced maternal age
■ Abdominal trauma (both accidental and resulting from domestic violence) ■
Smoking
■ Drug misuse (Cocaine and Amphetamines) during pregnancy.

Clinical presentation
■ Abrupt onset of per vaginal bleeding. In other cases, there may be no external bleeding or
blood stained liquor may be evident.
■ Continuous abdominal pain
■ Loss of foetal movements
■ Tense and tender uterus
■ Maternal hemodynamic instability due to blood loss, rapid pulse, low or undetectable
blood pressure, tachypnea, pallor
■ Non reassurance of foetal status or foetal demise

20
Obstetric and Gynaecological Disorders

General management
■ Emergency management
Ensure airway is patent and normal breathing pattern; Give Oxygen as required
Obtain Intravenous access, two large borehole cannula
Give 3000mls of Crystalloids – fast and then reassess. Aim to replace 1.5 to 3 times
of the blood loss until blood is secured.
Perform Bedside clotting time
Do FBC and Blood group and Cross match at least 4 units of whole blood and 2
Fresh frozen plasma, Blood coagulation tests, Renal function test, Liver function
test
Give blood transfusion depending on the amount of blood loss
Transfuse blood if necessary
Insert a urethral catheter and monitor urine output aiming at 30ml/hour ■ If
prolonged clotting time and or Disseminated Intravascular Coagulation: Give fresh
frozen plasma 15mls/Kg: 1 unit for every 4-6 units of whole blood If there is evidence
of thrombocytopenia, give 6 units of platelet concentrates ■ Monitor blood pressure,
pulse, vaginal bleeding hourly, clotting time every 2 hour
 Obstetrical management
■ Vaginal delivery is preferable
■ If in labour: Perform artificial rupture of membrane, then augment labour with Oxytocin ■
If no spontaneous labor: Induce labour with mechanical, medical and surgical means
depending on the situation
■ Provide adequate analgesia: Pethidine, Morphine and Diclofenac ■ Do active management
of third stage of labor and frequent monitoring of tonicity of the uterus every 15 minutes for
the first 2 hours
■ Provide prophylactic antibiotics
■ Emergency CS should be considered if:
Foetus is alive and viable
Worsening of maternal condition
Poor progress of labour
If there is obstetric indication

Follow up
Follow post-operative and postnatal guideline below

21
TREATMENT GUIDELINES

POSTPARTUM HAEMORRHAGE (PPH)

Definition
Postpartum Haemorrhage (PPH) refers to blood loss of 500 ml or more during puerperium.
It is considered as severe PPH when the blood loss is 1000 ml or more within the same
timeframe.

Classification of PPH
■ Primary PPH occurs within 24 hours of delivery
■ Secondary PPH occurs between 24 hours and six weeks postpartum

Etiology and risk factors

■ Traumatic site (“Trauma”): uterine rupture, cervical tear, vaginal tear, perineal tear ■
Placental site uterine atony (“Tone”): prolonged labour, increasing parity, oxytocin
withdrawal, uterine over distension, multiple pregnancy, polyhydramnios, macrosomia. ■
Retained products of conception (“Tissue”): placenta praevia, placenta accreta, uterine
inversion
■ Bleeding disorder (“Thrombin”): severe preeclampsia, thrombocytopenia, disseminated
intravascular coagulation, placental abruption, sepsis, IUFD, hereditary bleeding
Clinical presentation
■ Excessive and/or ongoing blood loss after delivery measured by visual estimation of blood
loss, weighing drapes, pads and swabs
■ Clinical signs of shock: tachycardia, low or undetectable blood pressure, tachypnea, pallor

Management of primary PPH

Emergency management
The successful management of PPH requires a multidisciplinary team approach including
obstetric and midwifery staff and other clinicians

Resuscitation
■ Immediately call for help
■ Assessment of airway and breathing - ‘ABC’ approach
■ Secure two large bore intravenous access and rapidly infuse 3litre of crystalloids then
reassess. Aim to replace 1.5 to 3 times of the blood loss
■ Transfuse blood if necessary
■ Insert a urethral catheter and monitor urine output aiming at 30ml/hour

22
Obstetric and Gynaecological Disorders

Investigations
■ Full blood picture
■ Blood group and Cross match
■ Bedside clotting time
■ Blood coagulation tests
■ Fibrinogen levels
■ Renal and Liver function test

Treatment
Treatment involves clinical assessment to determine the causes of bleeding, commonly known
as ‘the four Ts’ (Tone, Trauma, Tissue and Thrombin). A fifth ‘T’ has been added to emphasize the
important role of theatre and surgery in managing all causes of PPH.

■ Tone (Uterine atony)

Uterine massage and/or bimanual uterine compression.
Empty the bladder to enhance uterine contraction.
Give Oxytocin: 10 units by slow intravenous injection (even if already administered
for the third stage of labour) and then 20 units in 500mls of crystalloids over 2
hours.
Ergometrine: 0.5 mg by intramuscular injection; a second dose may be repeated
after 5 minutes if necessary (maximum dose of 1.0mg); in the absence of
contraindication.
Misoprostol: 1000mcg rectally or orally or 800mcg sublingual. They are the most
potent of the uterotonics but also have the most serious adverse effect profile
 which includes severe hypertension and bronchospasm.
Carboprost (15-methyl-PGF2α): Intramuscular injection of 0.25mg, in repeated
doses as required at intervals of not less than 15 minutes to a maximum total
cumulative dose of 2.0mg (up to 8 doses).
Tranexamic Acid: 1g intravenously can be used when uterotonics fail to control
bleeding and when the bleeding is partly due to trauma; the dose may be repeated
after 30 minutes if bleeding persists.

Note: Pharmacological treatment can be administered either singly or in combination depending

on severity and response to treatment.

■ Trauma of the genital tract

Thorough assessment of the entire genital tract (perineum, vagina and cervix) for
bleeding sources.
Apply pressure to bleeding areas.
Repair first and second degree perineal tears either in the labour ward. Repair
cervical tear; third and fourth degree perineal tears in the operating theatre. If the
patient is shocked and the amount of vaginal bleeding is normal, consider
intra-abdominal sources such as ruptured uterus, broad ligament haematoma,
subcapsular liver rupture.

23
TREATMENT GUIDELINES

■ Tissue (retained products of conception)

Commonly due to retained placenta, cotyledon or membranes.
Assess for obvious missing placental tissue.
If the placenta has not been delivered, perform manual removal of the placenta.
Uterine exploration is indicated for all cases of persistent PPH.

■ Thrombin (abnormalities of coagulation)

Replacement of platelets and clotting factors, if indicated.
□ Cryoprecipitate or fibrinogen concentrate, if available where the fibrinogen
level is < 1.5-2g/l.
□ Give fresh frozen plasma 15mls/Kg: 1 unit for every 4-6 units of whole blood □
If there is evidence of thrombocytopenia, give 6 units of platelet concentrates
Tranexamic acid 1gm intravenously; the dose may be repeated after 30 minutes if
bleeding persists
Management of specific abnormalities such as Von Willebrand’s disease or severe
thrombocytopenia in collaboration with haematologists.

■ Theatre (Surgical intervention)

Uterine and/or vaginal balloon tamponade
Hemostatic brace suture application (i.e. B-Lynch or Hayman compression suture).
Bilateral ligation of uterine arteries
Bilateral ligation of internal iliac arteries
Selective arterial embolization
Hysterectomy in cases of uterine rupture, placenta accreta or uncontrolled massive
haemorrhage.

Treatment of Secondary PPH

■ Secondary PPH is usually associated with endometritis (with or without retained products
of conception)
■ Conventional treatment usually includes antibiotic therapy and uterotonics ■
In case of excessive or continued bleeding evacuation should be performed ■
Hysterectomy should be considered, in case of persistent bleeding

Prevention of PPH
■ Active management of third stage of labour is the cornerstone for the prevention of PPH
■ This consists of the administration of a prophylactic uterotonic after the delivery of a baby
and the controlled traction of the umbilical cord during delivery of the placenta.
IM/IV oxytocin 10IU is recommended as the uterotonic drug of choice. Other
injectable uterotonics (i.e. ergometrine or combination of oxytocin and ergometrine)
Misoprostol 600mcg are recommended where oxytocin is unavailable.

24
Obstetric and Gynaecological Disorders

■ Early breast feeding

■ Surveillance of the uterine tonus through abdominal palpation and vaginal bleeding for 24
hours
■ Prophylactic uterotonics can be administered to women at risk of PPH (e.g. multiple
pregnancy, grandmultipara, abruptio placenta) after active management of third stage
of labor or for prevention of recurrent PPH.
Give Oxytocin 20 units in 500mls of crystalloids over 2 hours
Ergometrine: 0.5 mg by intramuscular injection in the absence of contraindication.
Misoprostol 600mcg rectally or orally

PRETERM LABOR

Definition
Preterm labor refers to labor that starts beyond 28 weeks of gestation and before the 37
weeks of gestation.

Risk factors
■ Preterm PROM
■ Previous history of induced or spontaneous abortion or preterm delivery ■
Pregnancy following assisted reproductive techniques
■ Genital tract infection: Bacterial vaginosis, beta-hemolytic streptococcus, bacteroides,
chlamydia, mycoplasma.
■ Acute infection or inflammation: acute pyelonephritis, acute appendicitis, asymptomatic
bacteriuria, recurrent urinary tract infection, toxoplasmosis, gastroenteritis and
abdominal operation.
■ Smoking habits
■ Low socioeconomic and nutritional status
■ Maternal stress
■ Pre-eclampsia
■ Antepartum hemorrhage
 ■ Polyhydramnios
■ Uterine anomalies
■ Cervical incompetence
■ Chronic diseases: Hypertension, nephritis, diabetes, decompensated heart lesion, severe
anemia, low body mass index (< 18.5)
■ Multiple pregnancy
■ Congenital malformations
■ Intrauterine death
■ Placental infarction, thrombosis
■ Iatrogenic: Indicated preterm delivery due to medical or obstetric complications. ■
Idiopathic

25
TREATMENT GUIDELINES

Clinical presentation
■ Pelvic pressure, backache and/or mucoid vaginal discharge or show ■
Progressive regular uterine contractions
■ Cervical changes: Dilatation (> 2 cm) and effacement (80%) of the cervix

Management

Investigations
■ Full blood count
■ Urine for routine analysis
■ High vaginal swab for culture and sensitivity
■ Fetal fibronectin
■ Ultra-sonography for fetal wellbeing, cervical length and placental localization ■
Other investigation depending on specific risk factors

Treatment
■ Initial assessment of abdominal and pelvic examination
■ Antibiotics to prevent neonatal infection with Group B Streptococcus (GBS) should be
limited to patients with PROM or positive GBS culture. Either of the following can be
used until delivery;
Ampicillin IV 2g stat, then 1g every 4 hours
Ceftriaxone 1g IV stat, then every 24 hours
Clindamycin 900mg IV every 8 hours
Vancomycin 1g IV every 12 hours
■ Careful intrapartum monitoring and inform neonatologist during delivery for proper
neonatal care.
■ Vaginal delivery is preferred, unless otherwise indicated for cesarean birth ■
If in latent phase of labor:
Dexamethasone 6mg IM 12 hourly for 48hrs; should be given even if there is
uncertainty of administration of the next dose to reduce neonatal RDS. Tocolytic
drugs:
 □ Magnesium sulfate 4gm loading dose is followed by an infusion of 1gm per hour
for 48 hours. It also has fetal neuroprotective effect when administered
before 32 weeks of gestation
□ Nifedipine short acting 20mg (PO) stat, then continue with long acting
Nifedipine 20mg every 8 hours for 48hours

26
Obstetric and Gynaecological Disorders

PRE-LABOR RUPTURE OF MEMBRANES

Definition
Pre-labor rupture of the membranes (PROM) refers to spontaneous membrane rupture
before the onset of uterine contraction any time from 28 weeks of gestation.

■ Term PROM: When PROM occurs at 37 weeks of gestation and beyond ■

Preterm PROM: When PROM occurs before 37 weeks.
■ Prolonged PROM: When PROM occurs 24 hours or more before the onset of labour

Risk factors
■ Genital tract and intrauterine infection
■ History of previous PROM and preterm labour
■ Antepartum bleeding
■ Polyhydramnios
■ Multiple pregnancy
■ Malpresentation
■ Cervical incompetence
■ Cervical length < 2.5 cm
■ Low BMI (< 18.5 kg/m2)
■ Cigarette smoking
■ Illicit drug use

Clinical presentation
Presence of vaginal leakage before the onset of labour

Sterile speculum examination

■ Direct observation of leakage of amniotic fluid coming from the cervical canal or pooling
of amniotic fluid in the posterior fornix.
■ Confirm the leakage of liquor by detection pH - Nitrazine or Litmus paper, a characteristic
of Ferning sign and Nile blue test for detection of fetal squam cells.
■ Exclude cord prolapse
 ■ Digital vaginal examination should be avoided, unless imminent delivery is anticipated ■
Remove cervical cerclage, if any.

Investigations
■ Full blood count
■ C-Reactive Protein (CRP)
■ High Vaginal Swab for microbiological examination

27
TREATMENT GUIDELINES

■ Lecithin: Sphingomyelin ratio

■ Urine for routine analysis
■ Ultrasound for foetal wellbeing

Management of Term PROM

■ Active management aiming at delivery within 24 hours
■ Induction of labor with prostaglandins or oxytocin depending of favorability of the cervix.
■ Cesarean section is performed with obstetric indications

Management of Preterm PROM

■ Late preterm PROM (34-36 weeks of gestational age) should be actively delivered ■ Early
Preterm PROM (<34 weeks of gestational age), conservative management should be used in
the absence of any maternal or fetal indications for immediate delivery. Fetal lung
maturation: Give Dexamethasone 6 mg IM every 12 hours for 48 hours Tocolysis: I/V
Magnesium Sulphate 4 gm (IV) loading dose and maintenance 1gms per hour for 48hours or
Tab. Nifedipine short acting 20mg (PO) stat, then continue with long acting Nifedipine 20mg
every 8 hours for 48hours.
Prophylactic antibiotic therapy: Clindamycin 900mg 8 hourly for 48 hours then
continue with Clindamycin 300mg 8 hourly (PO) or Erythromycin 500mg (PO) 8
hourly and or Azithromycin 1 gm (PO) once daily for 5-7 days.
Alternatively, Ampicillin IV 1g every 6 hourly for 48 hours; then continue with
Erythromycin 500mg 8hourly for 5-7 days
Abandon conservative management, If the patient has
□ Chorioamnionitis – maternal tarchycardia, pyrexia, foul smelling liquor,
leukocytosis and rising CRP
□ Non reassuring foetal status
□ Abruptio Placenta
□ Established labour
□ Severe oligohydramnious
■ Decide the mode of delivery depending on the obstetric indication ■ Induction of labour
protocol should be used after assessing the Bishop score ■ For patient with PROM of 18
hours or more, commence antibiotic treatment regime as per protocol
 28
Obstetric and Gynaecological Disorders

RECURRENT PREGNANCY LOSS

Definition
Recurrent Pregnancy Loss (RPL) is defined as the loss of two or more confirmed
pregnancies. It excludes ectopic pregnancy and molar pregnancy

Primary RPL is described as RPL without a previous pregnancy (viable pregnancy) beyond
28 weeks of gestation, while secondary RPL is defined as an episode of RPL after one or
more previous pregnancies progressing beyond 28 weeks of gestation.

Risk factors

Advanced female Age (>30 years)

■ Advanced female age is a risk factor for fetal anomalies, stillbirth, and obstetric
complications.

Stress
■ RPL is associated with stress, but couples should be informed that there is no evidence
that stress is a direct cause of pregnancy loss.

Smoking
■ Smoking, both active and passive, strongly associated with adverse obstetric and neonatal
outcomes, including ectopic pregnancy, stillbirth, placenta praevia, preterm birth, low
birth weight and congenital anomalies.

Obesity
■ Increased body mass index (BMI) is associated with sub-fertility, poorer outcomes
following fertility treatment, and pregnancy loss.

Alcohol
■ Couples with RFL should be informed that excessive alcohol consumption is a possible risk
factor for pregnancy loss and proven risk factor for fetal problems (Fetal alcohol
syndrome)
■ Couples with RFL should be advised to limit alcohol consumption from preconception
period.

Causes
 Genetics/ Chromosomal abnormalities
■ Trisomies
■ Congenital malformation

29
TREATMENT GUIDELINES

Haematological disorders
■ Rh incompatibility
■ Thrombophilia (hereditary or acquired)

Immunological factors
■ Antiphospholipid syndrome
■ Systemic Lupus Erythromatosus – SLE

Endocrinological factors
■ Diabetes Mellitus
■ Polycystic Ovarian Disease
■ Thyroid Antibodies and disease
■ Hyperprolactinemia
■ Luteal phase defect

Uterine abnormalities
■ Congenital- septate, bicornuate
■ Intrauterine adhesions
■ Submucosal myoma
■ Endometrial polyps
■ Cervical factor (Cervical incompetence)

Infections
■ Listeria, Cytomegalovirus and Toxoplasma
■ Primary genital herpes has been proven as cause of sporadic abortion but not as cause of
RPL

Management

Work up
■ Evaluation should be individualized depending on each woman’s or couple’s:
Age
Fertility/sub-fertility
Pregnancy history
Family history
Previous investigations and/or treatments
■ Medical and Family history
 Provide time and opportunity for discussion and be sensitive to the patient’s
experience
The history should include medical, obstetric, family history and information on
lifestyle of both the male and female partner.

30
Obstetric and Gynaecological Disorders

Previous diagnosis of medical conditions should include thrombophilia, PCOS, and

diabetes, or a family history of hereditary thrombophilia.
Inquire details of the circumstances associated with the previous pregnancy losses.
■ Investigations
Reproductive hormonal profile: Prolactin, Anti-Mullerian Hormone, Follicle
Stimulating Hormone
Thyroid Hormones profile: TSH, T3 & T4
Immunological Tests: Anticardiolipin Antibody (ACL), Lupus Anticoagulant (LAC),
Human Leucocyte Antigen - HLA class II, Anti-nuclear Antibodies – ANA
Karyotyping: To rule out balanced reciprocal or Robertsonian translocations or
mosaicism that could be passed to the fetus unbalanced
Sperm DNA fragmentation: Assessment can be more relevant in males with
unhealthy lifestyles (smoking, alcohol, excessive exercise, unhealthy body weight)
(indirect evidence from infertile couples)
Genetic Analysis of Pregnancy Tissue: Detection of developmental and genetic
abnormalities for explanatory purposes rather than routine purposes.
Thrombophilia screening: Hereditary Thrombophilia includes Factor V Leiden
mutation, Prothrombin mutation, Protein C, Protein S and Antithrombin
deficiency, while acquired Thrombophilia refers to Antiphospholipid syndrome
(APS)-(Lupus Anticoagulant (LA), Anticardiolipin Antibodies (ACA: IgG and IgM),
and β2 Glycoprotein I Antibodies (anti-β2GPI: IgG and IgM).
Fasting blood sugar to rule out Diabetes Mellitus
Uterine anomalies screening: Ultrasound – serial cervical sonographic surveillance,
preferably 3D for detecting uterine malformations, Hysterosalpingography (HSG)
can detect uterine malformations with intrauterine adhesions. MRI – to detect
malformations

Treatment plan
The treatment plan depends on the underlying causes of RPL such as:
■ Cervical Insufficiency:
Cervical cerclage is used to prevent preterm birth in women with previous preterm
birth and short cervix revealed at ultrasound examination.
■ Uterine anomalies:
Intrauterine adhesion (Asherman syndrome) - Hysteroscopic removal of
intrauterine adhesion. Precaution have to be taken to prevent recurrence of
adhesions (insertion of IUCD)
Submucosal myoma and Endometrial polyps – hysteroscopic removal of submucosal
fibroids and endometrial polyps
Congenital uterine abnormalities - Metroplasty (transabdominal or laparascopic) is
the only option for bicornuate uterus and septate uterus – hysteroscopic
metroplasty is the treatment of choice.
 31
TREATMENT GUIDELINES

Metabolic or Endocrinological abnormalities - Bromocriptine for prolactin (RPL)

associated with hyperprolactinemia Metformin/Insulin-improves pregnancy
outcome with polycystic ovarian syndrome or Insulin resistance.
Luteal phase insufficiency - Progesterone or Human Chorionic Gonadotrophin can
be used.
Thyroid abnormalities; subclinical hypothyroidism - TSH level should be checked in
early gestation 7-9 weeks overt hypothyroidism arising before conception or
during early gestation should be treated with levothyroxine.
Immunological disorders - Women with antiphospholipid antibodies Low Molecular
Weight Heparin (LMWH) combined with low dose of Aspirin starting as soon as 6
weeks. Administration of low dose Aspirin 75mg nocte starting before
conception with a prophylactic dose of Unfractionated Heparin (UFH) or LMWH
starting at the date of positive pregnancy test until delivery is recommended.
■ Anticoagulant regimens:
Prophylactic UFH 5,000-10,000 OR LMWH (Enoxaparin) 30-40 mg SC daily OR
Dalteparin 2,500-5,000 IU SC daily starting in first trimester.
■ Folic acid and vitamins:
Folic Acid and vitamin supplementation to prevent neurotube disorders Couples with
results abnormal fetal or parental karyotype should receive genetic counseling.

32
Obstetric and Gynaecological Disorders
 HYPERTENSIVE DISORDERS IN PREGNANCY
Hypertensive disorders in pregnancy refers to elevation of blood pressure (BP) of 140/90
mmHg or greater, measured on two occasions at least four hours apart during pregnancy

Elevated systolic BP >30mmHg, or diastolic BP 15mmHg from the baseline warrant close
observation.

Gestational Hypertension

Definition
▪ Blood pressure elevation after 20 weeks of gestation without proteinuria or systemic
findings including thrombocytopenia impaired liver function, new development of
renal insufficient, pulmonary edema and new onset of cerebral or visual disturbance.

▪ Evidence of pre-eclampsia/eclampsia and hypertension that resolves by 12 weeks of

postpartum period.

Management approach
■ Asymptomatic patient (Diastolic BP ≥ 90mmHg but < 110mmHg or Systolic BP ≥
140mmHg but < 160mmHg), can be managed as an outpatient. Repeat blood pressure
after resting for at least 4 hours; and within two days
■ If still ≥ 90mmHg but < 110mmHg [or systolic BP still 140-159mmHg, start treatment
with Methyldopa tablets 500mg orally 8 hourly
■ Make note on antenatal card and review within 1 week to ensure BP control and check for
proteinuria
■ Do Umbilical Artery Doppler test, if gestation ≥ 28 If the Doppler is normal and the blood
pressure is controlled, continue with follow up on antenatal clinic with the following
advice:
Follow up in every two weeks until 34 weeks, then every week
Maintain diastolic blood pressure at 90 - 100mmHg
Plan for delivery at 38 weeks
■ If BP is uncontrolled (diastolic BP > 100mmHg but < 110mmHg) and no proteinuria
increase Methyldopa to 750mg orally 8 hourly and review in 1 week.
■ If BP is still uncontrolled (diastolic BP > 100mmHg but < 110mmHg) and no proteinuria, if
appropriate add a second antihypertensive agent, Nifedipine tabs 20mg orally 12
hourly and review the patient in 1 week.
■ If the blood pressure is controlled, continue with follow up on antenatal clinic as
scheduled aiming for delivery at 38 weeks
■ If the blood pressure is still uncontrolled (diastolic BP > 100mmHg but < 110mmHg) and
no proteinuria, add a possible third line antihypertensive drug, Hydralazine tablets
25mg orally 8 hourly and/or plan for delivery

33
TREATMENT GUIDELINES

■ If at any stage a new onset proteinuria with no features of end organ damage noted,
schedule antenatal visits every 2 weeks up to 32 weeks and every week thereafter.
 Delivery should be planned at 37 completed weeks of gestation, and the mode of
delivery will depend on obstetric indications
■ Admit if the BP is uncontrolled with Diastolic BP ≥ 110mmHg for monitoring, control of
BP and plan for delivery.
■ Methyldopa 500mg 8 hourly and /or Nifedipine 10-20mg orally 12 hourly ■ If BP ≥
160/110 mmHg or higher, Hydralazine 10mg IV start; recheck the BP after 20 minutes if
DBP≥110mmHg give another dose of Hydralazine 5-10mg IV.
■ Consider Labetalol if the Blood Pressure is not controlled by Methyldopa, Nifedipine and
Hydralazine
■ If the patient is at risk of delivery before 34 weeks, corticosteroids should be given for
fetal lung maturation; Dexamethasone IM 6mg 12 hourly for 48 hours

Pre-eclampsia

Definition
■ Pre-eclampsia refers to a new onset of hypertension and proteinuria OR hypertension
and end organ dysfunctions with or without proteinuria after 20 weeks of gestation in
a previous normotensive woman.
■ The diagnostic criteria include systolic blood pressure ≥140 mmHg or diastolic blood
pressure ≥ 90 mmHg on two occasions at least four hours apart after 20 weeks of
gestation in a previously normotensive patient AND the new onset of one or more of
the following:
Proteinuria ≥ 0.3gm (a 24 hours’ urine specimen) or protein/creatinine ratio ≥ 0.3 (a
random urine specimen) or dipstick ≥1+
Platelet count <100,000/µL
Serum creatinine > 97.2 µmol/L or doubling in the absence of other renal disease
Uric acid > 0.35mmol/L
Liver transaminases at least twice the upper limit of the normal concentrations
Pulmonary edema
Cerebral or visual symptoms (e.g. new-onset and persistent headaches not
responding to usual doses of analgesics; blurred vision, flashing lights or sparks,
scotomata)

Preeclampsia without severe features

Pre-eclampsia at any stage with a new onset proteinuria but without features of end organ
damage is referred as Pre-eclampsia without severe feature

34
Obstetric and Gynaecological Disorders

Preeclampsia with severe features:

Refers to preeclampsia with the presence of one or more of the following:
■ Severe blood pressure elevation - Systolic blood pressure ≥160 mmHg or diastolic blood
pressure ≥110 mmHg on two occasions at least four hours apart while the patient is on
 bed rest
■ New-onset visual disturbance
■ Severe headache i.e. incapacitating or persists and progresses despite analgesia ■ Hepatic
abnormality such as severe persistent right upper quadrant or epigastric pain not accounted
for by an alternative diagnosis
■ Serum transaminase concentration ≥ 2 times the upper limit of the normal range ■
Thrombocytopenia: <100,000 platelets/L
■ Renal abnormality: progressive renal insufficiency (serum creatinine > 97.2 µmol/L) or a
doubling of the serum creatinine concentration in the absence of other renal disease ■
Pulmonary edema

Note: The quantity of proteinuria and fetal growth restriction have been eliminated from the
consideration of preeclampsia as severe disease.

Management - Preeclampsia without severe features

■ Schedule antenatal visits every 2 weeks up to 32 weeks and every week thereafter. ■ Do
FBP, serum creatinine, urea, uric acid, ALT, AST, LDH and Doppler USS if gestation ≥ 28
weeks.
■ Start treatment with Methyldopa tablets 500mg 8 hourly
■ Admit to the antenatal ward for initial evaluation, close monitoring and immediate
intervention if develops severe features
■ Delivery should be planned at 37 completed weeks of gestation, and the mode of delivery
will depend on obstetric indications
■ Early delivery may be indicated in case of onset of severe feature of pre-eclampsia ■ If the
patient is less than 34 weeks, corticosteroids should be given to enhance fetal lung
maturation; Dexamethasone IM 6 mg 12 hourly for 48 hours prior to delivery ■ If at term
deliver immediately when stable, preferably vaginal delivery

Management - Pre-eclampsia with severe features

■ Assess for the general condition of the patient; level of consciousness, for airway patency,
breathing pattern, maintain circulation
■ Control BP (refer management of pre-eclampsia without severe features) ■ Admit to the
antenatal ward for initial evaluation, close monitoring and immediate intervention including
control of BP and delivery plan.
Give Tabs Methyldopa 500mg orally 8hrly and / or Tab Nifedipine tablets 20 mg
orally 12 hourly

35
TREATMENT GUIDELINES

■ If diastolic BP ≥110mmHg
Give Nifedipine 10 mg sublingual or Hydralazine IV 10mg bolus, repeat the dose
after 20 minutes if DBP is still ≥110mmHg (maximum dose 30mg of Hydralazine) If
BP is refractory to Hydralazine, give Labetalol 10–20 mg intravenously bolus repeat
each 10–20 minutes, with doubling doses not exceeding 80 mg in any single dose for
maximum total cumulative dose of 300 mg.
■ If the blood pressure is still uncontrolled, add Hydralazine tablets 25mg orally 8 hourly ■
Consider Labetalol tablets 100mg orally 12 hourly, if the Blood Pressure is not controlled by
Methyldopa, Nifedipine and Hydralazine.
■ Prevent convulsion:
Give Magnesium Sulphate (MgSO4): loading dose 4gm of 20% MgSo4 infusion
slowly over 5 minutes continue with MgSO4 maintenance dose 1gm per hour for
24 hours.
The continuation of maintenance dose should only be given if: Patellar reflexes are
present, respiration rate is ≥ 12 per minute and urine output is >100mls in 4 hours. ■ Timing
of delivery:
Deliver soon after maternal stabilization irrespective of gestational age. If the
patient is less than 34 weeks of gestation with transient laboratory abnormalities
(ALAT, ASAT, low platelets), controlled BP in 24 to 48 hours, expectant management
can be considered.
Corticosteroids should be given to enhance fetal lung maturation; Dexamethasone
IM 6mg 12 hourly for 48 hours; and deliver thereafter.
■ Conditions to abandon expectant management:
Maternal hemodynamic instability (shock)
Non-reassuring fetal status
Persistent severe hypertension unresponsive to medical therapy
Severe headache or persistent progressive headache
Visual disturbance
Epigastric/right upper quadrant pain
Eclampsia
Pulmonary edema
Renal failure with a marked rise in serum creatinine and / or urine output less than
30 mL/hour for two hours
Placental abruption
Laboratory abnormalities including: Elevated aminotransferases over 12 – 24 hours
to twice the upper limit of normal, progressive decrease in platelet count to less
than 100,000 cells/µL and coagulopathy in the absence of an alternative
explanation
Preterm labor or Preterm prelabor rupture of membranes
Maternal request for immediate delivery
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)

36
Obstetric and Gynaecological Disorders

Eclampsia
Eclampsia refers to the occurrence of new onset of generalized tonic clonic seizures and/or
coma in a woman with preeclampsia that cannot be attributed to another cause. Eclampsia may
occur without prior elevation of BP and proteinuria

Investigations
■ Full blood count and cross-match
■ Serum Urea, creatinine and electrolytes
■ Liver enzymes tests; blood glucose
 ■ Blood slide for Malaria parasites
■ Urine for protein
■ Clotting profile
■ Obstetric Ultrasound (in case of dilemma of the fetal status)

Treatment
■ Assess the general condition of the patient; level of consciousness, airway patency,
breathing pattern and maintain circulation
■ Control BP (refer management of pre-eclampsia)
■ Manage convulsions with anticonvulsant:
Magnesium Sulfate (MgSO4): loading dose 4g of 20% MgSO4 intravenous slowly
over 5 minutes (should be given only to patients that have not started Magnesium
Sulphate at the referring site).
Continue with MgSO4 maintenance dose infusion 1gm per hour up to 24 hours
post-delivery or after last fit, whichever comes last.
The continuation of maintenance dose should only be given if patellar reflexes are
present, respiration rate is ≥ 12 per minute, and urine output is >100mls in 4 hours.
If convulsions recur when the patient is on maintenances give additional bolus of 2gm
of 20% MgSO4 and continue with maintenance dose
If two such additional boluses do not control seizures, consider the use of Diazepam
IV 5-10mg or Midazolam IV 1-2mg bolus
■ Observe for signs of Magnesium Sulphate toxicity that include
reduced patellar reflexes
respiratory depression (RR < 12 per minute)
reduced urine output (< 100ml in 4 hours)
cardiac arrhythmia/arrest.
Antidote for magnesium sulfate toxicity is Calcium gluconate 1g slow IV bolus in 2
to 3 minutes
■ Patients with eclampsia should be delivered within 12 hours after the onset of seizures,
even if the foetus is premature.
■ Vaginal delivery is the preferred method unless there is a contraindication for vaginal
delivery.

37
TREATMENT GUIDELINES

■ If the patient is already in labor, augment with oxytocin infusion to accelerate delivery. ■ If
not in labour, perform Bishop Score to assess the success of induction of labor. Proceed with
induction of labor, if favorable (Bishop Score > 7).
■ Caesarean section is indicated in cases of failed induction of labor, poor Bishop Score
(score <7) and those with obstetric indication.

Chronic Hypertension

Definition
■ Chronic hypertension refers to hypertension diagnosed in women with documented
blood pressures ≥ 140/90 mmHg before pregnancy and/or before 20 weeks of gestation. ■
Newly detected chronic hypertension should require further evaluation to find underlying
 cause e.g. renal artery stenosis, chronic renal disease, Cushing syndrome etc.

Management
■ Investigation
FBP
ALAT, ASAT, Serum Creatinine, BUN
Echocardiogram, ECG
Obstetric Ultrasound for fetal surveillance
Women with features suggestive of secondary hypertension should be refer to
physician.
■ Asymptomatic patients can be managed as an outpatient
■ Review prior prescribed antihypertensive to minimize fetal adverse effect. ■ in newly
diagnosed patients, start treatment with Methyldopa tablets 500mg orally 8 hourly
■ Make note on antenatal card and review within 1 week to ensure BP control and check for
proteinuria
■ If blood pressure is well controlled, continue with follow up on antenatal clinic with the
following advice:
Follow up is every two weeks until 34 weeks, then every week
Maintain systolic BP at 130-150mmHg and diastolic blood pressure at 90
-100mmHg
Plan for delivery at 38 weeks
■ If blood pressure is uncontrolled (diastolic BP > 100mmHg but < 110mmHg) and no
proteinuria increase Methyldopa to 750mg orally 8 hourly and review in 1 week. ■ If blood
pressure is still uncontrolled (diastolic BP > 100mmHg but < 110mmHg) and no proteinuria,
if appropriate add a second antihypertensive agent, Nifedipine tabs 20mg orally 12 hourly
and review the patient in 1 week.
■ If the blood pressure is controlled, continue with follow up on antenatal clinic as
scheduled aiming for delivery at 38 weeks

38
Obstetric and Gynaecological Disorders

■ If the blood pressure is still uncontrolled (diastolic BP > 100mmHg but < 110mmHg) and
no proteinuria, add a possible third line antihypertensive drug, Hydralazine tablets
25mg orally 8 hourly and/or plan for delivery

Chronic Hypertension with superimposed pre-eclampsia

Definition
Refers to a new onset or worsening of baseline hypertension accompanied by new onset of
proteinuria or other features of end organ damage.

Management
■ Investigations
Full blood count
Blood group and Rhesus factors
Serum Urea, creatinine and electrolytes
 Liver enzymes tests; blood glucose
Blood slide for Malaria parasites
Urine for protein
Clotting profile
Obstetric Ultrasound
■ Treatment (refer to pre-eclampsia)

39
TREATMENT GUIDELINES

PERIPARTUM CARDIOMYOPATHY
Peripartum cardiomyopathy (PPCM) is a pregnancy associated idiopathic condition secondary
to marked left ventricular systolic dysfunction (LVEF of less than 45%) that presents towards
the end of pregnancy through the first five months following delivery.

Risk factors
■ Age greater than 30 years
■ Genetic predisposition
■ Multiple pregnancy
■ Preeclampsia, Eclampsia, or Gestational hypertension
■ Diabetes Mellitus
■ Subclinical cardiac dysfunction
■ Maternal cocaine abuse
■ Long term (>4 weeks) oral tocolytic therapy with beta adrenergic agonists such as
terbutaline

Clinical manifestations
■ PPCM presentations are variable and similar to those in other forms of systolic heart
failure due to cardiomyopathy.
■ Common symptoms include dyspnea, cough, orthopnea, paroxysmal nocturnal dyspnea,
pedal edema and hemoptysis
■ Signs includes elevated jugular venous pressure, displaced apical impulse with a third
heart sound and a murmur of mitral regurgitation
■ Signs and symptoms of systemic or pulmonary thromboembolism may be present

Diagnosis
■ Diagnosis of PPCM is based upon three clinical criteria
Development of heart failure (HF) toward the end of pregnancy or within five
months following delivery
Absence of another identifiable cause of HF
Left ventricular systolic dysfunction with an ejection fraction (LVEF) <45 percent ■
PPCM is a diagnosis of exclusion. Some pre-existing cardiac lesions may become manifested
during pregnancy due to pregnancy-associated hemodynamic changes. Pre-existing
cardiomyopathy
Pre-existing acquired or congenital valvular heart disease
Pre-existing undetected congenital heart disease
Diastolic heart failure due to hypertensive heart disease
Hypertensive heart disease including preeclampsia and eclampsia
Myocardial infarction
Pulmonary embolus

40
Obstetric and Gynaecological Disorders

Thyrotoxicosis
Maternal sepsis

Management
PPCM management requires multidisciplinary team approach including Obstetrician,
Cardiologist, Pulmonologist, Paediatrician, Anaesthesiologist and Intensivist.

Investigations
■ Full blood picture
■ Serum creatinine, urea, electrolytes
■ Liver function test
■ Cardiac enzymes, including troponin
■ Thyroid stimulating hormone, T3, T4
■ Electrocardiogram (ECG)
■ Echocardiogram
■ Chest X-ray
■ In selected cases, cardiac magnetic resonance (CMR) imaging, cardiac catheterization,
coronary angiography, Plasma Brain natriuretic peptide (BNP) or N-terminal pro-BNP
and endomyocardial biopsy (EMB) may be helpful.
 Treatment
■ Treatment of PPCM is similar to that employed for other types of HF with left ventricular
systolic dysfunction with some modifications to standard therapy to ensure the safety
of the mother and the unborn or breastfeeding child.
■ Additional therapeutic issues include arrhythmia management, anticoagulation therapy,
mechanical support and investigational therapies.
■ Heart failure treatment include:
Supplemental oxygen and assisted ventilation as needed
Diuretics: Furosemide intravenously or orally; 40–80 mg once a day or every 12
hours depending on the severity and response.
Vasodilators: Isosorbide mononitrate (ISMN) orally 10mg every 8 hours
β-blockers: Carvedilol orally 3.125 mg every 12 hours
Aldosterone antagonists: Spironolactone orally 12.5 mg once a day
Anticoagulants: Claxane 40mg once daily or Enoxaparin subcutaneous 40mg once
daily
■ Angiotensin converting enzymes inhibitors (ACEI) e.g. Captopril, Angiotensin receptor
blockers (ARB) e.g. Losartan and aldosterone antagonists e.g. Spironolactone, are to be
avoided, as they are contraindicated during pregnancy.
■ For women with peripartum cardiomyopathy who have delivered and are not
breastfeeding, HF should be managed using standard therapy.

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TREATMENT GUIDELINES

Delivery
■ Decisions regarding timing and mode of delivery should be based on combined inputs
from the Cardiology, Obstetrics, Anesthesiology, and neonatology services ■
Patient-specific issues, including gestational age, cervical status, fetal status, and the
potential cardiovascular impact of continuing pregnancy should be considered in timing
delivery
■ In women with PPCM with advanced heart failure (HF), prompt delivery may be required
in women with hemodynamic instability.
■ Planned cesarean delivery is preferred for women with advanced HF requiring inotropic
therapy or mechanical circulatory support.
■ If the maternal and fetal conditions are stable, early delivery is not required. ■ Intravenous
fluid infusion should be restricted; High concentrated oxytocin dose regimen (half the
volume of fluid to be used) should be employed in case of induction or augmentation of
labour to reduce the risk of fluid overload
■ Oxygen therapy may be provided when the patient in failure or when SPO2 <90% ■
Assistance of second of stage of labour should be provided with the use of vacuum extractor
■ Furosemide IV 60mg bolus dose should be given during the second stage of labour

Postnatal care
■ Breastfeeding is encouraged for a stable woman as long as it is compatible with their heart
failure medications
■ Women with PPCM should receive counseling, including the option of avoidance of
subsequent pregnancy due to the risk of relapse of PPCM, heart failure (HF), and death. ■
Sterilization procedure or use implant, intrauterine contraceptive device (IUCD) may be
considered.
■ Patients with PPCM should be continued on HF treatment and follow up plan as
scheduled in cardiology specialty.

42
Obstetric and Gynaecological Disorders

ANAEMIA IN PREGNANCY

Definition and Classification

Anaemia in pregnancy refers to hemoglobin concentration of less than 11 g/dL in the first
and third trimesters; less than 10.5 g/dL in the second trimester of pregnancy and less than
10.0 g/dL during postpartum period.

Classification
■ Mild anaemia, hemoglobin concentration between 9 to 10.5 g/dL ■
Moderate anaemia, hemoglobin concentration 7 to 8.9 g/dL
■ Severe anaemia, hemoglobin concentration less than 7 g/dL
■ Very severe anaemia, hemoglobin concentration less than 4 g/dL

Causes of anaemia
■ Deficiency anaemia (isolated or combined)
Iron deficiency
Folic acid deficiency
Vitamin B12 deficiency
Protein deficiency
■ Impaired iron intake and/ or absorption during pregnancy i.e. nausea and vomiting of
pregnancy, inflammatory bowel disease, bariatric surgery (e.g., gastric bypass) ■
Haemorrhagic
Acute: Following bleeding in early months or APH
Chronic: Hookworm infestation, bleeding piles, Blood losses from previous
pregnancies; and/or heavy and prolonged menstruation
 ■ Hereditary
Thalassemia
Sickle cell hemoglobinopathies
Hereditary haemolytic anaemias (RBC membrane defects, spherocytosis) ■ Bone
marrow insufficiency—hypoplasia or aplasia due to radiation, drugs (aspirin, indomethacin)
■ Anaemia of infection (malaria, tuberculosis)
■ Chronic disease (renal) or neoplasm

Clinical features
■ The clinical presentation depends more on the degree and chronicity of anemia ■ Majority
of the patients are asymptomatic and detected incidentally during clinical evaluation.
■ Some may present with lassitude and a feeling of exhaustion or weakness, anorexia and
indigestion; palpitation, dyspnea, giddiness and swelling of the legs.

43
TREATMENT GUIDELINES

■ Varying degree of pallor; evidences of glossitis and stomatitis; gallop rhythms; crepitation
may be heard at the base of the lungs due to congestion.

Management

Investigation
■ Full blood picture
■ Peripheral blood smear
■ Iron studies: serum ferritin, total iron binding capacity
■ Serum bilirubin
■ Stool analysis
■ Urine analysis
■ Further investigations should be done based on the clinical presentation to find out the
cause of anaemia i.e. renal panel, sickling test, bone marrow aspiration etc.

Treatment
■ The goal is to raise the hemoglobin level as near to normal as possible before delivery. ■
Treatment will depend on severity of anemia, gestational age, cause and the associated
complications
Ferrous sulfate, fumarate or gluconate tablets orally that will provide about 200 mg
daily of elemental iron
Ferrous sucrose intravenously 100 mg in 100 mL normal saline over 15 minutes;
dose can be repeated every other day depending the deficit for those who cannot
take oral iron preparations.
Elemental iron of 60 mg daily as a maintenance dose of elemental iron has to be
continued after correction of anaemia for at least 3 months following delivery to
replenish the iron stores.
■ Management of women who are intolerant to Iron tablets include:
Omitting Vitamin C
Give coated tablets
Reducing or subdivide the dose by breaking tablets in half
 Give small frequent doses
Advise consumption of meat, particularly liver (for iron) and fresh fruit (for vitamin
C) Discourage pica (consumption of ash, soil, clay, or other non-nutritive items)
Discourage iron intake with calcium or antacids
Discourage excessive consumption of tea or coffee
Advise taking iron during meals
Refer the patient to haematology clinic if, the above interventions do not work ■
Indications for referring a patient to obstetric haematology clinic Haemoglobin level
decreasing on antiretroviral therapy and haematinics Anaemia with a mean cell
volume (MCV) ≥100 fL

44
Obstetric and Gynaecological Disorders

Thrombocytopaenia other than that caused by pre-eclampsia or acute crises

Current or previous leukaemia or lymphoma
Patients who have recently received cancer chemotherapy
Other pre-existing haematological disease including Sickle cell disease, Haemophilia
■ Hospitalization for evaluation and correction of haemoglobin level should be considered
in all patients with
Very severe anaemia regardless of the gestational age
Symptomatic severe anaemia regardless of the gestational age
Moderate anaemia at 37 weeks or more
■ Blood transfusion should be considered for optimization of haemoglobin levels in patient
with
Severe anaemia in advanced pregnancy (beyond 36 weeks)
Very severe anaemia regardless of the gestational age
Symptomatic severe anaemia regardless of the gestational age
Anaemia due to blood loss following antepartum and postpartum hemorrhage
Anaemia not responding to either oral or parenteral therapy
Anaemia with bone marrow suppression (aplasia)
Severe symptoms of anaemia after ruling out vasovagal symptoms, or tiredness
post-partum
Anaemia before caesarean section (Hb <8 g/dL)
Anaemic women at high risk of haemorrhage e.g. with placenta praevia
Acute severe haemorrhage
Anaemic women who need to undergo an immediate general anesthetic
Anaemia with severe sepsis
■ Obtain specialist advice before transfusing patients with chronic haemolytic anaemias e.g.
sickle cell anaemia
■ Definitive management of specific cause of anaemia requires multidisciplinary approach.

Intrapartum care
■ Intravenous fluid infusion should be restricted; High concentrated oxytocin dose regimen
(half the volume of fluid to be used) should be employed in case of induction or
augmentation of labour to reduce the risk of fluid overload
 ■ Oxygen therapy may be provided when the patient is in failure or SPO2 <90% ■ Assistance
of second of stage of labour should be provided with the use of vacuum extractor
■ Furosemide IV 60mg bolus dose should be given during the second stage of labour ■
Avoid the use of ergometrine except in cases of PPH
■ Avoid blood transfusion intrapartum; transfuse packed RBC 24 hours after delivery; one
unit slowly over 6 hours.

45
TREATMENT GUIDELINES

Principals of Red cell blood transfusion

■ Do FBC, reticulocyte indices, red cell morphology and differential count. ■ Transfuse to
reverse symptoms or reach a satisfactory Haemoglobin level for delivery or operation (One
unit may be sufficient)
■ Reassess clinical findings and blood requirements before giving multiple transfusions ■
Patients with uninvestigated anaemia requiring transfusion, except for an acute bleed,
should in addition have blood taken for vitamin B12, red cell folate, and iron studies before
transfusion.
■ Any question of marrow aplasia or abnormal morphology must be referred to
Haematology Clinic or haematologists.
■ If giving 2 or more units in normovolaemic patients, give 40 mg furosemide IV with each
unit of blood

Prevention
■ All pregnant women should be supplemented with Ferrous sulfate, fumarate, or gluconate
tablets orally that will provide dose of 30-60 mg daily of elemental iron. ■ The supplement
has to be continued for at least 3 months following delivery to replenish the iron stores.

SICKLE CELL DISEASE AND PREGNANCY

Introduction
■ SCD is a group of inherited single-gene autosomal recessive disorders caused by the
‘sickle’ gene, which affects haemoglobin structure. Improved care of Sicklers
contributes to demand of a standardized management of Sickle cell disease in
Obstetrics.
■ The term SCD includes sickle cell anaemia (HbSS) and the heterozygous conditions of
haemoglobin S and other clinically abnormal haemoglobins.
■ Clinical presentation of SCD is a consequence of polymerization of the abnormal
haemoglobin leading to formation of rigid and fragile sickle-shaped red cells that cause
dysfunction of various body tissues hence diversity in symptomatology and severity

Clinical features
■ Jaundice and anaemia due to excessive breakdown of RBC
■ Acute painful crises due to vaso-occlusion in the small blood vessels ■
Systemic medical disorders including
■ Stroke
■ Pulmonary hypertension
■ Renal dysfunction
■ Retinal disease
■ Leg ulcers
■ Cholelithiasis
■ Avascular necrosis, commonly affecting the femoral head

46
Obstetric and Gynaecological Disorders

Management

Preconception care
■ From adolescence, pregnancy and contraception warrants monitoring by sickle care team.
■ Counselling is required to improve outcome for mother and newborn ■ Optimitise
screening for complications including end organ damage. ■ Counselling should be done on
risk of sickle cell crisis associated with dehydration, cold, hypoxia, overexertion and stress
■ Nausea and vomiting in pregnancy resulting in dehydration and the precipitation of crises
■ Risk of anaemia and acute chest syndrome
■ Increased risk of infection such as urinary tract infection during pregnancy ■
Increased risk of intrauterine growth restriction and fetal distress ■ High
likelihood of induction of labour and caesarean section
■ The chance of their baby being affected by SCD
■ Give Folic Acid 5 mg daily to reduce the risk of neural tube defect and to compensate for
the increased demand for folate during pregnancy

Antenatal care
■ Provided high-risk antenatal care in consultation with haematologist ■ Counsel the
patient to avoid precipitating factors of sickle cell crises such as exposure to extreme
temperatures, dehydration and overexertion.
■ Iron supplementation should be given only if there is laboratory evidence of iron
deficiency.
■ Women with SCD should be considered for low-dose aspirin 75 mg once daily from 12
weeks of gestation in an effort to reduce the risk of developing pre-eclampsia. ■ Antenatal
appointments for women with SCD should provide routine antenatal care as well as care
specifically for women with SCD.45
■ Thromboprophylaxis should be given to women admitted to hospital with acute painful
crisis.

Care during delivery

■ Women with SCD should be advised to give birth in hospitals that are able to manage both
the complications of SCD and high-risk pregnancies.
■ In view of the anticipated risks of SCD in pregnancy, a woman should be delivered at
38-40weeks by induction of labour, when caesarean section is not indicated. ■ Women
should be kept warm and given adequate fluid during labour. ■ Continuous intrapartum
electronic fetal heart rate monitoring is recommended owing to the increased risk of fetal
distress which may necessitate operative delivery. ■ Women with SCD should be offered
anesthetic assessment in the third trimester of pregnancy.

47
 TREATMENT GUIDELINES

■ Avoid the use of pethidine, but other opiates can be used.

■ Regional analgesia is recommended for caesarean section.
■ Maintain maternal oxygen saturation above 94% and adequate hydration based on fluid
balance until discharge.
■ Low-molecular-weight heparin should be administered while in hospital and 7 days
post-discharge following vaginal delivery or for a period of 6 weeks following
caesarean section

Care during puerperium

■ SCD at puerperium should be managed as during preconception period ■
Progesterone only contraception is recommended

MALARIA IN PREGNANCY

Introduction
Malaria is an important cause of morbidity and mortality for the pregnant woman, the foetus
and the newborn.

Malaria can be a life threatening during pregnancy, hence necessitate prevention, early
diagnosis and effective case management of malaria illness to prevent the progression of
uncomplicated malaria to severe disease and death.

Clinical presentation
■ Malaria can be asymptomatic in pregnancy or is associated with only mild and non specific
symptoms in areas with high transmission of Malaria.
■ Uncomplicated malaria refers to symptomatic malaria without signs of severity or
evidence (clinical or laboratory) of vital organ dysfunction. It may present with
Fever, chills, sweats, rigors
Headache
Joint and muscle pains
Malaise
Abdominal discomfort, vomiting, diarrhea, poor appetite
Pallor, enlarged spleen
■ Complicated (Severe) malaria refers to symptomatic malaria with one or more of vital
organ dysfunction or laboratory evidence of hyperparasitemia. It may present with:
High grade fever
Hypoglycemia
Severe haemolytic anaemia, Jaundice
Cerebral malaria: Impaired consciousness, change of behavior, convulsions
Prostration/extreme weakness

48
Obstetric and Gynaecological Disorders

Respiratory distress (due to lactic acidosis and/or pulmonary oedema)

 Bleeding tendency/DIC
Circulatory collapse/shock
Severe vomiting

Management

Investigation
■ All suspected cases of malaria should have a parasitological test to confirm malaria with
either of
Malaria rapid diagnostic test (MRDT)
Blood slide for malaria parasites for diagnosis and quantify parasitemia ■
Blood glucose level
■ Full blood cell count and differential white cell count
■ Serum creatinine, urea and electrolytes
■ Blood gases analysis
■ Lumbar puncture to exclude meningitis
■ Obstetric ultrasound for fetal surveillance

Treatment of uncomplicated malaria

■ First trimester:
Quinine sulfate tablets 10mg/kg (maximum 600mg) orally, 8 hourly for 7 days PLUS
Clindamycin tablets 300 mg orally, 8-hourly for 7 days OR
Quinine sulfate monotherapy if Clindamycin is not available OR
Artesunate or Artemisinin-based combination therapy (ACT) oral plus clindamycin
for 7 days as an alternative if quinine plus clindamycin fails or not available ■ Second and
third trimester:
Artemether+Lumefantrine (ALU) tablets 20+120 mg orally, 4 tablets per dose orally
with fatty food or full fat milk at 0, 8, 24, 36, 48 and 60 hours, making a total adult
dose of 24 tablets in 6 doses OR
Artesunate oral plus clindamycin for 7 days OR
Quinine orally plus clindamycin for 7 days
If unable to tolerate oral therapy, treat as for severe malaria as below

Treatment of complicated (severe) malaria

■ First trimester
Artesunate IV or IM, 2.4 mg/kg on admission and repeat at 12 hours and 24 hours,
then once daily until oral therapy is tolerated; complete treatment by giving a
complete course of 3 days of ALU or other ACT.
OR

49
TREATMENT GUIDELINES

Quinine dihydrochloride IV, 20 mg / kg in 5% dextrose over 4 hours as a loading

dose, then 10 mg / kg over 4 hours (starting 4 hours after the loading dose is
completed) every 8 hours until oral therapy is tolerated, if Artesunate is not
immediately available; complete treatment by giving a complete course of 3 days
 of ALU or other ACT
□ Quinine dosing should be reduced to 12 hourly dosing if IV therapy extends
more than 48 hours or if the patient has renal or hepatic dysfunction.
OR
Artemether IM, 3.2mg/kg loading dose stat, then 1.6mg/kg after 24, 48 and 72
hours.
■ Second and third trimester
Artesunate IV as above
Quinine IV should be given with caution in the second and third trimesters as it is
associated with recurrent hypoglycemia
■ Monitoring of parasitemia should be done every 12 hours in the first 3 days.

Complications
Coma (cerebral malaria): maintain airway and exclude other causes of coma (e.g. hypoglycemia,
bacterial meningitis); avoid giving corticosteroids

Hyperpyrexia: administer antipyretics i.e. Paracetamol IV 1g every 8 hours

Convulsions: maintain airways; treat with Diazepam IV, 10 mg; repeat dose if convulsions
continue, give a further dose of diazepam IV or phenobarbitone 20 mg/ kg IM or IV after
another 10 minutes

Hypoglycemia: Give 2mls/kg of 50% Dextrose OR give 6-10 mls/kg of 10% dextrose; reassess 30
minutes after every bolus; encourage oral feeding

Severe anaemia: transfusion of packed cells as in management of anaemia

Acute pulmonary oedema: Prop patient up to 45-degree angle; review fluid balance and
furosemide IV but avoiding inadequate perfusion of kidneys; Central venous pressure (CVP)
line monitoring, give oxygen. Intubation and mechanical ventilation may be necessary

Acute kidney injury: exclude prerenal causes, check fluid balance and urinary sodium. If
adequately hydrated (CVP>5cm) try diuretics. Haemodialysis /hemofiltration (or if available
peritoneal dialysis) should be started early in established renal failure.

50
Obstetric and Gynaecological Disorders

DIABETES MELLITUS IN PREGNANCY

Definitions
Diabetes mellitus is a chronic metabolic disorder due to either insulin deficiency (relative
or absolute) or due to peripheral tissue resistance (decreased sensitivity) to the action of
 insulin.

Gestational diabetes mellitus (GDM) refers to any degree of glucose intolerance with the
onset or first recognition during pregnancy.

▪ GDM includes undiagnosed diabetes mellitus detected for the first time during
pregnancy.

▪ GDM usually resolves following delivery and it may be associated with significant
morbidities for the woman and her newborn

Risk factors
■ Family history of diabetes (first-degree relative with diabetes)
■ Previous gestational diabetes
■ Previous birth of an overweight baby of 4 kg or more
■ Previous stillbirth
■ Unexplained perinatal loss
■ Advanced maternal age (>40 years)
■ Obesity (BMI ≥30)
■ Polycystic ovarian syndrome
■ Medications: corticosteroids, antipsychotics
■ Multiple pregnancies

Diagnostic criteria
■ Diabetes is diagnosed where one or more threshold value is exceeded
Fasting blood glucose ≥ 5.1 mmol/l (92mg/dl)
1-hour blood glucose ≥ 10.0 mmol/l (180mg/dl)
2-hour blood glucose ≥ 8.5 mmol/l (153mg/dl)
HbA1c ≥ 48 mmol/ml or 6.5% in early pregnancy
If the value of the glucose challenge screening test is ≥11.1 mmol/L

Clinical presentation
■ Thirst, polyuria, polydipsia
■ Tiredness
■ Loss of weight
■ Blurring of vision
■ Non healing ulcer

51
TREATMENT GUIDELINES

■ Paresthesia or pain in the limbs

■ Recurrent bacterial infections
■ Presence of polyhydramnious in index pregnancy
■ Recurrent vaginal candidiasis in index pregnancy
■ Persistent glycosuria

Management
■ Management of GDM requires a multidisciplinary approach (obstetrician, diabetologist or
internist, diabetes educator, neonatologist).
■ It should be focused on assessment of maternal and fetal wellbeing, timing and route of
delivery, glycemic management, and postpartum assessment and counseling.

Investigation
■ Full blood picture
■ Check blood glucose (fasting/ random blood glucose)
■ Urine for ketones, glucose, protein
■ Arterial blood gases analysis
■ Urea, creatinine, electrolyte
■ Glycosylated Haemoglobin (HbA1c)
■ Lipid profile (total cholesterol, High density lipoproteins, low density lipoproteins,
triglycerides)
■ Obstetric ultrasonography
■ Eye examination including fundoscopy
■ ECG

Screening
■ GDM is an asymptomatic condition hence screening would be necessary for early
diagnosis, treatment and management.
■ All pregnant women should have a risk factors based screening at first antenatal visit and
at 24 to 28 weeks of gestation.
■ All pregnant women with one or more risk factors for glucose impairment, screening test
should be performed.
■ Methods for screening for GDM include the following:
Screening with biochemical tests: random plasma glucose, fasting blood glucose or
glycosylated hemoglobin
One step or two step oral glucose tolerance test (OGTT)

Treatment
■ Glycemic control is the key intervention for reducing the frequency and severity of
complications related to GDM.
■ This will include glucose monitoring, nutritional therapy, exercise, and use of anti
hyperglycemic agents.

52
Obstetric and Gynaecological Disorders

■ All women with pre-gestational (overt) diabetes should have

Glycaemic control using glucose monitoring of both fasting and postprandial values
Preconception folate supplementation, 5mg orally, continuing up to 12 weeks of
gestation
Fundoscopy examination
Renal assessment (urine albumin and serum creatinine)
Review self-monitoring blood glucose, blood pressure and urine protein and
ketones by dipstick at each visit and eye examination in each trimester. ■ Target glycaemia
Preprandial blood glucose 3.5–5.5mmol/L
 Postprandial blood glucose 5–7.5mmol/L
■ For patients with preexisting DM on oral hypoglycemic should be changed to Insulin
therapy before conception or in the first trimester.
■ Lifestyle management is the preferred means of managing gestational diabetes ■ Diet is
based around the principles of optimal nutrition and controlled weight gain ■ Exercise can
be helpful in lowering blood glucose (walking in their normal daily routine) ■
Pharmacological therapy should be considered in addition to diet where fasting or
two-hour glucose levels are above target. It should be initiated at any of the following
thresholds:
Fasting blood glucose concentration >5.3 mmol/L (>95 mg/dL)
One-hour postprandial blood glucose concentration >7.8 mmol/L (>140 mg/dL)
Two-hour postprandial glucose concentration >6.7 mmol/L (>120 mg/dL) ■ Insulin is the first
drug of choice and can be started any time during pregnancy; and metformin can be
considered after 20 weeks of gestation.
■ If the blood sugar is not controlled with the maximum dose of metformin, Insulin can be
added.
■ Oral antihyperglycemic agents are a reasonable alternative for women who refuse to take
or are unable to comply with insulin therapy
■ Twin gestations complicated by gestational diabetes mellitus may require an approximate
doubling of the insulin requirement throughout pregnancy.
■ Doses:
Insulin: a starting dose of 0.7 to 2 units per kg (present pregnant weight) and the
dose will be adjusted based on the response to achieve glucose control. Metformin
tablets 500mg orally, every 12 hours, maximum 2000mg in 2–3 doses Glibenclamide
tablets 2.5mg orally, once daily to a maximum of 10mg daily Supplemental insulin
can be prescribed to patients who fail to achieve glycemic control with an oral
medication.

53
TREATMENT GUIDELINES

Delivery
■ The timing of delivery should be individualized by the obstetrician accordingly and
neonatologist should be informed.
■ GDM pregnancies are associated with delay in lung maturity of the fetus; so elective
delivery should be planned at or after 39 weeks for a patient with well controlled blood
sugar.
Vaginal delivery should be preferred and cesarean delivery should be done for
obstetric indications only
Induction of labour should be scheduled at or after 39 weeks’ pregnancy if the
woman has not already gone into labor spontaneously
Primary cesarean section should be considered in case of fetal macrosomia
(estimated fetal weight >4 kg)
■ Dexamethasone 6 mg IM every 12 hours for 48 hours should be given with close glucose
monitoring and/or surfactant therapy should be arranged in patient requiring early
 delivery.

Intrapartum glucose and insulin requirements

■ All patients should have a 2 hourly blood sugar monitoring during labor and cesarean
delivery
■ The morning dose of insulin/metformin is withheld on the day of induction/labour ■ In
latent phase, an intravenous glucose-containing solution can be administered if oral intake is
prohibited or severely restricted
■ IV infusion with normal saline (NS) to be started & regular insulin to be added according to
blood sugar levels as per the table below.
Blood sugar level Amount of Insulin added in 500 ml NS Rate of NS Infusion

5.0-6.5 mmol/L 0 100 ml/hr (16

drops/min)

6.6-7.7 mmol/L 4 IU 100 ml/hr (16

drops/min)

7.8-10 mmol/L 6 IU 100 ml/hr (16

drops/min)

>10 mmol/L 8 IU 100 ml/hr (16

drops/min)

■ Newborn should be monitored for hypoglycemia at the first hour of delivery and
continued every 4 hours (prior to next feed) till four stable glucose values are obtained. ■
Neonate should also be evaluated for other neonatal complications like respiratory distress,
convulsions, hyper-bilirubinemia and congenital anomalies.

Postpartum care
■ Glucose levels usually return to normal after delivery in women with GDM however, they
have a higher risk of developing Type II Diabetes Mellitus in future.
■ For evaluation of glycemic status, OGTT (fasting and 2 hours postprandial) should be
performed at 6 weeks after delivery in patients with GDM.
■ Women who had DM prior to pregnancy should resume their pre-pregnancy treatment
regime
■ Woman with DM or at high risk of DM should be counselled life style modification and
blood sugar follow up before next pregnancy.

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Obstetric and Gynaecological Disorders

MANAGEMENT OF HIV IN PREGNANCY

Introduction
HIV refers to the human immunodeficiency virus of two types: HIV-1 and HIV-2. HIV-1 is
responsible for the vast majority of HIV infections globally.
■ Acute infection is the period between a person being infected with HIV and HIV
antibodies being detectable by a serological assay; this may take up to 3 months. ■ During
this period, the risk of transmission of HIV is very high, however the infected person may be
asymptomatic or present with nonspecific symptoms.
 ■ Infected mothers become more susceptible to opportunistic infections and malignancies,
if untreated it is associated with high maternal and perinatal morbidity and mortality.

Clinical presentation
■ Patients with HIV infection may be asymptomatic or may present with one or more of the
following;
Fever, diarrhoea, weight loss, skin rashes, sores, generalized pruritus
Altered mental status, persistent severe headache
Oral thrush or Kaposi’s sarcoma may be found in patients with advanced disease
Symptoms due to opportunistic infections e.g. tuberculosis, candidiasis or pyogenic
infections, genital ulcers or vaginal discharge
Hepatomegaly, splenomegaly

Management
Investigation
■ Full blood picture
■ Biochemistry: Serum creatinine, urea, AST, ALT
■ CD4 count
■ Viral load
■ Hepatitis panel
■ Obstetric ultrasonography
■ Other investigations will be individualized depending on the suspected specific condition
i.e. lumbar puncture, sputum for AFB, Chest X-ray, CT scan, MRI

General approach in treatment

■ Comprehensive medical care of the HIV-infected pregnant woman is associated with
favorable maternal health outcomes and low rates of perinatal HIV transmission ■
Management should involve multidisciplinary team, including HIV physician, obstetrician,
midwife, HIV counsellor and neonatologist
■ Prenatal care providers should address potentially modifiable behaviors, which have been
associated with an increased risk of HIV perinatal transmission and or harmful effects
on fetal development, such as

55
TREATMENT GUIDELINES

Cigarette smoking
Illicit drug use (e.g., cocaine, heroin)
Unprotected intercourse
■ Patients should be evaluated for evidence of sexually transmitted infections as part of
routine antenatal care and should be advised to use condoms with sexual activity. ■ All
women who are newly diagnosed with HIV infection should have an early assessment
of their clinical status and social circumstances (living condition, partner status,
socioeconomic status, confidants, social supports and dependents)
■ Women should be encouraged to disclose their HIV status to their partner or confidant
and given appropriate support.

Antiretroviral treatment (ART) in pregnant and breastfeeding women ■ All

pregnant and breastfeeding women living with HIV infection should continue with ART as
recommended.
■ All women newly diagnosed to have HIV infection should be initiated on ART as soon as
possible and continuous counseling for a lifelong ART regardless of their CD4 count/
viral load or WHO clinical stage.
■ First line treatment
Tenofovir (TDF) 300mg/ Lamivudine (3TC) 300mg/ Efavirenz (EFV) 600mg, a single
pill combination regime once a day at night
Alternative first line regime can be
□ Tenofovir (TDF)/ Emtricitabine (FTC)/ Efavirenz (EFZ)
□ Tenofovir (TDF)/ Emtricitabine (FTC) or Lamivudine (3TC)/ Dolutegravir (DTG)
□ Abacavir (ABC)/ Lamivudine (3TC)/ Efavirenz (EFZ) or Dolutegravir (DTG) □
Zidovudine (AZT)/ Lamivudine (3TC)/ Efavirenz (EFZ) or Dolutegravir (DTG) □
Zidovudine (AZT)/ Lamivudine (3TC)/ Nevirapine (NVP)
■ Second line treatment
Zidovudine (AZT)/ Lamivudine (3TC)/ Atazanavir boosted by Ritonavir (ATV/r) if
TDF was used in 1st line
Tenofovir (TDF)/ Emtricitabine (FTC)/ Atazanavir boosted by Ritonavir (ATV/r) if
AZT was used in 1st line
Alternative regimen
□ Zidovudine (AZT)/ Lamivudine (3TC) + LPV/r in case of TB
□ Abacavir (ABC)/ Lamivudine (3TC) + Atazanavir boosted by Ritonavir (ATV/r) □
Abacavir (ABC)/ Lamivudine (3TC) + Lopinavir boosted by Ritonavir (LPV/r) □
Tenofovir (TDF)/ Emtricitabine (FTC) + Lopinavir boosted by Ritonavir (LPV/r)
■ Third line treatment
Dolutegravir (DTG) or Raltegravir (RAL) + Darunavir/Ritonavir (DRV/r) + Etravirine
(ETV)

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Obstetric and Gynaecological Disorders

Alternative regimen
□ Dolutegravir (DTG) + Atazanavir boosted by Ritonavir (ATV/r) + Etravirine
(ETV)

Perinatal care
■ Viral load test should be done at 34 - 36 weeks of gestation prior to the decision of the
mode of delivery.
■ In women with viral load ≤1000 copies/mL on ART or have been adherent on ART for at
least three months, vaginal delivery is preferred unless indicated for obstetric reasons. ■
Cesarean delivery at 38 weeks of gestation should be considered before the likelihood of
labor onset and rupture of membranes in women:
Viral loads remain >1000 copies/mL
Not taking ART
Have not been on ART for less than 3 months prior to term
Poor adherent to ART
Not responding to their current ART regimen
 Obstetric indications
■ If a woman present in labor or with ruptured membranes, management must be
individualized while taking into account the duration of the rupture of membranes,
current ART regimen and duration, and HIV viral load.
■ In preterm PROM, the timing for delivery and mode of delivery should be according to
obstetrical indications.
■ Administration of antenatal corticosteroids to accelerate fetal lung maturity should be
given if appropriate.
■ Women should continue taking their ART regimen as much as possible during labor and
delivery or scheduled cesarean delivery.
■ Invasive obstetric management should be avoided to minimize maternal fetal
transmission of HIV.
■ The possible risks of interventions during management of labor should be weighed against
the obstetrical indications and benefits.

Infant prophylaxis
■ All infants born to HIV-infected mothers should receive antiretroviral post-exposure
prophylaxis (PEP) after birth to decrease the risk of HIV acquisition.
■ Infant antiretroviral prophylaxis (Nevirapine syrup) should be initiated as soon as possible,
ideally within the first 6 to 12 hours after birth and should continue until six weeks of
age.
■ The recommended dosage: 2mg/kg in infants <2000g, 10mg in 2000- 2499gm and 15mg
in ≥ 2500gm.
■ Early infant diagnosis should be done at 6-8 weeks, those found seropositive should be
referred to CTC for early treatment.

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TREATMENT GUIDELINES

Postpartum use of ART

■ All HIV infected women should continue with lifelong ART after delivery and be referred
to care and treatment center for follow up care.
■ The newly diagnosed HIV infected women during intrapartum or postpartum should start
on ART to reduce the risk of disease progression and to prevent HIV transmission
through breastfeeding and to others.
■ Continuous careful adherence counseling and social support should be emphasized during
the postpartum period in order to maintain mother and infant good health and to
reduce the risk of poor compliance of ART.
■ Mothers living with HIV should be counseled, supported, encouraged and provided
counseling about infant feeding before leaving the health facility.
Mothers who choose breastfeeding, should breastfeed exclusively for the first six
months of life and then introduce complementary foods while continuing to
breastfeed to 12 months of age.
Mothers who choose replacement feeding their infants, should do so exclusively for
the first 6 months of life.
However, exclusive replacement feeding is recommended only when it is
acceptable, feasible, affordable, sustainable and safe for her and her infant.
 58
Obstetric and Gynaecological Disorders

PART 2: GYNAECOLOGICAL
CONDITIONS

GYNAECOLOGICAL TUMORS

GYNAECOLOGICAL BENIGN TUMORS

Uterine Fibroids/myomas

Introduction
■ Fibroids are benign smooth muscle tumours found in the submucous, intramural and/or
subserosal regions of the uterus occur commonly in women of reproductive age. ■
Symptoms often attributed to uterine fibroids are heavy menstrual bleeding and pressure
symptoms.
■ A fibroid uterus is one of the most common indications stated for hysterectomy and yet,
 while the exact proportion is unknown, many cases of uterine fibroids are
asymptomatic and surgical interventions may therefore be unjustified and
unnecessary.
■ Even if the fibroids are associated with symptoms, there are new management options
that may reduce the need for hysterectomy.

Risk Factors
■ Increasing age is associated with increasing prevalence of fibroids until menopause when
oestradiol levels begin to fall.
■ Family history is associated with increased prevalence, with up to a 3-fold higher risk in
first degree relatives.
■ African- and Caribbean-American women have a higher prevalence of fibroids ■ Obesity is
strongly associated with fibroids (24), with the risk being three times greater in women
weighing >70 kg compared with those weighing <50 kg.
■ There is an association between nulliparity and fibroids, and an inverse relationship
between number of pregnancies and fibroids.

Clinical features and work up

■ Asymptomatic women with fibroids where the uterine size is less than 16 weeks in size,
where other causes of pelvic mass have been excluded, interventions is indicated if
symptoms occur.
■ Asymptomatic women with fibroids >16/40 should have specialist referral to discuss
options including observation.

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TREATMENT GUIDELINES

■ Women who have fibroids detected during pregnancy should be referred to a specialist
for a consult but do not require additional surveillance
■ Although there is no evidence that asymptomatic women with a fibroid uterus ■
Transvaginal sonohysterography (TVSH) should be considered prior to hysteroscopy in
women where intrauterine pathology such as submucous fibroids and polyps ■ Transvaginal
ultrasound of the endometrium is accurate in excluding endometrial hyperplasia but is often
unable to distinguish submucosal fibroids and polyps. ■ Transabdominal ultrasound may be
required for uteri greater than 12 weeks’ size as these will be beyond the reach of the
transvaginal ultrasound.
■ MRI should be considered for women in whom the location or nature of the fibroids
remains uncertain after transvaginal ultrasound and transvaginal sonohysterography
or who wish to avoid the possible discomforts of a TVSH.

Medical Treatments
■ Gonadotrophin-releasing hormone analogue (GnRH) treatment effectively reduces
uterine and fibroid size with unpleasant side effects and a reduction in bone mineral
density that limit its use to 6 months.
■ Gonadotrophin-releasing hormone (GnRH) analogue treatment for 3 months followed by
combined ‘addback’ therapy (Oestrogen plus progestin) result in fibroid shrinkage and
are an alternative for women who have contraindications to surgery or who do not
wish to undergo it
■ Gestrinone is effective in reducing uterine and fibroid size but androgenic side effects may
limit its use.
■ Progestogens, Oral contraceptive Hormonal replacement therapy should not be
recommended in the treatment of uterine fibroids as there is insufficient evidence of
benefit
■ Women who bleed while on continuous combined HRT and who are known to have
fibroids should have adjustments made to their HRT by either decreasing the
Oestrogen dose or increasing the progesterone dose.
■ RU486 is effective in reducing uterine fibroid size without causing a reduction in bone
mineral density
■ Danazol should not be recommended as initial treatment for fibroids as it is not as
effective as gonadotrophin-releasing hormone analogues and has androgenic side
effects which limit its use

Surgical Management
■ Women who are diagnosed with submucous uterine fibroids and heavy or abnormal
menstrual bleeding should be offered hysteroscopic ablation or resection as an
alternative to hysterectomy.
■ Women with sub serous and intramural fibroids associated with symptoms such as heavy
menstrual bleeding and pressure symptoms should be offered a myomectomy as an
alternative to hysterectomy.

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Obstetric and Gynaecological Disorders

■ Laparoscopic myomectomy should not be undertaken in women who wish to conceive

because of case reports suggesting increased risk of uterine rupture.
■ Embolization of uterine fibroids may be an effective alternative to myomectomy or
Hysterectomy.

Uterine fibroids in pregnancy

Obstetric risks
■ Mode of delivery, foetal growth and premature rupture of membranes appear to be
generally unaffected by the presence of fibroids.
■ Increase in threatened preterm labour
■ The likelihood of developing particular complications appears to be related to the
position, location and size of the fibroid.
■ Placental abruption has been identified as a particular risk in women with fibroids larger
than 20 cm where the fibroid is in direct contact with the placenta.
■ Pelvic pain also appears more likely to occur in women with fibroids larger than 20 cm. ■
Pregnancy and implantation rates were not influenced by the presence of subserosal
fibroids
■ The recommendation from this was the need to consider surgical or medical treatment in
women who have intramural and/or submucosal fibroids with a history of infertility
before attempting assisted reproductive therapies.

Surgery during pregnancy

Surgery during pregnancy for the removal of fibroids is not recommended because of the
increased risk of hemorrhage.
 Alternative Therapies
A number of alternative therapies have been suggested for the treatment of fibroids including
herbal preparations, homoeopathic remedies and lifestyle changes. No RCTs have been carried
out to evaluate the effectiveness of any of these treatments

Ovarian cysts

Introduction
■ A benign cyst may be a serous or mucinous cystadenoma, a mature cystic teratoma (a
dermoid), an endometrioma or a follicular or functional cyst.
■ Cyst ‘accidents’ include twist (torsion), rupture, bleed, or sudden expansion. ■ Cyst torsion
is the most frequent and is a common presentation of benign cysts with sudden pain.
■ Patients have, rarely, bled over 2 liters from a simple corpus luteum rupture in a normal
menstrual cycle

61
TREATMENT GUIDELINES

■ Pain with a palpable mass or a cyst on sonar in the absence of pyrexia is suggestive of a
cyst accident rather than PID.
■ If a cystic swelling is not round but sausage shaped it may be a chronic hydrosalpinx.
Consider ectopic pregnancy if there is amenorrhea and a positive pregnancy test.
Heterotopic pregnancies do occur.
■ A cyst may coexist with a threatened miscarriage.
■ Malignant cysts more frequently present in older patients with vague symptoms, chronic
pain weight loss often accompanied by ascites.

Diagnosis
■ A normal pre-ovulatory follicle grows up to 2.5 cm in diameter.
■ Larger cysts - torsion or rupture causes a sudden onset of severe constant or intermittent
pain (torsion-untorsion)
■ Gradual expansion may cause a slower-onset dull ache
■ Weakness and dizziness from hemorrhage occur unusually
■ Gastrointestinal and urinary symptoms are minimal
■ Amenorrhea is usually absent in the absence of an intrauterine pregnancy ■
Pregnancy-associated cysts usually undergo torsion at 14-16 weeks or in the puerperium
when the uterus shrinks to this size (they roll on the pelvic brim)
■ Abdominal and pelvic signs are variable; a mass may or may not be palpable ■ A
pleural effusion is rare (if associated with a benign cyst this is ‘Meig’s Syndrome’)

Investigations
■ Ultrasound - record the cyst diameter, appearance (simple, or solid/cystic, septate), and
bilaterally, look for ascites or haemoperitoneum,
■ Urinary pregnancy test if there is ANY possibility of ectopic pregnancy ■
Do pre-operative routine blood tests – FBC, Creatinine and Urea ■ Do
CA-125 in women >35 years’ old
■ Do hCG and AFP in pre-menstrual girls
■ Do CEA in suspicion of mucinous cystadenocarcinoma

Management
■ This depends on the presentation If there is not an acute abdomen, and the cyst is simple
and ≤6 cm in diameter
Explain to the patient that the ovary normally makes cysts and that these may
resolve hence a follow up of ultrasound scan in 2-4 weeks
Advise the patient to return if they are unwell or if the pain worsens
Give simple analgesics, e.g. Paracetamol 1 g orally 6 hourly 5.
If >35 years, take blood for CA-125
Perform urgent laparotomy/laparoscopy if in case of torsion ovarian cyst or
bleeding rupture cyst
■ If the cyst has solid elements, or if it is ≥7 cm in diameter, in the absence of an acute
abdomen, laparotomy/laparoscopy should be done as soon as conveniently possible

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Obstetric and Gynaecological Disorders

Vulva warts
Diagnosis
■ The causative organism is the human papillomavirus (HPV 6 and 11) ■
The cauliflower appearance is typical
■ Large warts may be obstructive, painful, infected and foul-smelling ■ Large warts are more
frequent in teenagers, pregnant women and immunocompromised patients

Management
Management of small warts
■ Prescribe podophyllin paint (25%) for the patient to bring to the clinic ■
Do NOT use unless you are sure pregnancy has been excluded.
■ Trichloroacetic acid 85% can be used as an alternative in the same way ■
Moderate warts, or not responding, treat with diathermy, cryotherapy

Management of large warts

■ Discuss with a subspecialty team or consultant.
■ Consider HIV testing (positivity is likely and probably known)
■ Give amoxicillin 500 mg orally 3 times daily and metronidazole 400 mg orally 3 times daily
for 7 days if the warts are infected or foul smelling
■ In pregnancy, defer treatment until after delivery.
■ Warts resolve significantly postpartum
■ Burn the wart, not the surrounding skin
■ Radiotherapy has been recommended in HIV seropositive non-pregnant patients with
very advanced warts.

Vulva skin problems and dysplasia

Allergic Vulvitis
■ The rash appears as a typical allergic rash
■ The patient may be using a new type of underwear, soap or skin care product in the region
 of the external genitals
■ Shaving may produce an eczema-like response Management
■ Remove the allergen

Vulva dermatoses
■ Dermatoses affecting the vulva include psoriasis, eczema and lichen planus ■
Ask for a history of rash anywhere on the body
■ Look for evidence of dermatosis elsewhere: o Psoriasis on extensor surfaces or Eczema on
flexor surfaces or Lichen planus in the mouth
■ Ask for an experienced colleague’s opinion or refer to dermatology ■
Steroids are frequently used for these conditions

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TREATMENT GUIDELINES

Vulva dysplasia
■ These conditions include lichen sclerosus, vulval intraepithelial neoplasia, Paget’s disease
of the vulva.
■ These lesions have variable malignant potential or may be associated with carcinoma,
which must therefore be excluded.
■ Common presentation includes itching or soreness
■ Non-troublesome lesions may be noticed by the patient, or incidentally by a clinician ■
Before making a diagnosis, arrange for vulvoscopy and biopsy
■ Call an experienced colleague for guidance with vulvoscopy

Vulvodynia
■ This is a chronic condition of unknown aetiology that may occur at any age of adulthood
that has no known cause.
■ Common presentation includes sharp pain, burning, stinging, or irritation is experienced
on the vulva.
■ In a severe form vulva pain is experienced by touch with a cotton bud or swab at the
introitus and is called ‘Vulvar vestibulitis’.
■ This is a diagnosis of exclusion of the following deferential diagnoses:
Infections (candidiasis, herpes, HPV)
Inflammation (lichen planus, other dermatoses)
Neoplasm or dysplasia (Paget’s disease, VIN, vulval cancer)
Neurological disorder (neuralgia secondary to herpes virus, spinal nerve injury) ■
Supportive counseling may have some but sometimes limited benefit. ■ SSRIs have been
used.
■ Ultimately vestibulectomy may be performed but should only be the choice of a clinician
experienced in the condition.
 64
Obstetric and Gynaecological Disorders

GYNAECOLOGICAL MALIGNANCIES

Introduction
■ Cancer is a word covering a wide range of malignant diseases which contribute
significantly to the overall morbidity and mortality of people world-wide. ■ Estimated
50,000 new cancer cases occur each year in Tanzania, about 60% gynaecological admissions
at Muhimbili National Hospital (MNH) are malignancies. ■ The majority of patients present
with advanced stages (stage 3 and 4) where cure is rarely possible.
■ More effort is required to create public awareness on risk factors, symptom and screening
for prevention and early diagnosis from the Community level to Tertiary level.

Cancer of the cervix

Overview
■ Cancer of cervix is the most common female malignancy in developing countries
accounting for 30-40% of admissions patients with malignancies at MNH. ■ Cervical cancer
is caused by persistent infection with Human Papilloma Virus (HPV). Risk factors include
early coitus and childbirth, multiple sexual partners, smoking and HIV infection.
■ It is preventable through avoiding risk factors, screening and vaccination. When detected
early, the disease is curable by surgery or radiotherapy hence regular screening is
required for all women at risk.

Cervical screening
Guiding principles include:
■ Cervical smears (Pap smears) provides a safe, simple and effective method of preventing
cervical cancer. This allows early detection of its precursor, cervical intraepithelial
neoplasia (CIN).
■ The Ayre’s spatula is used particularly in the parous patient.
■ Cervical brushes may be better still, but are expensive. Endocervical brushes have special
 applications.
■ HPV testing may be of value, If CIN 1 is discovered on biopsy, a finding of HPV 16 or 18
may necessitate an excisional or ablative procedure.
■ Cervical cancer screening guideline include:
Cytology test alone at age between 21 – 65 years in every 3 years, if cytology result
is Negative*
HPV and cytology co-testing at age 30 – 65 years, every 5 years, if cytology result is
Negative or ASC-US +HPV negative
All patients going for operations must have recent Pap smear results Pap smears
should always be done for patients presenting without a Pap in the previous 3 years

65
TREATMENT GUIDELINES

Cervical screening should be avoided when:

□ Age ≥ 65 years with adequate prior screening and NOT High risk □
3 consecutive negative cytology result
□ 2 negative co- test within 5 years last test
□ Avoid doing smears on teenagers, unless there are risk factors, e.g. sexually
transmitted infections.
□ After TAH due to benign disease, if NO history of CIN II or III in the past 20
years or cervical cancer
In a woman treated for CIN II or AIS must be regularly screened for 20 years even if
65 years or older with cytology alone 3 yearly or with Co-testing 5 years
*Immune-compromised patients should have annual screening.

How to take a cervical smear

■ Write the patient’s details clearly on both the slide and the form
■ Use a small amount of lubricant jelly on the outside of the vaginal speculum ■ Good
visualization of the cervix is essential hence a need for good lighting ■ Turn the spatula or
brush around several times with the extended tip in the cervical os. ■ If the
squamo-columnar junction is not clearly seen, or if there has been a previous
excisional procedure with a positive endocervical margin, twist the brush inside the
canal and wipe it onto the slide at a different point or onto a separate slide ■ Wipe the
spatula or brush several times onto the slides
■ Put the slides into the Papanicholaou solution or spray the slides immediately with fixative
from about 10-20 cm
■ Make clear arrangements for follow-up

Management of Co Testing result

■ If cytology (-ve) and HPV (-ve) advise the client for Co test in 5 years* ■ If cytology (-ve)
but HPV (+ ve) advise the client for Co test in 12 months or do subtype for HPV 16/18. If
HPV 16 or 18 is (+ve) advise the client for Annual screening ■ If cytology (ASC-US +ve) and
HPV (-ve) advise the client for Co test in 5 years* ■ If cytology (ASC-US +ve) and HPV (+ve)
then advise the client for Colposcopy *Immune-compromised patients should have annual
screening.
The Bethesda Classification of carcinoma of the cervix
2001 Squamous abnormalities include:
■ HSIL: High grade squamous intra-epithelial lesion (suggesting CIN 2 or 3) ■
LSIL: Low grade squamous intra-epithelial lesion (suggesting CIN1) ■ ASC-H:
Atypical squamous cells – high grade abnormality cannot be excluded ■ ASCUS:
Atypical squamous cells of uncertain significance

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Obstetric and Gynaecological Disorders

Glandular abnormalities
■ AIS: Adenocarcinoma-in-situ
■ AGC: Atypical glandular cells
■ AGNOS: Atypical glandular cells not otherwise specified

Management of abnormal smears

■ HSIL, recurrent LSIL, ASC-H, AIS, AGC should be referred for colposcopy. ■ In certain
cases, ASCUS, AGNOS, or first LSIL, it is permissible to defer colposcopy and repeat the
smear
■ Before referral, explain to the patient that:
The abnormality is not cancer
The possible treatment involves removal of a coin-sized piece of cervix which grows
back
Colposcopy and follow-up will help to prevent cervical cancer

Indication for colposcopy and associated ablative

procedures ■ Prerequisite of Colposcopic examination include:
Eliciting a history of referral cervical smear, previous abnormal smears and
treatment, LMP, parity and past medical history
Exclusion of pregnancy
■ Perform Colposcopy in case of:
A single high grade cervical smear result
qA recurrent low grade smear (at least two)
A patients older than 35 years, with HPV subtypes 16 and 18.
HIV infection that increase risk of progression from low grade to high grade
dysplasia, and recurrence after treatment, but follow up is essential.
■ Colposcopy procedure entails:
Explanation of colposcopy procedure to the patient
Putting the patient in the proper lithotomy position
Bimanual examination to assess uterine size and axis
Speculum: examine the cervix with the naked eye, then by colposcope at low power,
then high power.
Wipe excessive mucus if present off the cervix with cotton wool mounted on a
sponge holder
 Soak the cervix with 2% Acetic acid on a drenched cotton wool ball on a sponge
holder
■ Interpretation of colposcopy findings:
Aceto-white epithelium (a brilliant white patch with a sharp border) suggests
dysplasia, as opposed to the grey-white with indistinct border of squamous
metaplasia (non-pathological).
The acetone-white areas may have a pavement like pattern (‘mosaic’), or fine evenly
spaced red dots (‘punctation’).
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TREATMENT GUIDELINES

With experience, low grade abnormalities can be distinguished from high grade
which tends to have larger mosaic squares for example.
The presence of ‘corkscrew’ vessels or abruptly branching vessels suggests frank
invasion. These are best seen with a green filter.
‘Adequate’ colposcopy is defined as complete visualization of the squamo-columnar
junction and the upper limit of acetone-white areas.
Inadequate colposcopy is an indication for LLETZ however excision LLETZ, laser
Cone, knife Cone is preferable to ablative procedures (cryotherapy or laser
vaporization) – for the latter there is no histology

Indication for LLETZ procedure

■ To assess the cervix by colposcopy and immediately perform a LLETZ is called ‘See and
Treat.’
■ LLETZ procedure include:
A diathermy plate is needed – LLETZ uses monopolar diathermy
A special speculum is used with an exhaust pipe inside the upper blade.
Stain the cervix with 2% acetic acid to see the lesion
Inject, with a dental syringe, 1% lignocaine at the junction of the cervix with the
vaginal fornices at 12, 3, 6, and 9 o’clock
After a minute, with the diathermy machine set to blended cut (with coagulation),
pass the loop from left to right, or from above down to a depth deepest at the
cervical canal of 1 cm.
Antiseptic creams and antibiotics are optional
Follow up plans must be properly explained

Clinical Presentation
■ Asymptomatic in early stages of the disease/ Premalignant stages. ■ Majority present
with abnormal vaginal bleeding (post coital, inter- menstrual or postmenopausal vaginal
bleeding).
■ Foul smelling discharge, pain and incontinence (VVF or RVF) are symptoms of late disease.

Principle of Management
■ Investigations
Full Blood Count (FBC)
Liver Function Test (LFTs) including ALAT, ASAT, AlKP; Bil D and Bil T
Renal Function Test including Creatinine, Urea
Serology for HIV test.
Chest X-ray
 Abdominal and pelvic ultrasonography.
CT Scan of the abdomen and pelvis and/or pelvic MRI.
Colposcopy and biopsy of cervix for histology, when appropriate.
Bimanual Examination under Anaesthesia (EUA +/- cystoscopy).

68