!

OBSTETRICS
AND
GYNAECOLOGY

BY:
FAREHA HATTA
MBBS (UiTM)
OnG$

Dear%colleagues,%
%
These%are%some%of%the%important%topics%in%OnG%which%I%think%will%help%most%of%us%
to% grasp% the% practical% knowledge% of% the% subject.% I% have% emphasized% on% the%
fundamental% aspect% and% stuff% that% we% need% to% know% to% achieve% a% better%
understanding% in% OnG.% Different% people% have% different% opinions% about%
management,% thus% there% is% no% exact% management% per% se.% It% is% all% about%
experience.% Always% refer% to% your% hospital% protocol% for% the% latest% updates% on%
management.%
!
!
TOPICS!
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1! DEFINITION%IN%OBSTETRICS%
2! IOL%&%AUGMENTATION%OF%LABOUR%
3! INSTRUMENTAL%DELIVERIES%
4! CAESAREAN%SECTION%
5! HYPERTENSION%IN%PREGNANCY%
6! GESTATIONAL%DIABETES%MELLITUS%
7! PPROM%&%PROM%
8! POSTPARTUM%HEMORRHAGE%
9! MISCARRIAGES%
10! ECTOPIC%PREGNANCY%
11! GESTATIONAL%TROPHOBLASTIC%DISORDERS%
12! MENORRHAGIA%
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Thank%you%Allah%for%giving%me%the%strength%and%patience%to%go%through%one%of%the%
most% difficult% postings% in% housemanship.% Alhamdulillah,% I% survived% in% OnG.% Ive%
gained%so%much%from%this%posting%and%no%word%can%describe%my%%excitement%upon%
successful%completion%of%the%posting.%Alhamdulillah.%!%
%
With%that,%I%present%to%you%my%latest%personal%HO%notes%in%OnG.%
%
%
%
Dr%Nurfareha%Mohd%Hatta%
MBBS%(UiTM)%
Hosp.%Tengku%Ampuan%Rahimah,%Klang.%
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$DEFINITION$
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DEFINITION(IN(OBSTETRICS(
$
$
Presentation$
The$part$of$the$fetus$in$the$lower$pole$of$uterus$overlying$the$pelvic$brim$
Example:$cephalic$(vertex,$face,$brow),$breech$(frank,$complete,$footling),$shoulder$
$
Attitude$
Relation$of$the$different$part$of$fetus$to$one$another$
$
Lie$
The$relation$of$the$long$axis$of$the$fetus$to$the$uterus$
Example:$longitudinal,$transverse,$oblique$
$
Position$
The$relationship$of$the$presenting$part$to$the$mothers$pelvis$
$
$
$ OA!
$
! ROA! LOA!
!
! ROT! LOT!
!
ROP! LOP!
!
!
! OP!
!
!
Presenting$part$
The$leading$point$of$the$fetus$in$the$lower$pole$of$uterus$overlying$the$pelvic$brim$
(on$VE)$
Example:$vertex,$buttocks,$feet$
$
Denominator$
Arbitrary$part$of$the$presentation$of$the$fetus$(the$bony$point)$
Example:$occiput$in$vertex$presentation,$sacrum$in$breech$presentation,$mentum$in$
face$presentation$
$
Engagement$
Descent$of$the$biparietal$diameter$through$the$pelvic$brim$
$
Vertex$
DiamondLshaped$area$of$the$fetal$skull$bounded$by$the$2$parietal$eminences$and$
anterior$and$posterior$fontanelles$
$
Effacement$
Shortening$of$the$cervix$
Normal$cervical$length:$~$2.5$cm$
$

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Station$
The$level$of$the$presenting$part$in$relation$to$ischial$spine$
$
Caput$
Diffuse$swelling$of$the$scalp$caused$by$pressure$of$the$scalp$against$the$dilating$
cervix$during$labour$
$
Moulding$
Overlapping$of$the$bones$of$the$fetal$head$
Parietal$bones$overlap$occipital$and$frontal$bones$
Significant$moulding$and$caput$!$sign$of$CPD$
Degree$of$moulding$
No$moulding$
+1$$parietal$bones$are$touching$
+2$$parietal$bones$are$overlapped$but$easily$reduced$
+3$$irreducible$(sign$of$relative/absolute$CPD)$
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$
$

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OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$IOL$&$AUGMENTATION$OF$LABOUR$ !
!
INDUCTION(AND(AUGMENTATION(OF(LABOUR(
$
Induction$$Stimulation$of$contractions$before$the$spontaneous$onset$of$labour$
Augmentation$$Stimulation$of$spontaneous$contractions$that$are$considered$inadequate$
$
Indications$of$IOL:$
Post$dates$
Maternal$factors$
Significant$APH$
Gestational$HPT$disorders$
GDM$
Underlying$renal$or$lung$disease$
Fetal$factors$
Suspected$fetal$jeopardy$
Reduced$fetal$movement$at$term$
Fetal$demise$(IUD),$severe$IUGR$
MaternalOfetal$factors$
Prolonged$PROM$(if$more$than$24$hours)$
Chorioamnionitis$$
$
Contraindications$of$IOL$
$
Maternal$ Fetal$
Small$pelvis$(in$case$of$CPD)$ Macrosomia,$CPD$
Abnormal$placentation$ Multifetal$gestation$
Active$genital$herpes$infection$ Severe$hydrocephalus$
Cervical$abnormalities$ Malpresentation$(obstructed$labour),$
transverse$fetal$lie$
Prior$classical$or$other$high$risk$caesarean$ NonOreassuring$fetal$status$
incision$
Placenta$praevia$or$vasa$praevia$ Umbilical$cord$prolapse$
$
Bishop$score$$
To$assess$whether$cervix$is$favourable$and$to$determine$whether$the$patient$needs$
cervical$ripening$or$to$proceed$with$augmentation$
If$Bishop$score$<$4$!$cervix$not$favourable$
Modified$Bishops$score$is$currently$used$in$practice$
$
$ 0$ 1$ 2$
Cervical$dilatation$ 0$cm$ 1$cm$ 2$cm$or$more$
Cervical$length$ 2$cm$ 1$cm$ Effaced$
Consistency$ Firm$ Soft$ Soft$and$
stretchable$
Station$ O2$ O1$ 0$
Position$ Posterior$ Axial$ Anterior$
$
$
*A$preOIOL$CTG$of$at$least$20$minutes$recording$is$mandatory$and$reviewed$before$proceed$
with$IOL.$
$

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Methods$of$induction$
$
1. Prostaglandin$E2$(Prostin)$
To$promote$cervical$ripening$if$cervix$is$not$favourable$(Bishop$score$<$4)$
To$assess$Bishop$score$prior$to$prostin$insertion$
Gravida$1O5$(1.5mg$for$multigravida$with$previous$scar$or$3mg$for$no$scar)$inserted$
at$posterior$fornix$
After$prostin$insertion,$
CRIB$for$1$hour$
CTG$postOprostin$1$hour$
Review$VE$in$6$hours$
Monitor$labour$progress$chart$(LPC)$and$FKC$
There$should$not$be$more$than$2$prostin$insertion$in$24$hours$
MAXIMUM$no.$of$prostin$inserted:$3$doses$
If$the$3rd$prostin$fails,$the$specialist$will$have$to$review$and$assess$the$patient$
Oxytocin$infusion$should$not$be$started$at$least$6$hours$after$last$prostin$insertion$
!$to$avoid$risk$of$uterine$hyperstimulation$
$
2. Amniotomy$followed$by$oxytocin$induction$
When$cervix$is$favourable$
Amniotomy$(ARM)$
Amniotic$fluid$is$rich$in$prostaglandin,$can$cause$uterine$contraction$
Criteria$for$ARM$
" Os$is$$4cm$(in$active$phase)$
" Station$is$not$high$and$the$vertex$is$wellOapplied$$to$assess$head$
engagement$on$abdominal$examination$prior$to$ARM$
" Contraction$must$be$present$
" The$umbilical$cord$or$other$fetal$part$is$not$presenting$
Aim$of$ARM$
" To$speed$up$labour$process$
" For$internal$fetal$monitoring$
" To$look$for$presence$of$meconium$
Is$not$part$of$a$routine$in$labour$management,$especially$in$spontaneous$
labour$
Some$studies$show$that$early$ARM$(when$os$$<$4cm)$in$nulliparous$labour$
induction$shortened$the$time$of$delivery$by$>$2$hours$and$increased$the$
proportion$of$deliveries$within$24$hours,$given$the$fetus$head$is$engaged$
(commonly$practised$in$HTAR$when$there$is$prolonged$latent$phase$and$cervix$
is$favourable)$*$
Complications$of$ARM$$cord$prolapse,$infection$
Oxytocin$induction$
Oxytocin$is$a$polypeptide$hormone$produced$in$the$hypothalamus$and$
secreted$from$posterior$pituitary$in$a$pulsatile$fashion$
Synthetic$oxytocin$administration$is$most$commonly$given$IV$
Short$halfOlife:$3O6$minutes$
How$to$dilute$$1$ampoule$of$Syntocinon$has$10$units,$dilute$in$1000ml$normal$
saline,$yielding$an$oxytocin$concentration$of$10mU/mL$
Dose$initiated$at$0.5O1$mU/min$and$increased$by$1$mU/min$at$30O40$minute$
intervals$using$infusion$pump$

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!
Amniotomy$plus$oxytocin$is$MORE$EFFECTIVE$than$amniotomy$alone$!$shortened$
the$time$to$delivery$by$44$minutes$
After$ARM,$
For$CTG$postOARM$with$20$minutes$tracing$
Review$VE$in$4$hours$
Review$contractions$
Plot$partogram$
If$CTG$reactive,$to$start$Syntocinon$as$per$regime,$to$aim$for$moderate$
contraction$4:10$
For$CTG$hourly$if$CTG$reactive$
Hydration$with$1$pint$Hartmann$solution$over$4$hours$as$maintenance$
For$IM$Pethidine$75mg$and$IM$Phenergen$25mg$stat$once$contraction$
moderate$and$CTG$reactive$OR$to$offer$epidural$
$
Augmentation$of$labour$
Indicated$when$the$patient$is$in$labour$and$CPD$has$been$ruled$out$
When$there$is$poor$progress$of$labour$secondary$to$poor$uterine$contractions$based$
on$the$partograph$
Initial$steps$
Assess$general$condition$of$mother$$vital$signs$and$hydration$status$
Review$partogram$and$assess$the$progress$of$labour$
Palpate$the$abdomen$and$assess$
" Strength$&$frequency$of$contraction$
" Estimate$the$size$of$baby$(compare$with$previous$baby)$
" Engagement$of$the$head$
" ?Full$bladder$(to$catheterize$before$VE)$
Do$VE$and$assess$
" Cervical$effacement$
" Cervical$os$dilatation$
" Position$of$fetus$$OA/OP/OT$
" Degree$of$caput$or$moulding$if$present$
" Nature$of$liquor$if$present$
Baseline$CTG$before$augmentation$with$at$least$20$minutes$tracing$to$ensure$fetal$
wellbeing$is$not$compromised$
Augmentation$regime$
Primigravida$$2,$4,$8$units$
Gravida$2O5$$1,$2,$4$units$
Multipara$with$previous$scar$$may$consider$,$1,$2$units$
For$every$increase$in$the$strength$of$oxytocin$infusion,$CTG$monitoring$is$mandatory$
Good$effective$contraction$!$4O5$contractions$in$10$mins$
$
Side$effects$of$oxytocin:$
Uterine$hyperstimulation$(def:$>$5$contractions$in$10$mins)$
Uterine$rupture$(especially$in$scarred$uterus)$
Hyponatremia$due$to$excessive$water$retention$(oxytocin$has$ADH$properties,$when$
administered$in$high$doses)$
Hypotension$(as$a$result$from$rapid$IV$injection$of$oxytocin)$
Fetal$distress$
$
FAILED$INDUCTION$&$AUGMENTATION$!$CAESAREAN$SECTION$

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

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OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$INSTRUMENTAL$DELIVERY$
!
INSTRUMENTAL+DELIVERY+
$
a.k.a$Operative$Vaginal$Delivery$
$
A$delivery$in$which$the$operator$uses$forceps$or$a$vacuum$device$to$assist$the$mother$in$
transitioning$the$fetus$to$extrauterine$life.$
$
Indications$
Prolonged$2nd$stage$of$labour$
Nulliparous$$3$hours$with$regional$anaesthesia,$2$hours$without$
Multiparous$$2$hours$with$regional$anaesthesia,$1$hour$without$
Maternal$distress$(underlying$cardiac$disease,$HPT$crisis,$etc)$
Presumed$fetal$compromise$
Maternal$exhaustion$
$
Prerequisites$
FT$Fully$dilated$cervix$
OT$OP/OA$position$
RT$Ruptured$membrane$
CT$Cephalic$
ET$Empty$bladder$(to$catheterize$first)$
PT$Pain$relief$(adequate$analgesia)$
ST$Skills,$Station$low$
$
Complications$
The$relative$merits$of$vacuum$extraction$and$forceps$have$been$evaluated$in$a$Cochrane$
Systematic$Review$of$ten$randomized$controlled$trials$involving$2923$primiparous$and$
multiparous$women$
$
Compared$with$forceps,$vacuum$extraction$is:$
more$likely$to$fail$delivery$with$the$selected$instrument$(OR:$1.7;$95%$CI:$1.32.2)$
more$likely$to$be$associated$with$cephalohaematoma$(OR:$2.4;$95%$CI:$1.73.4)$
more$likely$to$be$associated$with$retinal$haemorrhage$(OR:$2.0;$95%$CI:$1.33.0)$
more$likely$to$be$associated$with$maternal$worries$about$baby$(OR:$2.2;$95%$CI:$1.2
3.9)$
less$likely$to$be$associated$with$significant$maternal$perineal$and$vaginal$trauma$(OR:$
0.4;$95%$CI:$0.30.5)$
no$more$likely$to$be$associated$with$delivery$by$caesarean$section$(OR:$0.6;$95%$CI:$
0.31.0)$
no$more$likely$to$be$associated$with$low$5Tminute$Apgar$scores$(OR:$1.7;$95%$CI:$1.0
2.8)$
no$more$likely$to$be$associated$with$the$need$for$phototherapy$(OR:$1.1;$95%$CI:$0.7
1.8).$
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!
FORCEPS$DELIVERY$
$
$

The$blade$has$two$curves:$
Cephalic$curve$$relates$to$
fetal$head$
Pelvic$curve$$relates$to$
maternal$pelvis$
!
$
$
Conditions$when$forceps$are$preferable:$
Poor$maternal$effort$
Operator$or$maternal$preference,$when$either$instrument$would$be$suitable$
Large$amount$of$caput$
Gestation$of$less$than$34$weeks$
Marked$active$bleeding$from$a$fetal$bloodTsampling$site$
AfterTcoming$head$of$the$breech$
Face$presentation$
$
Types$of$forceps:$
$
1. Wrigleys$$for$liftTout$deliveries$and$Caesarean$section$

$
2. Neville$Barnes$
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3. Rotational$forceps$(Kiellands$forceps)$
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!
Classification$of$forceps$delivery:$
$
OUTLET$ Fetal$head$is$at$or$on$the$perineum$
$ Scalp$is$visible$at$the$introitus$without$separating$the$labia$
Fetal$skull$has$reached$the$pelvic$floor$
Sagittal$suture$is$in$the$AP$diameter$or$right$OA$or$OP$
Rotation$does$not$exceed$45$degrees$
LOW$ Leading$point$of$the$fetal$skull$is$at$the$station$+2$cm$or$
more$
Rotation$$45$degrees$from$OA$position$
Rotation$>$45$degrees$including$OP$position$
$
MID$ Leading$point$of$the$fetal$skull$is$above$station$+2$cm$but$
not$above$the$ischial$spines$
Rotation$$45$degrees$from$OA$position$
Rotation$>$45$degrees$including$OP$position$
Head$is$engaged$
$
Technique:$
Procedure$explained$to$patient$
Lithotomy$position$
Clean,$drape$and$catheterize$
Assemble$the$blades$
Left$blade$applied$first$(hold$like$a$pencil)$
Right$blade$follows$
Proper$application$and$positioning$of$forceps$will$bring$the$blades$together$and$locks$
easily$
If$fail,$to$proceed$with$LSCS$
$
Clinical$checks$for$forceps$application:$
Sagittal$suture$lies$in$the$midline$of$the$shanks$
Operator$is$unable$to$place$more$than$a$fingertip$between$the$fenestration$of$the$
blade$and$the$fetal$head$on$either$side$
Posterior$fontanelle$is$no$more$than$a$finger$breadth$above$the$plane$of$the$shanks$of$
the$forceps$
Apply$traction$intermittently$and$synchronously$with$uterine$contraction$
Direction$of$traction$should$be$in$the$axis$of$the$birth$canal$
Head$descent$must$be$present$during$each$contraction$
$
$
VENTOUSE$DELIVERY$
$
Risk$of$damage$to$the$maternal$tissue$is$considerable$
Preterm$pregnancy$(<$34$weeks)$$contraindicated$
Head$softer$
Wider$separation$of$suture$
Increased$risk$of$subgaleal$and$intracranial$hemorrhage$
Can$be$applied$in$any$fetal$position$
$
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!
Advantages$ Disadvantages$
Avoid$marked$compression$of$the$fetal$head$ Injuries$to$the$fetal$scalp$
by$the$forceps$
Forceps$occupies$a$space$and$may$injure$the$ Cephalohematoma$
vagina$
Forceps$carries$the$infection$in$the$genital$ Intracranial$hemorrhage$
tract$
$
Types$of$cup:$
$
1. Silastic$cup$

$
2. Metal$cup$
$

$
$
3. Kiwi$cup$
$

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!
Conditions$when$ventouse$is$preferable:$
Urgent$low$liftTout$delivery$with$no$previous$analgesia$
Rotational$delivery$
Operator$or$maternal$preference,$when$either$instrument$is$suitable$
$
Technique:$
Cup$must$be$directed$to$the$occiput$in$the$midline$of$the$head$application$diameter$at$
the$flexion$point$
Ensure$that$maternal$tissue$have$not$caught$in$the$cup$
Increase$the$pressure$to$0.2$kg/cm2,$check$for$maternal$tissue$entrapment$between$
the$cup$and$the$fetal$head,$then$increase$to$0.8$kg/cm2.$Recheck$for$any$maternal$
tissue$entrapment$prior$to$applying$traction$
With$contraction,$apply$traction$downward$and$backward$with$one$hand$while$the$
other$hand$applied$to$steady$the$cup$on$the$head$
Head$should$descend$with$each$pull$
Delivery$should$be$completed$within$3$pulls$
Cup$should$be$reapplied$no$more$than$twice$
If$fail,$do$not$try$forceps$
$
$
$
$
$
$ The$flexion+point$is$located$on$the$
$ sagital$suture$3+cm+in+front$of$the$
$ posterior$fontanelle$and$+6+cm+
$ posterior$to$the$anterior$fontanelle$
$
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References:$
1. HTAR$protocol$
2. Royal$College$of$Obstetricians$&$Gynaecologists$$Instrumental$Delivery$

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!
CAESAREAN'SECTION'
$
2$types$of$Caesarean$section:$
Lower$segment$section$ Classical$section$(Upper$segment)$
Transverse$ incision$ made$ ~2cm$ above$ Midline$ longitudinal$ incision$ made$ in$
symphysis$pubis$(Pfannenstiel)$ uterine$upper$segment$
Advantages:$ Indications:$
!$adhesion$formation$ Fibroid$distorting$the$uterus$
!$blood$loss$ Anterior$ PP$ with$ abnormally$
!$ incidence$ of$ scar$ dehiscence$ in$ vascular$lower$uterine$segment$
subsequent$pregnancies$ Poorly$formed$lower$segment$
scar$heals$well$ Advantages:$
short$duration$of$hospital$stay$ Rapid$delivery$
!$risk$of$bladder$injury$
$
Layers$cut$in$CS:$
Skin$
Subcutaneous$layer$(Camper$&$Scarpa$fascia)$
Rectus$sheath$(aponeuroses$of$the$external$oblique,$internal$oblique,$and$tranversus$
abdominis$muscles$
Rectus$abdominis$muscle$
Transversalis$fascia$
Peritoneum$$
$
PreQOp$
Keep$patient$NBM$with$IV$Drip$5$pints$(3$pints$NS$+$2$pints$D5%)$
If$patient$planned$for$elective$CS,$to$keep$NBM$at$12am$
Consent$form,$blood$transfusion$form$signed$
For$baseline$blood$investigations$$FBC,$GSH$
Prepare$GXM$2$units$packed$cells$
Shave$the$pubic$area$
Bladder$catheterization$
Prophylactic$antibiotic$$IV$Cefuroxime$1.5g$stat$&$IV$Flagyl$500mg$stat$
Pre$med$$IV$Ranitidine$50mg,$IV$Maxolon$10mg,$Oral$Sodium$citrate$30ml$given$stat$
Presence$of$Anaes$and$Paeds$
Regional$block$$spinal$intrathecal$morphine$
$
Post$Op$
CRIB$for$6$hours$
Monitor$BP/PR$$15mins$x$4,$30mins$x$4,$1$hrly$x$4,$2$hrly$x$4,$then$4$hrly$if$stable$
Allow$orally$as$tolerated$
IV$drip$5$pints$(3$pints$NS$+$2$pints$D5%)$until$tolerating$orally$
Strict$IO$charting$
Wound$inspection$Day$2,$no$need$for$STO$
FBC$6$hours$post$op$
To$start$S/C$Heparin$5000$U$BD$for$1/52$after$review$FBC$post$op$
Keep$CBD$for$1/7,$to$inform$if$bloodQstained$urine$
Strict$pad$chart$monitoring,$to$inform$if$more$than$2$pads$soaked$
IV$Pitocin$40$U$in$1$pint$NS$for$4Q6$hours$
Analgesia$as$per$Anaes$order$

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$

HYPERTENSION+IN+PREGNANCY+

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

Definition$

1. PregnancyHinduced$HPT$$HPT$after$20$weeks$of$gestation$in$a$previously$normotensive$woman$
with$no$significant$proteinuria,$usually$condition$returns$to$normal$within$6$weeks$postpartum$
2. Chronic$HPT$$HPT$that$is$present$at$the$booking$visit$of$before$20$weeks$of$gestation$or$if$the$
woman$ is$ already$ taking$ antiHPT$ medication$ when$ referred$ to$ maternity$ services.$ (NICE$
guidelines)$
3. PreHEclampsia$ $ BP$ of$ $ 140/90$ mmHg$ with$ significant$ proteinuria$ ($ 300$ mg/24hrs)$ after$ 20$
weeks$of$gestation$
4. Chronic$ HPT$ with$ superimposed$ preHeclampsia$ $ PreHeclampsia$ in$ patient$ with$ preHexisting$
hypertension$
5. Eclampsia$$preHeclampsia$with$convulsion$
6. Severe$ PreHEclampsia$ (Impending$ Eclampsia)$ $ PreHEclampsia$ with$ severe$ HPT$ $ symptoms,$ $
biochemical$$haematological$impairment$

$
Pathophysiology$of$preHeclampsia$
H Failure$ of$ normal$ invasion$ of$ trophoblast$ cells$ leading$ to$ maladaptation$ of$ maternal$ spiral$
arterioles$
H The$cytotrophoblast$infiltrates$the$decidual$portion$of$the$spiral$arteries,$but$fails$to$penetrate$
the$myometrial$portion,$thus$the$large,$tortuous$vascular$channels$characteristic$of$the$normal$
placenta$do$not$develop,$instead,$the$vessels$remain$narrow,$resulting$in$hypoperfusion$
H Abnormalities$of$spiral$artery$adaptation$are$immunologically$based,$with$genetic$influences$
H The$ ischemic$ placenta$ appears$ to$ alter$ maternal$ endothelial$ cell$ function$ and$ leads$ to$ signs$
and$symptoms$of$preHeclampsia$
H Many$of$the$clinical$features$can$be$explained$as$clinical$response$to$generalized$endothelial$
dysfunction$
$
Risk$factors:$
H Family$history$
H Multiple$gestation$
H PreHexisting$HPT,$DM,$renal$disease$or$vascular$disease$
H Previous$severe/early$onset$PE$
H Previous$SGA$
H Age$$40$y/o$
H Primigravida$
H Obesity$(BMI$$30)$
$
Symptoms$of$impending$eclampsia$(severe$PE):$
H Severe$headache$
H Vomiting$
H Blurring$of$vision$
H Epigastric$or$RUQ$abdominal$pain$(due$to$liver$capsule$distention)$
H Sudden$onset$of$swelling$of$the$face,$hands,$feet$
$
Systemic$involvement$
H CVS:$generalised$vasospasm,$$peripheral$resistance$
H Haematological:$thrombocytopenia$

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H CNS:$cerebral$edema,$cerebral$haemorrhage$
H Renal:$proteinuria,$$GFR$
H Hepatic:$subcapsular$hematoma$(which$gives$rise$to$epigastric$pain),$generalised$edema$
$
AIM$TO$KEEP$BP$<$150/100$mmHg!$
$
HELLP$syndrome$
H Hemolysis,$elevated$liver$enzymes,$low$platelet$
H Severe$form$of$preHeclampsia$
$
According$ to$ ACOG$ criteria,$ severe$ PE$ is$ considered$ if$ one$ or$ more$ of$ the$ following$ criteria$ are$
present:$
H BP$$160/110$on$2$occasions$at$least$4$hours$apart$
H Proteinuria$of$$5g/24hr$or$$3+$on$2$random$urine$samples,$collected$at$least$4$hours$apart$
H Oliguria$<$500ml/24hr$
H Cerebral$or$visual$disturbances$
H Pulmonary$edema$
H Epigastric$or$RUQ$pain$
H Impaired$liver$function$
H Thrombocytopenia$(<$100$x$109/L)$
H Fetal$growth$restriction$
$
Investigations$
H FBC$(platelet$count)$
H LFT,$including$AST$
H RP$(serum$creatinine)$
H Coagulation$profile$
Usually$normal$in$PE$
May$be$abnormal$with$advanced$disease$affecting$the$liver,$or$in$placenta$abruption$
H Serum$uric$acid$
H UFEME$and$urine$dipstick$test$$
H 24hr$urinary$protein$(standard$diagnostic$test)$
$
Antenatal$management$
H Identify$risk$factor$and$monitor$BP$
H Physical$examination$
$
1. Outpatient/KK$
H BP$monitoring$
H Urinalysis$(check$for$urine$albumin)$
H SFH$and$liquor$volume$
H RP,$FBC,$serum$uric$acid$
H Fetal$monitoring$$USG$monthly,$FKC$
$
2. Inpatient$
H Monitor$BP$4$hourly,$to$inform$MO$if$BP$$150/100$mmHg$
H Daily/biweekly$PE$profile$$
LFT,$coagulation$profile$if$suspected$HELLP$or$proteinuric$PIH$
H Urine$albumin$per$shift$
H Update$PE$chart$
H For$24$hour$urinary$protein$

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$

H Watch$out$for$signs$&$symptoms$of$impending$eclampsia$
H Fetal$surveillance$$FKC,$CTG,$USG$(for$fetal$growth,$AFI,$Doppler)$
$
$
$$$$$$$$$Timing$of$delivery$
$$$$$$$$$Uncomplicated$PIH$not$on$treatment$$40$weeks$
$$$$$$$$$PIH$on$treatment/$complicated$PIH$$~36$to$38$weeks$
$
$
Intrapartum$management$$
H BP/PR$half$hourly$
H If$patient$is$on$medication,$to$continue$meds$
H Strict$I/O$chart$
H Adequate$analgesia$
H CTG$monitoring$
H NOT$for$syntometrine/ergometrine!$
H To$give$Syntocinon$10$U$
$
Postpartum$management$
H Watch$ out$ for$ signs$ &$ symptoms$ of$ impending$ eclampsia$ and$ pulmonary$ edema$ (fluid$
overload)$
H BP$monitoring$
$hourly$monitoring$for$at$least$2H4$hours$before$sending$to$postnatal$ward$
4$hourly$monitoring$in$the$ward$for$24H48$hours$before$discharge$
H Continue$ with$ antihypertensive$ meds$ (if$ patient$ is$ on$ methyldopa$ $ discontinue,$ in$ view$ of$
postpartum$depression)$
H Strict$I/O$chart$
H Daily$urine$albumin$&$PE$profile$
H If$discharge,$$
EOD$BP$monitoring$at$KK$for$2$weeks$and$to$review$BP$in$2$weeks$by$MO$
Continue$antihypertensive$meds$
$
The$use$of$antihypertensive$medications$in$pregnancy$
H Mild$PIH$usually$do$not$require$antiHPT$
H Consider$antiHPT$if$diastolic$BP$above$100mmHg$
H Pregnant$women$with$chronic$HPT$who$take$ACEi,$ARBs$or$thiazide$diuretics$preHpregnancy$
To$ discontinue$ the$ meds$ in$ view$ of$ increased$ risk$ of$ congenital$ abnormalities$ during$
pregnancy$
H Indications$of$IV$antiHPT:$(as$per$protocol)$
When$BP$>$160/110$mmHg$sustained$for$more$than$30$minutes$
MAP$>$125$mmHg$
$
$$$$$$$$*Mean$Arterial$Pressure$(MAP)$=$DBP$+$1/3$(SBPHDBP)$
$
$
$
$
$
$
$
$

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$ MAP+>+125mmHg+
$
$
$
$ IV$bolus$5mg$(2.5cc)$
$ Hydralazine$over$1$min$
H 1$ampoule$contains$
$
$ 20mg$in$1$ml$
$ H add$9cc$of$normal$
$ saline$in$10cc$syringe$
$ (0.5mg/ml)$
$ $
$
$
$ Recheck$MAP$
$ after$15$mins$
$
$
$ MAP+>+125mmHg+
$ MAP+<+125mmHg+
$

$
$
Repeat$Hydralazine$ $ Maintenance$therapy$
every$15$mins$until$ $
$
either$cumulative$dose$
$
of$20mg$or$side$effects$
$ Hydralazine$infusion$(if$HR$<$
present$ $ 120$bpm)$
$ H dilute$50mg$in$50cc$
$ normal$saline$
MAP$>$125mmHg$and$ $ H start$at$5ml/hour$and$
$ increase$2.5$ml/hour$
HR$>$120$bpm$or$15mg$
$ every$30$minute$until$DBP$
Hydralazine$given$
$ 90H100$
$
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $ $ $
$ $ $ $ $ $ $ $ $ $$$$$$$$$$OR$
$
IV$Labetolol$20mg$(at$ $ Labetolol$infusion$(if$HR$>$120$
least$1$min)$followed$at$$ $ bpm$or$side$effects$of$
10$mins$intervals$by$40,$ $ hydralazine)$
80,$80,$160$ $ H 200mg$in$50cc$normal$
H each$ml$contains$ $ saline$
5mg$(1$ampoule$=$ $ H start$at$5ml/hour$
25mg$in$5ml$ $ (20mg/hour)$and$double$
$ every$30$minutes$by$10,$
$ 20,$40$
$
$
$
Source:$HTAR$protocol$

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H AntiHPT:$
$
AntiHPT$ MOA$ Starting$dosage$ Max.$dosage$ Side$effects$
Methyldopa$ Centrally$acting$ 250mg$TDS$ 3000mg/day$ PostHpartum$
depression$
Labetolol$ ,$$blockers$ 100mg$TDS$ 2000mg/day$ Bronchoconstriction,$
IUGR,$heart$block$
Nifedipine$ CCB$ 15mg$TDS$ 60mg/day$ Headache,$flushing$
Hydralazine$ Vasodilator$ 25mg/day$ 300mg/day$ Tachycardia,$
(only$IV)$ hypotension$
$
H Role$of$Aspirin$in$PIH$and$PE$
Women$at$high$risk$of$PE$are$advised$to$take$low$dose$aspirin$75mg$daily$starting$from$12$
weeks$
High$risk:$previous$PIH,$chronic$hypertension,$chronic$kidney$disease,$autoimmune$
disease,$DM$
$
$
Management$of$Eclampsia$
H Obstetrical$emergency!$
H Put$on$left$lateral$position$with$head$slightly$lowered$
H Maintain$airway$
H Give$O2$by$ventimask$
H Set$2$IV$lines$(large$bore$branula)$
H Abort$fit$by$MgSO4$
1$ampoule$contains$2.47gm$(~2.5$gm)$of$50%$MgSO4$in$5ml$
IV$regime$
! LOADING$dose:$4gm$MgSO4$
H 8ml$=$4gm$(need$2$ampoules),$then$mixed$with$12ml$normal$saline$in$20cc$
syringe$
H Give$20ml$slow$bolus$IV$over$10H15$minutes$
! Followed$by$MAINTENANCE$dose$1gm/hour$for$at$least$24$HOURS$after$last$fit$
H 5gm$of$MgSO4$(2$ampoules$=$10ml)$mixed$with$40ml$normal$saline$in$50cc$
syringe$using$infusion$pump$titrating$at$10ml/hour$
! Recurrent$seizure$$repeat$IV$MgSO4$but$at$a$lower$strength$dose;$2gm$given$slow$
bolus$over$10H15$minutes$
IM$regime$(usually$given$at$KK)$
! LOADING$dose:$10gm$MgSO4$
! 4$ampoules$H$2$ampoules$of$10ml$(5gm)$with$1ml$lignocaine$2%$for$each$buttock$into$
upper$outer$quadrant$of$the$buttock$in$zigzag$manner$
! MAINTENANCE$therapy$with$further$IM$5gm$MgSO4$(2$ampoules)$every$4$hours$
(alternate$buttocks)$
! Recurrent$seizure$$IM$5gm$MgSO4$
H After$fit$aborted,$to$take$GXM$and$PE$profile$
H Assess$GCS$level$and$neurological$status$
H Close$monitoring$of$vital$signs$
H Monitoring$during$MgSO4$therapy$
Clinical$signs$of$MgSO4$toxicity$
! Loss$of$deep$tendon$reflexes$(knee$jerk)$
! Respiratory$depression$<$16/min$
! Urine$output$<$25mls/hour$

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How$to$manage:$
! STOP$the$infusion$
! Give$ANTIDOTE$$IV$Calcium$Gluconate$10%$10mls$over$10$minutes$
! Oxygen$and$maintain$the$airway$if$respiration$is$depressed$
! If$knee$jerk$absent$but$normal$respiration$$withhold$further$doses$of$MgSO4$until$
reflexes$return$
! If$urine$output$<$100ml/4$hours$in$the$absence$of$above,$reduce$the$maintenance$
dose$IV$to$0.5gm/hour$or$IM$2.5gm$
Monitor$knee$jerk,$RR,$urine$output,$SpO2$hourly$
H Control$BP$by$using$antihypertensive$
Aim$to$keep$diastolic$BP$between$90H100$mmHg$
H DELIVERY$is$the$mainstay$of$treatment$of$eclampsia$
Preferably$Caesarean$section$
If$patient$is$already$in$2nd$stage,$to$proceed$with$assisted$SVD$
Paeds$to$be$present$at$delivery$$
H Fluid$therapy$
Fluid$restriction$of$80ml/hour$to$avoid$the$risk$of$fluid$overload$
$
Complications$of$preHeclampsia$
$
Maternal$ Fetal$
DIVC$ IUGR$
ARDS$ Abruptio$placenta$
Renal$failure$ Preterm$delivery$
Pulmonary$edema$ $
Cerebral$haemorrhage$ $
Cerebral$edema$ $
Subcapsular$hematoma$ $
$
$
References:$
1. HTAR$OnG$protocol$
2. NICE$clinical$guidelineH$The$management$of$hypertensive$disorders$during$pregnancy$
3. http://www.uptodate.com/contents/gestationalHhypertension$
4. http://www.uptodate.com/contents/pathogenesisHofHpreeclampsia$
5. BMJ$practice$$PreHEclampsia$
6. Ten$Teachers$Obstetrics$
7. American$College$of$Obstetricians$&$Gynaecologists$
$
$

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

GESTATIONAL*DIABETES*MELLITUS*

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

Physiology!
!hPL!and!cortisol!!insulin!antagonists!!relative!insulin!resistance!(most!marked!during!3rd!
trimester,!from!28!weeks!onwards)!
!
Risk!factors!(indication!for!MGTT,!to!be!documented!in!pink!book)!
P Obesity!(BMI!>30)!
P Age!>35!y/o!
P Family!history!of!DM!
P Prev.!big!baby!(>4.0!kg)!
P Prev.!unexplained!stillbirth!
P Prev.!congenital!abnormalities!
P Prev.!GDM!
P PCOS!
P Polyhydramnios!
P Presence!of!glycosuria!in!>2!occasions!
!
MGTT!!!done!at!around!12P14!weeks!
!!!!!!!!!!!!!!if!normal!but!have!significant!risk!factors,!to!repeat!at!28P32!
!!!!!!!!!!!!!!!!!!weeks!and!again!at!32P34!weeks!
!!!!!!!!!!!!!!if!high!risk,!to!repeat!as!early!as!24!weeks!
!
!!!!!!!!!!!!!!!!!!!Normal!range!MGTT:!
!!!!!!!!!!!!!!!!!!!FBS!P!<!5.6!
!!!!!!!!!!!!!!!!!!!2HPP!P!<7.8!
!
!
Aim!!to!maintain!blood!glucose!level!at!4P6mmol/L!
!
!
Antenatal!management!
P Refer!dietician!for!diet!control!
P Blood!sugar!profile!(BSP)!monitoring!2!weekly!at!KK!
Done!4!times!(fasting,!postPbreakfast,!postPlunch,!postPdinner)!
!
!!!!!!!!!!!!!!!!!!!!Fasting:!3.5P5.2!
PrePmeal:!3.5P5.9!
2HPP:!4.4P6.7!
!
Admission!for!BSP!stabilisation!
! FBS!!8!and!2HPP!!12!in!MGTT!
! Deranged!BSP,!at!least!2!point!!8!mmol/L!
BSP!monitoring!in!ward!
! On!diet!control!!4!point!BSP!(fasting,!postPbreakfast,!postPlunch,!postPdinner/before!
bed)!
! On!insulin!!7!point!BSP!(fasting,!pre!&!post!meals)!
! Investigations:!FBC,!BUSE,!HbA1C,!UFEME!
If!patient!is!given!IM!Dexamethasone,!BSP!reading!might!be!off!because!of!the!steroid!
effect!(!glucose)!

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

! Advise!patient!to!repeat!BSP!after!72hrs!of!IM!Dexa!administration!
P HbA1c!!<!7.0!
P SelfPmonitoring!blood!glucose!at!home!
P Early!detection!of!complications!
P Fetal!monitoring!for!growth!and!fetal!wellPbeing!
Ultrasound!(macrosomia,!polyhydramnios)!
Biophysical!profile!
Fetal!kick!chart!
CTG!
P Insulin!therapy!
Actrapid!(short!acting,!given!before!meal)!
Insulatard!(long!acting,!given!before!bed)!
P Refer!pharmacist!for!insulin!injection!technique!
P Timing!of!delivery!(do!NOT!exceed!post!date!)!
On!diet!control!!40!weeks!
On!insulin!!38!weeks!
!
Management!of!GDM!in!active!labour!
*!applicable!to!all!diabetic!mothers!with!insulin!therapy!only!
P Keep!NBM!
P Omit!morning!!dose!of!insulin!injection!if!SI!<!20U!or!give!!dose!if!SI!>!20U!
P Hourly!DXT!monitoring!
P Start!sliding!scale!(depend!on!DXT!reading)!
P 4!hourly!BUSE,!RBS!
P Take!GSH!
P Pain!relief!
P Hourly!CTG!monitoring!
P Urine!ketone!2!hourly!if!labour!>!8!hours!(to!look!for!dehydration)!
!
Sliding!scale!regime:!
DXT! Insulin!infusion!
<!4! Omit!
4!!6! 1U/hr!(5U!insulin!in!500mls!D5%!+!1gm!KCl)!
6.1P9! 2U/hr!(10U!insulin!in!500mls!D5%!+!1gm!KCl)!
9.1P12! 3U/hr!(15U!insulin!in!500mls!D5%!+!1gm!KCl)!
12.1P15! 4U/hr!(20U!insulin!in!500mls!D5%!+!1gm!KCl)!
15.1P18! 5U/hr!(25U!insulin!in!500mls!D5%!+!1gm!KCl)!
18.1P21! 6U/hr!(30U!insulin!in!500mls!D5%!+!1gm!KCl)!
!
!
DIK!regime!
P A!constant!infusion!of!500!ml!of!D5%!dextrose!water!at!100mls/hr!
P Preparation!of!soluble!insulin:!50U!Actrapid!in!50!ml!NS!(1U/ml)!
P Baseline!BUSE,!check!K+!prior!to!KCl!infusion!
P Separate!infusion!from!Syntocinon!infusion!(in!this!case,!patient!may!need!2!lines)!
P Insulin!causes!potassium!shift!from!extracellular!into!intracellular!environment,!can!lead!to!!
K+!in!the!bloodstream!!hypokalemia!(the!reason!we!add!on!KCl)!

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

P Insulin!also!can!cause!hypoglycaemia!and!we!dont!want!our!patients!to!go!into!
hypoglycaemic!state!so!we!give!dextrose!solution!
P DXT!monitoring!is!important!and!sliding!scale!is!adjusted!according!to!serial!DXT!reading!
!
PostPpartum!
P Delivery!of!baby!!!insulin!requirement!!off!insulin!
P Monitor!DXT!in!baby!and!mother!prior!to!discharge!
P Repeat!MGTT!in!6!weeks!post!delivery!to!check!if!GDM!has!resolved!
P If!patient!is!a!known!case!of!DM,!start!back!their!prePpregnancy!dose!and!regime!
P Encourage!breastfeeding!
P Advice!for!contraception!
!
!
Complications!of!GDM!
!
Mother! Fetal!
Nephropathy! Neural!tube!defect,!sacral!
agenesis*!
Retinopathy! Macrosomia!
Coronary!artery!disease! Hypoglycaemia!
Hyperglycemia/hypoglycaemia! Polycythemia!
PrePeclampsia! Polyhydramnios!(fetal!polyuria)!
Infection!!UTI,!vaginal! Unexplained!IUD!
candidiasis!
Thromboembolism! RDS!
DKA! Cardiac!anomalies!
! Hyperbilirubinemia!
! Preterm!labour!
! Birth!trauma:!shoulder!dystocia,!
Erbs!palsy!
!
!
!
References:!
1. HTAR!OnG!protocol!
2. Oxford!handbook!
3. Ten!teachers!

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! ! ! ! !
OnG! ! ! !!!!!!!!!PPROM,(PROM!
!
PRETERM&PRELABOUR&RUPTURE&OF&MEMBRANE&
(
Spontaneous(rupture(of(membrane(at(LESS(THAN(37(weeks(of(gestation(before(onset(of(
labour(i.e(the(onset(of(regular(uterine(contractions.(
(
Complicates(2%(of(pregnancies(but(associated(with(40%(of(preterm(deliveries(and(can(
result(in(significant(neonatal(morbidity(and(mortality(
(
ALWAYS(CONFIRM(THE(GESTATION!!!(
(
History((
Sudden(gush(of(fluid(*(
Clear(fluid,(not(foul(smelling(*(
No(history(of(recent(trauma,(fall(or(abdominal(massage(
Last(sexual(intercourse?(
History(of(fever,(URTI(or(UTI(symptoms(
(
Differential(diagnosis(
UTI(
Urinary(incontinence(
Vaginal(candidiasis(!(may(have(thick(curdy(discharge(
(
Risk(factors(
(
Maternal( Fetal( (
Infection((commonest)( Congenital(anomaly( (
Cervical(incompetence( Multiple(gestation( (
Multiparity( ( (
Low(socioeconomic(class( ( (
Poor(nutrition( ( (
Previous(scars( ( (
(
Investigations(
Nitrazine(testing(
Based(on(testing(the(vaginal(fluid(pH((pH:(4.5]6.0)(
Amniotic(fluid(pH:(7.1]7.3((alkaline)(
Nitrazine(paper(will(turn(blue(if(pH(>(6.0(
Microscopic(examination(of(vaginal(fluid(
Characteristic(ferning(of(the(crystalline(pattern(of(dried(amniotic(fluid(owing(to(its(
sodium(chloride(and(protein(content((
Litmus(test((red(to(blue)(
Amniocater(
High(vaginal(swab(
Ultrasound(to(look(for(oligohydramnios(
(
Management(of(PPROM(
Assess(for(signs(of(infection,(watch(out(for(signs(of(chorioamnionitis(
FBC,(CRP(
Sterile(speculum(examination(
Look(for(POOLING(of(fluid(in(the(posterior(fornix(

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OnG! ! ! !!!!!!!!!PPROM,(PROM!
!
Cough(reflex((fluid(leaking(out(of(cervix(
Os(open(or(close?(
Litmus(test(
Amniocater(if(in(doubt(
Take(sample(of(HVS(for(culture(
CTG((for(>30(weeks)(
Steroids(administration(for(fetal(lung(maturity((IM(Dexamethasone(12mg(BD)(for(24]
36(weeks(of(gestation(
Start(prophylactic(antibiotic((T.(EES(250mg(QID(for(10(days)(
Strict(pad(chart(monitoring(
Avoid(digital(VE(unless(contraction(is(stronger(
Ultrasound(scan(for(fetal(assessment(
Inform(Paeds(for(neonatal(support(especially(ventilator(booking(
Monitor(vital(signs,(look(for(temperature(spike(
EXPECTANT(management:(
(
Maternal( Fetal(
Temperature( Fetal(movement(FKC(
FBC(and(CRP(biweekly( Growth(scan(biweekly(
Pad(chart((change(of(liquor(colour( Daily(fetal(heart(monitoring(
Uterine(assessment(](clinical( (
(
Expectant(management(is(the(preferred(management(provided(there(is(no(fetal(or(maternal(
contraindication(till(34]36(weeks(of(gestation(depending(on(the(ventilator(support.(
(
If(patient(is(in(labour,(
>34(weeks(:(consider(steroids(and(allow(labour(to(progress(
<34(weeks:(if(assessment(shows(no(adverse(factors,(to(proceed(with(tocolysis(and(
allow(delivery(at(34(weeks(
According(to(RCOG,(tocolysis(is(not(recommended(because(this(treatment(does(
not(significantly(improve(perinatal(outcome(
Intrapartum(antibiotics(as(per(protocol(
(
Signs(of(chorioamnionitis:(
Maternal(pyrexia(
Tachycardia(
Leukocytosis(
Uterine(irritability(
Offensive(vaginal(discharge(
Fetal(tachycardia(
(
Complications(of(PPROM(
Preterm(delivery(leading(to(prematurity(
Chorioamnionitis(
Neonatal(sepsis(
Pulmonary(hypoplasia(
Cord(prolapse(
&
&
&

farehatta(
(
OnG! ! ! !!!!!!!!!PPROM,(PROM!
!
PRELABOUR&RUPTURE&OF&MEMBRANE&
(
Spontaneous(rupture(of(membrane(AFTER(37(weeks(of(gestation(before(the(onset(of(regular(
uterine(contractions(
(
PROM((SROM(
SROM(=(spontaneous(rupture(of(membrane(after(regular(uterine(contractions(
(
Management(of(PROM(
Sterile(speculum(examination(to(confirm,(with(litmus(paper/(amniocater(as(an(adjunct(
to(diagnosis((when(rupture(of(membrane(is(not(obvious)(
Avoid(digital(examination(as(it(can(introduce(infection(
If(per(speculum(shows(os(open,(to(proceed(with(VE(to(assess(os(dilatation(
CTG(stat((
For(VE(upon(stronger(contractions((to(avoid(regular(VE(if(possible)(
Strict(pad(charting(with(noting(of(liquor(colour(
Monitor(vital(signs,(look(for(temperature(spike(
Watch(out(for(signs(of(chorioamnionitis(
Monitor(LPC/FKC/FHR(
To(report(any(decrease(in(fetal(movement(
IOL(if(not(delivered(within(24(hours(
Expectant(management(criteria((for(IOL(24(hours(later):(
Normal(pregnancy(
Sterile(speculum(with(NO(prior(digital(examination(
Reactive(CTG(
No(antenatal(risk(factors(
No(meconium(stained(liquor(
No(malpresentation(
Daily(CTG(
If(patient(is(in(labour,(to(commence(intrapartum(antibiotics(
To(start(IV(Benzylpenicillin(3gm(stat(and(1.5gm(TDS(if(leaking(>(18(hours((for(GBS(
prophyaxis)(
Alternative:(IV(Ampicilin(2gm(stat(and(1gm(QID(
(
(
(
(
(
References:(
1. HTAR(OnG(protocol(
2. Royal(College(of(Obstetricians(&(Gynaecologists((Preterm(Prelabour(Rupture(of(
Membranes(
3. Ten(Teachers(Obstetrics(

farehatta(
(
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$PPH! !
!
POSTPARTUM)HEMORRHAGE)
$
Primary$PPH$0$Blood$loss$of$$500$ml$from$genital$tract$within$24$hours$after$delivery$
Secondary$PPH$0$Abnormal$or$excessive$bleeding$from$the$birth$canal$between$24$hours$and$
6$weeks$postnatally$
$
Priorities$
Call$for$help$(to$assist$in$controlling$bleeding)$
Assess$the$patients$condition$
Find$the$cause$of$bleeding$
Stabilize$or$resuscitate$the$patient$
Prevent$further$bleeding$
$
Causes$of$PPH$
4$T$$tone,$trauma,$tissue,$thrombin$

Tone$ Uterine$atony$(most$common$cause)$
Trauma$ Genital$ tract$ trauma,$ laceration,$ hematoma,$ uterine$ inversion,$ uterine$
rupture$
Tissue$ Retained$placenta$
Thrombin$ Coagulation$disorder$
$
Risk$factors$
Prolonged$3rd$stage$of$labour$
Multiple$pregnancy$
Caesarean$section$
Episiotomy$
Antepartum$hemorrhage$
History$of$PPH$
History$of$retained$placenta$
Fetal$macrosomia$
Polyhydramnios$
Grandmultipara$
Anemia$$
$
GENERAL$measures$in$managing$PPH$
ABC$
Set$2$IV$lines$(large$bore$branula)$and$take$blood$for$FBC,$GXM$(4$units),$PT,$aPTT$
Stabilize$ patient$ with$ crystalloids$ (Hartmanns$ or$ normal$ saline)$ or$ colloids$
(Gelafundin,$Hemacel)$and$run$fast$
High$flow$oxygen$
Monitor$parameters$closely$
General$condition$
Level$of$consciousness$
BP,$PR$
Pad$chart$
Strict$I/O$charting$
Abdominal$palpation$
If$the$uterus$is$not$contracting$and$soft$(boggy)$!$atony$
" Perform$uterine$massage$to$stimulate$contraction$

farehatta! ! !
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$PPH! !
!
" Empty$bladder$
" Give$uterotonic$drugs$
If$the$uterus$is$well$contracted,$the$cause$of$bleeding$is$likely$to$be$genital$tract$
trauma$
Careful$inspection$of$cervix,$vagina,$vulva,$perianal$area$for$lacerations,$hematoma$
Manual$exploration$of$uterine$cavity$$remove$clots,$retained$tissue$
Consider$coagulopathy$if$no$other$cause$identified$
$
SPECIFIC$measures$in$managing$PPH$
$
1. Uterine$atony$
Initially$ treated$ with$ bimanual$ uterine$ compression$ and$ massage$ to$ produce$
contraction$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Medical$treatment:$
IM$ Syntometrine$ 1ml$ (Syntocinon$ 5U$ +$ Ergometrine$ 0.5mg)$ $
contraindicated$in$HPT,$heart$disease$
IM/IV$Syntocinon$5U$if$Syntometrine$is$contraindicated$
IV$Pitocin$40U$in$500mls$normal$saline$at$40dpm$$may$increase$up$to$80U$
IM$Carboprost$(Hemabate)$250mcg$$dose$can$be$repeated$every$15$mins$
up$to$a$maximum$of$2mg$
*$Carboprost$is$150methyl$prostaglandin$F2a$
Insert$Foleys$catheter$to$empty$bladder!
Check$the$placenta$for$completeness$to$rule$out$retained$placenta$and$look$for$
cervical$lacerations$to$rule$out$genital$tract$trauma!
If$bleeding$persists$!$surgical$intervention!
Balloon$tamponade!
Hemostatic$brace$suturing$(B0Lynch$compression$sutures)!
Bilateral$ligation$of$uterine$arteries!

farehatta! ! !
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$PPH! !
!
Selective$arterial$embolization!
Hysterectomy$(last$resort$if$everything$fails)!
!
2. Retained$placenta!
Assess$the$patients$condition$&$estimate$blood$loss!
Empty$the$bladder!
Attempt$controlled$cord$traction$!
If$successful,$examine$the$placenta$to$ensure$completeness.$Maintain$the$
uterine$ contractions$ by$ massaging$ the$ fundus$ of$ the$ uterus.$ Put$ up$ IV$
Pitocin$40U$in$500mls$normal$saline$and$run$over$406$hours!
If$fails$!$manual$removal$of$placenta$under$anaesthesia!
Cover$with$broad$spectrum$antibiotics$(IV$Cefuroxime$1.5gm$and$IV$Flagyl$
500mg)!
!
3. Genital$tract$trauma$
Stabilize$patient$first$
Put$patient$in$lithotomy$position$
Find$the$bleeding$point$if$visible$and$clamp$it$
Suture$tear$immediately$
Watch$out$for$further$bleeding$
For$examination$under$anaesthesia$(EUA)$if$
Failed$to$identify$the$source$of$bleeding$
Patient$restless$or$uncooperative$or$vital$signs$are$unstable$
Bleeding$continues$despite$repair$done$
Cover$with$broad$spectrum$antibiotics$
$
Prevention$of$PPH$
Active$management$of$the$third$stage$of$labour$lowers$maternal$blood$loss$and$reduces$
the$risk$of$PPH$
Prophylactic$oxytocics$should$be$offered$routinely$in$the$management$of$the$third$stage$
of$labour$in$all$women$as$they$reduce$the$risk$of$PPH$by$about$60%$
For$ women$ without$ risk$ factors$ for$ PPH$ delivering$ vaginally,$ oxytocin$ (10U$ by$ IM$
injection)$is$the$agent$of$choice$for$prophylaxis$in$the$third$stage$of$labour$
For$women$delivering$by$caesarean$section,$oxytocin$(5U$by$slow$IV$injection)$should$be$
used$to$encourage$contraction$of$the$uterus$and$to$decrease$blood$loss$
$
$
References:$
1. HTAR$OnG$protocol$
2. American$Family$Physician$$Prevention$&$Management$of$Postpartum$
Hemorrhage$
3. Royal$College$of$Obstetricians$&$Gynaecologists$$Postpartum$Hemorrhage$

farehatta! ! !
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MISCARRIAGES$
!
MISCARRIAGES)
)
Spontaneous$loss$of$pregnancy$before$the$fetus$reaches$viability,$before$22$weeks$of$
gestation$
$
Classification$of$miscarriage$
Types$ Description$
Threatened$miscarriage$ PV$bleeding$or$spotting$that$may$persist$for$days$or$
weeks,$cramping$abdominal$pain$
Cervical$os:$Closed$
Uterus$$date$
USG:$IUGS$seen,$viable$fetus,$FH$+,$fetal$echo$+$
Plan:$Allow$discharge$with$reassurance;$TCA$2/52$to$
repeat$scan$to$confirm$fetal$viability;$TCA$stat$if$pass$out$
POC,$PV$bleed,$abdominal$pain$
DDX:$ectopic$pregnancy,$twisted$ovarian$cyst$
Inevitable$miscarriage$ Bleeding$is$heavy$or$increasing,$and$abdominal$cramping$
is$present$but$NO$passing$out$POC$
Cervical$os:$Open$
Uterus$$date$
USG:$IUGS,$no$fetal$heart$beat$
Plan:$
Counseling$
Keep$patient$in$ward$until$expulsion$has$occurred$
completely$
Monitor$VS$and$pad$chart$
Analgesics$
Repeat$per$speculum$if$PV$bleeding$and$abdominal$
pain$increasing$
If$expulsion$has$not$occurred$within$12$hours$for$
Cervagem$1mg$to$hasten$the$process$
Incomplete$miscarriage$ Pass$out$parts$of$POC$but$some$remains$in$the$uterus,$PV$
bleeding$(may$be$heavy$bleeding),$abdominal$pain$
Cervical$os:$Open$
Uterus$<$date$
USG:$heterogenous$tissues$in$uterus$$gestational$sac,$
any$endometrial$thickness$
Plan:$
Assess$the$degree$of$PV$bleeding,$resuscitate$if$
necessary$
If$POC$can$be$seen$on$per$speculum$!$to$remove$
with$sponge$forceps,$then$scan$to$determine$any$
retained$products$
IM$Syntometrine$1$amp$stat;$if$contraindicated,$to$
give$IV$Syntocinon$10$U$
If$retained$!$emergency$ERPOC$
Allow$discharge$after$6$hours$of$ERPOC$if$stable$
MC$for$2/52$
$
$

farehatta$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MISCARRIAGES$
!
Missed$miscarriage$ Gestational$sac$containing$embryonic$death$but$no$
passing$out$of$POC$
PV$bleeding,$pain,$loss$of$pregnancy$symptoms$
Cervical$os:$Closed$
Uterus$<$date$
USG:$collapsed$empty$IUGS,$gestational$sac$diameter$
>20mm$with$no$fetal$pole,$no$FH$activity$
Plan:$conservative$vs$active$management$
Allow$discharge,$TCA$2/52$to$repeat$scan$to$confirm$$
Conservative$$let$POC$comes$out$naturally$
Active$$ERPOC$(S+C,$D+C)$
FBC,$GSH,$screening$for$coagulopathy$
DDX:$TRO$wrong$date,$early$pregnancy$
Complete$miscarriage$ All$POC$have$been$expelled$
Commonly$occurs$before$12$weeks$of$pregnancy$
After$the$miscarriage$there$is$a$period$of$bleeding$and$
cramping,$which$resolves$without$treatment$
Cervix$os:$Closed$
USG:$empty$uterus$with$no$sign$of$gestational$sac$or$
embryo$seen,$endometrial$thickness$<15mm$
Plan:$
Examine$POC,$send$POC$for$HPE$
Assess$bleeding$
Scan$to$confirm$
IM$Syntometrine$1$amp$stat,$then$reassess$in$an$
hour$
If$bleeding$stops,$can$allow$discharge$
MC$for$1/52$
Avoid$sexual$intercourse$for$2^3$weeks$
Counseling$before$discharge$
Septic$miscarriage$ Any$abortion$that$becomes$infected$
Symptoms$include$fever,$chills,$flu^like$aches,$abdominal$
pain,$vaginal$bleeding,$and$vaginal$discharge,$which$may$
be$thick$and$may$have$a$foul$odor$
Commonest$organisms:$E.coli,$Streptococci,$anaerobes$
May$lead$to$septic$shock$
Causes$
Delay$in$evacuation$of$uterus$
Trauma$$
Plan:$
D&C$as$soon$as$possible$
Cover$with$broad$spectrum$antibiotics$(IV$
Cefuroxime$750mg$TDS,$IV$Flagyl$500mg$TDS)$
FBC,$RP,$blood$C+S,$urine$C+S,$HVS$C+S,$coagulation$
screening$
Complications:$Pelvic$abscess,$septic$shock,$chronic$PID,$
uterine$synechae$
$
$
$

farehatta$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MISCARRIAGES$
!
Diagnosis$
In$some$cases,$miscarriage$can$be$diagnosed$based$upon$the$woman's$symptoms$and$
the$physical$exam$
Ultrasound$
In$early$pregnancy$!$TVS$$
If$an$embryo$is$present,$its$size$is$measured$and$compared$to$the$size$that$is$
expected$at$the$woman's$stage$of$pregnancy$
The$sac$and$other$materials$surrounding$the$embryo$are$also$examined$to$look$for$
abnormalities$in$these$structures$
Fetal$heart$beat$
At$about$6$weeks$after$the$LMP,$the$motion$of$the$fetal$heart$should$be$visible$on$
ultrasound$
If$the$pregnancy$has$progressed$to$the$stage$where$a$heart$beat$should$be$present,$
the$failure$to$detect$a$heart$beat$during$an$ultrasound$exam$indicates$that$the$
pregnancy$has$likely$ended$
On$the$other$hand,$the$presence$of$a$fetal$heart$beat$(in$the$absence$of$other$
abnormalities$in$the$pregnancy)$indicates$the$pregnancy$may$still$be$viable$and$
that$miscarriage$may$not$occur$
$
$
Counselling$before$discharge$
Cause$of$miscarriage$
Avoid$sexual$intercourse$for$2^3$weeks$
Contraception$for$3$months$(incomplete$miscarriage)$
TCA$stat$if$"$PV$bleeding,$severe$abdominal$pain,$or$pass$out$POC$
TCA$gynae$clinic$for$assessment$
$
$
$
$
$
$
$
References:$
1. Ten$Teachers$Gynaecology$
2. Kedah$Hospital$Protocol$
$

farehatta$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ECTOPIC$PREGNANCY$
!
ECTOPIC'PREGNANCY'
$
Definition:$Implantation$of$conceptus$outside$the$uterine$cavity$
$
A$potentially$lifeAthreatening$condition$
Ruptured$ectopic$pregnancy$is$a$gynaecological$emergency$
Recurrence:$10%$
95A98%$of$ectopic$pregnancies$occur$in$Fallopian$tube$with$ampulla$is$the$most$
common$site$for$tubal$pregnancies$
$
Risk$factors$
Advanced$maternal$age$(>$35$years$old)$
Previous$history$of$PID$and$tubal$surgery$
Previous$history$of$ectopic$pregnancy$
Pregnancy$with$IUCD$in$situ$
Infertility$
Congenital$abnormality$of$Fallopian$tube$
Assisted$reproductive$technique$
Smoking$$
$
History$
PV$bleeding$
Severe$abdominal$pain$$
UPT$positive$
Ruptured$ectopic$"$intraperitoneal$
Shoulder$tip$pain$(blood$irritating$the$diaphragm)$
bleeding$
Fainting$spells,$dizziness$
$
Physical$examination$
Pale,$hypotension,$tachycardia$
Abdominal$tenderness$if$intraperitoneal$bleeding$
Pelvic$examination:$bluish$cervix$with$os$closed,$+$cervical$excitation,$adnexal/POD$
tenderness/mass$
$
TVS$(must$be$interpreted$together$with$serum$AhCG)$
Empty$uterus$(no$IUGS$seen)$
Free$fluid$in$POD$(nonAspecific)$
Ectopic$gestational$sac$(extrauterine$sac$with$an$embryo$or$embryonic$remnants)$
Presence$of$adnexal$mass/sac$$free$fluid$
$
Investigations$
UPT$to$confirm$pregnancy$
FBC$
Coagulation$profile$if$signs$of$coagulopathy$present$$
GXM$4$pints$packed$cell$
Ultrasound$
Serial$serum$AhCG$if$diagnosis$in$doubt$$
In$99%$of$viable$intrauterine$pregnancies$A$!$hCG$levels$of$at$least$53%$
(doubling)$in$48$hours$
When$level$is$above$discriminatory$level$(>$1000$U/L)$&$no$sign$intrauterine$
gestation$on$TVS$$viable$intrauterine$gestation$is$extremely$unlikely$

farehatta$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ECTOPIC$PREGNANCY$
!
Serum$quantitative$hCG$can$be$used$to$differentiate$between$an$ectopic$
pregnancy$&$a$failing$intrauterine$gestation$
$
$
$
$
Suboptimal$increase$
$ A$steady$decrease$in$ (<53%)$or$plateauing$
$ hCG$in$48$hours$$ of$hCG$values$
$
$
$
$
$
$
$ Failing$intrauterine$ Ectopic$pregnancy$
$ pregnancy$
$
$
General$management$
Resuscitation$
Arrange$for$surgical$intervention$
Counseling$regarding$the$diagnosis$and$plan$
To$give$IM$Rhogam$500$IU$if$mother$is$Rhesus$negative$
$
Definitive$management$"$Surgery!$
Laparoscopy$is$the$gold$standard$of$treatment$to$establish$the$diagnosis$and$should$
be$considered$in$women$with$hCG$above$the$discriminatory$level$and$absence$of$IUGS$
on$ultrasound$
Laparoscopy/laparotomy$with$salphingectomy/salphingostomy$
$
Criteria$for$IM$Methotrexate$50mg/m2$single$dose$
Unruptured$ectopic$<$3.0cm$
No$fetal$heart$motion$
Patient$being$fully$counseled$and$good$compliance$
Decision$made$by$OnG$specialist$
No$contraindication$to$methotrexate$such$as$
Active$hepatic$disease$
Renal$disease$
Abnormal$serum$creatinine$and$SGOT$
Active$peptic$ulcer$disease$
Leucocyte$<3000$and$platelet$<100,000$
$
$
References:$
1. Kedah$Hospital$Protocol$
2. Ten$Teachers$Gynaecology$
3. BMJ$Practice$$Ectopic$Pregnancy$
4. American$College$of$Obstetricians$&$Gynaecologists$$Ectopic$Pregnancy$

farehatta$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$GESTATIONAL$TROPHOBLASTIC$DISORDERS$
!
GESTATIONAL*TROPHOBLASTIC*DISORDERS*
$
Arise$from$placental$trophoblasts$
Syncytiotrophoblasts$secrete$hCG$!$used$as$tumour$marker$
$
$
Molar$Pregnancy$
$
Complete*hydatidiform*mole* Partial*hydatidiform*mole*
Generalized$swelling$of$the$villous$tissue$ Focal$swelling$of$the$villous$tissue$
Diffuse$trophoblastic$hyperplasia$ Focal$trophoblastic$hyperplasia$
No$embryonic$or$fetal$tissue$ Presence$of$embryonic$or$fetal$tissue$
Diploid$ chromosomal$ constitution$ derived$ Usually$ triploid$ and$ of$ diandric$ origin,$
from$ paternal$ genome$ &$ usually$ resulting$ having$ 2$ sets$ of$ chromosomes$ from$
from$ the$ fertilization$ of$ an$ oocyte$ by$ a$ paternal$origin$&$1$from$maternal$origin$
diploid$spermatozoon$ O$ most$ have$ a$ 69XXX$ or$ 69XXY$ genotype$
derived$ from$ a$ haploid$ ovum,$ with$ either$
reduplication$ of$ the$ paternal$ haploid$ set$
from$ a$ single$ sperm,$ or$ from$ dispermic$
fertilization$
$
Risk$factors$
Advanced$maternal$age$(>35$years$old)$
Previous$history$of$molar$pregnancy$
Blood$group$A$(assoc.$with$choriocarcinoma)$
$
Signs$&$symptoms$
PV$bleeding$
Uterus$larger$than$dates$
Abnormally$high$serum$hCG$for$gestational$age$
Medical$ complications:$ PIH,$ hyperthyroidism,$ hyperemesis,$ anemia,$ ovarian$ theca$
lutein$cysts$
$
Ultrasound$
Uterine$ cavity$ filled$ with$ multiple$ sonolucent$ areas$ of$ varying$ size$ &$ shape$ (snowO
storm$appearance)$with$no$embryonic$or$fetal$tissue$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

farehatta$
OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$GESTATIONAL$TROPHOBLASTIC$DISORDERS$
!
Investigations$
Serial$serum$beta$hCG$
HPE$of$placental$tissue$:$placental$villi$with$irregular$architecture,$edema$with$true$
villous$cavitation,$and$trophoblast$hyperplasia$
$
Management$
Uterine$evacuation$(S&C)$
Serial$ measurement$ of$ hCG$ levels$ is$ the$ gold$ standard$ for$ diagnosis$ &$ monitoring$$
the$therapeutic$response$of$GTD$
After$ evacuation,$ hCG$ level$ should$ be$ monitored$ weekly$ until$ detectable,$
followed$by$monthly$monitoring$for$6O24$months$
$
$
Choriocarcinoma$
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A$highly$malignant$tumour$that$arises$from$trophoblastic$epithelium$
Rapidly$metastasizes$to$the$lungs,$liver$and$brain$
Following$ uterine$ evacuation,$ molar$ pregnancy$ can$ progress$ to$ develop$
choriocarcinoma$
Many$patients$will$present$with$SOB,$neurological$symptoms$&$abdominal$pain$for$few$
weeks$or$months$
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References:$
1. Ten$Teachers$Gynaecology$
2. BMJ$Practice$$Molar$Pregnancy$

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OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MENORRHAGIA$
!
MENORRHAGIA*
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Heavy$cyclical$menstrual$blood$loss$over$several$consecutive$menstrual$cycles$in$a$woman$of$
reproductive$years,$or$more$objectively,$a$total$menstrual$blood$loss$of$more$than$80$ml$per$
menstruation$(Hallberg$et$al,$1966).$
$
Causes:$
1. Idiopathic$$Dysfunctional$uterine$bleeding$(DUB)$
2. Secondary$$
Uterine$fibroid$
Endometrial$polyp$
Endometriosis$
Coagulopathy$
Drug$therapy$(warfarin,$IUCD)$
Hypothyroidism$
$
Dysfunctional$uterine$bleeding$
A$diagnosis$of$exclusion$
Abnormal$uterine$bleeding$in$the$absence$of$pregnancy,$genital$tract$pathology,$or$
systemic$disease$
Mechanisms$of$DUB$
Abnormal$ prostaglandin$ ratios$ and$ other$ inflammatory$ mediators$ !$
vasodilatation$&$platelet$nonTaggregation$
Excessive$fibrinolysis$$
$
Management$of$Menorrhagia$
Full$history$
Pattern$of$menstrual$blood$loss$
Association$with$dysmenorrhea$
Symptoms$of$anemia$
Symptoms$of$hypothyroidism$
Bleeding$tendencies$
Risk$ factors$ for$ endometrial$ disease$ (age$ >40,$ obesity,$ nulliparity,$ infertility,$
tamoxifen$therapy,$underlying$DM,$PCOS)$
Smear$history$
Use$of$contraception$
History$of$drug$therapy$
Physical$examination$
Abdominal$examination$
Per$speculum$examination$
Bimanual$examination$
Investigations$
FBC,$GXM$
TFT$and$coagulation$profile$if$clinically$indicated$
Pap$smear$if$indicated$
Ultrasound$$
TVS$to$identify$fibroids$&$polyps,$measure$endometrial$thickness$(ET)$$usually$
indicated$if$age$>40,$failed$medical$therapy,$presence$of$risk$factors$
Pipelle$ sampling$ to$ exclude$ endometrial$ hyperplasia$ or$ cancer$ $ indicated$ if$
bleeding$persists,$presence$of$risk$factors$and$ET$>$12mm$

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OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MENORRHAGIA$
!
Hysteroscopy$$
Medical$treatment$
Tranexamic$acid$500mgT1g$TDS$(antifibrinolytic$agent)$
Mefenamic$acid$500mg$TDS$(NSAIDs)$$can$relieve$dysmenorrhea$
T.$Provera$10mg$OD$for$21$days$from$D5$for$3$cycles$(medroxyprogesterone)$or$
T.$Duphaston$10mg$BD$for$21$days$from$D5$(dydrogesterone)$or$COCP$
Levonorgestrel$intrauterine$system$(Mirena)$
GnRH$analogues$ If$bleeding$persists$for$
T.$Danazol$100mg$BD$for$3T6$months$ more$than$6$months$
Hematinics$$
Surgical$treatment$(if$failed$medical$therapy)$
Endometrial$ablation$
Hysterectomy$$
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References:$
1. Kedah$Hospital$Protocol$
2. Oxford$Handbook$of$Obstetrics$&$Gynaecology$
3. CPG$Menorrhagia$(2004)$
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