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MOH Pocket Manual in Obstetrics and Gynaecology PDF
MOH Pocket Manual in Obstetrics and Gynaecology PDF
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MOH Pocket Manual in Obstetrics & Gynaecology
MANAGEMENT OF PATIENT ON
ANTI – COAGULANT
INSTRUMENTAL DELIVERY
PERIMORTEM CAESAREAN SECTION
MANAGEMENT OF HIV IN PREGNANCY
ECTOPIC PREGNANCY
SEPTIC SHOCK
3RD AND 4TH DEGREE PERINEAL TEAR
GESTATIONAL TROPHOBLASTIC DISEASE
EPISIOTOMY
MANAGEMENT OF COUPLE WITH RECURRENT ABOR-
TION
EARLY PREGNANCY LOSS MANAGEMENT
MENORRHAGIA
MANAGEMENT OF HEMATOMAS RESULTING FROM OC
DELIVERY
ANTENATAL CARE
MANAGEMENT OF DIABETES
IN PREGNANCY ( GDM )
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MOH Pocket Manual in Obstetrics & Gynaecology
WORK UP:
• It is a team work.
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MOH Pocket Manual in Obstetrics & Gynaecology
Causes of PPH:
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MOH Pocket Manual in Obstetrics & Gynaecology
Coagulation defect 1%
§
• Clinical drill
MANAGEMENT:
It is a team work.
- Multidisciplinary approach:
• Experienced midwife
• Senior Obstetrician
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MOH Pocket Manual in Obstetrics & Gynaecology
• Alert Anesthesiologist
Resuscitation by :
b) Oxygen saturation
c) Foley’s catheter
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MOH Pocket Manual in Obstetrics & Gynaecology
Plasma.
every 30 minutes
3.6 ECG
Blood transfusion:
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MOH Pocket Manual in Obstetrics & Gynaecology
• 6 units of PRBC
• 6 units of Platelets
• 10 units of cryoprecipitate
2. Aim to maintain:
• Hb> 8 g/dl
• Platelet > 75 x 10 9
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MOH Pocket Manual in Obstetrics & Gynaecology
it as needed.
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MOH Pocket Manual in Obstetrics & Gynaecology
rupture:
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MOH Pocket Manual in Obstetrics & Gynaecology
ALERT:
3. Activate the massive blood loss > 2.5 liter protocol as early
as possible to ensure proper and volume replacement.
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MOH Pocket Manual in Obstetrics & Gynaecology
References:
• WHO Guideline
•RCOG 2009
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MOH Pocket Manual in Obstetrics & Gynaecology
SHOULDER DYSTOCIA
OVERVIEW:
WORK UP:
MANAGEMENT:
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MOH Pocket Manual in Obstetrics & Gynaecology
internal manoeuvers.
E - Enter : Rubins 2 : Enter the vagina from below and apply the
digital pressure to the posterior aspect of the anterior shoul-
der towards the baby’s chest.
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MOH Pocket Manual in Obstetrics & Gynaecology
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MOH Pocket Manual in Obstetrics & Gynaecology
ALERT:
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MOH Pocket Manual in Obstetrics & Gynaecology
• Serious complications:
- Eclamptic seizures
- Cerebral haemorrhage
- Abruptio placenta
WORK UP:
• Investigations:
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MOH Pocket Manual in Obstetrics & Gynaecology
MANAGEMENT:
• Stabilization:
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MOH Pocket Manual in Obstetrics & Gynaecology
• Treatment Goals:
1) Prevent seizures:
Magnesium sulphate:
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MOH Pocket Manual in Obstetrics & Gynaecology
AGENT DOSAGE
Start with 20 mg. IV, repeat at 20 – 80 mg
1.) LABETALOL
IV every 30 minutes or 1 – 2 mg/min, max
OR
)300 mg. ( then switch to oral
mg. capsule to be bitten and swal� 10 – 5
2.) NIPEDIFINE
lowed or just swallowed every 30 minutes
10 mg. tablet orally every 45 minutes to a
OR
maximum 80 mg./day
Start with 5 mg. IV, repeat 5 – 10 mg.
3.) HYDRALAZINE IV every 30 minutes to a maximum of 20
. mg IV
AGENT DOSAGE
1.) METHYLDOPA mg. Orally BID– QID ( 500 - 250
OR )max. 2 g/day
1.) LABETALOL mg. Orally BID – TID 400 – 100
OR )Max. 1200 mg/day (
2.) NIPEDIFINE Oral Tablets ( 10 – 20 mg. Orally
)BID – TID ( Max. 180 mg./day
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MOH Pocket Manual in Obstetrics & Gynaecology
• Delivery:
may be required.
• Postpartum:
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ALERT:
References:
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WORK UP:
MANAGEMENT:
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In massive haemorrhage :
• Bi manual compression
• Uterine packing
• B-Lynch
• Hysterectomy
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ALERT:
References:
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MOH Pocket Manual in Obstetrics & Gynaecology
CORD PROLAPSE
OVERVIEW:
WORK UP:
MANAGEMENT:
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ALERT:
References:
• William 24 Edition
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MOH Pocket Manual in Obstetrics & Gynaecology
PRETERM LABOUR
OVERVIEW:
WORK UP:
MANAGEMENT:
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MOH Pocket Manual in Obstetrics & Gynaecology
24 – 32 Week:
6 – 8 hours up to 48 hours
32 – 34 Week:
1- Nifedipine or
2-ß – Adenergic Receptor Agonist:
A. Ritodrine - 100 mg. Ritodrine HCL in 500 ml LR , 15 ml/
hr = 0.05 mg/min.
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MOH Pocket Manual in Obstetrics & Gynaecology
Ø ECG changes
Ø Hypotension unresponsive to position change
Ø Respiratory symptoms: tachycardia, shortness of
breath, chest pain
Ø Excessive maternal nervousness, palpitations,
tremors or headache
Ø Vaginal bleeding
B. Terbutaline
Then reduce the dose to the lowest dose that maintain the
uterine quiescence.
1. Atosiban (Tractocile)
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MOH Pocket Manual in Obstetrics & Gynaecology
3- Magnesium Sulphate
ALERT:
References:
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MOH Pocket Manual in Obstetrics & Gynaecology
WORK UP:
2. Physical Examination:
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MANAGEMENT:
2) 24 – 33 weeks:
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MOH Pocket Manual in Obstetrics & Gynaecology
Hospital admission.
-Antibiotics:
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MOH Pocket Manual in Obstetrics & Gynaecology
• Hospital admission.
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ALERT:
References
• RCOG
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MOH Pocket Manual in Obstetrics & Gynaecology
WORK UP :
Investigation :
Ø Biometry
Ø Doppler velocimetry
Ø Abdominal circumference and estimated fetal
weight (EFW)
• Serial measurement of abdominal circumference and EFW
every 2-4 weeks.
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MANAGEMENT :
ALERT :
References:
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WORK UP:
MANAGEMENT:
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MOH Pocket Manual in Obstetrics & Gynaecology
ALERT:
Missing cases of fetal compromise ( e.g. Intrauterine
Growth Restriction) can lead to fetal demise.
References:
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MOH Pocket Manual in Obstetrics & Gynaecology
PERIPARTUM HYSTERECTOMY
OVERVIEW:
WORK UP:
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MANAGEMENT:
possible.
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MOH Pocket Manual in Obstetrics & Gynaecology
operative infection.
hysterectomy.
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ALERT:
References:
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MOH Pocket Manual in Obstetrics & Gynaecology
CAESAREAN SECTION
OVERVIEW:
WORK UP:
- Physical examination
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MOH Pocket Manual in Obstetrics & Gynaecology
MANAGEMENT:
- Informed Consent:
The women should be aware that the fetus or fetuses will be de-
livered by the abdominal through open incision in the abdomen
and uterus. Explain the procedure as describe in the patient in-
formation.
Women, who are obese, have had previous surgery or have pre
existing medical conditions must understand that the quoted risks
for serious or frequently complications will
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MOH Pocket Manual in Obstetrics & Gynaecology
Other procedures:
ALERT:
Women with placenta praevia who have had a previous cae-
sarean at high risk of having a morbidly adherent placenta.
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MOH Pocket Manual in Obstetrics & Gynaecology
References:
• Up to date , 2013
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BREECH IN LABOUR
OVERVIEW:
WORK UP:
• ECV IS COSIDERED
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MANAGEMENT:
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Term Breech:
• Footling breech
References:
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WORK UP:
MANAGEMENT:
• Induction of labour.
• COAGULATION PROFILE
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MOH Pocket Manual in Obstetrics & Gynaecology
ALERT:
For woman who have intrauterine fetal death and who have a pre-
vious caesarean section, the risk of uterine rupture is increased.
The dose of vaginal prostagladin should be reduced accordingly,
particularly in the third trimester
Reference:
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MOH Pocket Manual in Obstetrics & Gynaecology
INDUCTION OF LABOUR
OVERVIEW:
WORK UP:
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MANAGEMENT:
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5. Breech presentation
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Ø For women who have intrauterine fetal death and who have
had a previous caesarean section, the risk of uterine rupture
increased. The dose of vaginal prostaglandin should be re-
duced accordingly, particularly in the third trimester.
Ø Membrane sweeping
Ø Pharmacological Methods
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MOH Pocket Manual in Obstetrics & Gynaecology
- Maximum = 4 doses
- Maximum = 4 doses
- Maximum = 4 doses
A. Previous Scar:
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MOH Pocket Manual in Obstetrics & Gynaecology
• Oral PGE2
• Intravenous PGE2
• Intracervical PGE
• Hyaluronidase
Ø Surgical Methods
Ø Mechanical Methods
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Ø Failed Induction
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Ø Cord Prolapse
ALERT:
Reference:
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WORK UP:
MANAGEMENT:
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MOH Pocket Manual in Obstetrics & Gynaecology
SCORE PARAM-
0 1 2 3
ETERS
)Dilatation (cm 0 2–1 4–3 5+
)Length of cervix (cm 3 2 1 0
Station -3 -2 -1 +2 +1
Consistency Firm Medium Soft -
Ante-
Position Posterior Mid -
rior
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MOH Pocket Manual in Obstetrics & Gynaecology
• Oxytocin Regimen:
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MOH Pocket Manual in Obstetrics & Gynaecology
w M i l l i u n i t s / Infusion .Microdrops/min
Minutes pump )ml. = 60 drops 1 (
)ml/ hour ( ).hour = 60 mins 1 (
1 6 6
2 12 12
3 18 18
4 24 24
5 30 30
6 36 36
7 42 42
8 48 48
9 54 54
10 60 60
11 66 66
12 72 72
13 78 78
14 84 84
15 90 90
16 96 96
17 102 102
18 108 108
19 114 114
20 120 120
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MOH Pocket Manual in Obstetrics & Gynaecology
6 ml/hour.
NOTE:
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21 63 63
22 66 66
23 69 69
24 72 72
25 75 75
26 78 78
27 81 81
28 84 84
29 87 87
30 90 90
31 93 93
32 96 96
ALERT:
The syntocinon should be reduced or stopped:
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MOH Pocket Manual in Obstetrics & Gynaecology
every 10 min.).
Refrences:
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MOH Pocket Manual in Obstetrics & Gynaecology
TWIN PREGNANCY
OVERVIEW:
WORK UP:
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MOH Pocket Manual in Obstetrics & Gynaecology
MANAGEMENT:
Ø Polyhydramnios/oligohydramnios
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MOH Pocket Manual in Obstetrics & Gynaecology
- It has complications:
Ø Cord entanglement
Ø Prematurity
Ø TTTS ( uncommon)
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MOH Pocket Manual in Obstetrics & Gynaecology
Ø Give corticosteroids
Ø Arrange for MRI of fetal brain will give your earlier and
more detailed information about brain lesions then ultrasound
do.
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MOH Pocket Manual in Obstetrics & Gynaecology
ALERT:
References:
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MOH Pocket Manual in Obstetrics & Gynaecology
TWINS IN LABOUR
OVERVIEW:
WORK UP:
• Start I.V. line and extract blood for CBC, cross match and
Indirect Coomb’s test
MANAGEMENT:
• 2nd Twin :
Ø After delivery of 1st , heart rate and lie of 2nd twin should be
evaluated using ultrasound and electronic fetal monitoring.
Ø Both the fetal and placental sides of the cut umbilical cord
of 2nd twin is double clamped.
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MOH Pocket Manual in Obstetrics & Gynaecology
ALERT:
References:
• William 24th Edition
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CARDIAC DISEASE
OVERVIEW:
WORK UP:
• ECG monitoring
• Vital signs
• Fetal monitoring
MANAGEMENT:
• Insert IV line.
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oxytocin, if needed.
• Postpartum :
- Pulse oxymetry
- ECG monitoring
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MOH Pocket Manual in Obstetrics & Gynaecology
- Fluid balance
Ø Inform Consultant.
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• Endocarditis Prophylaxis:
- Indications:
- Regime:
ALERT:
References:
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MOH Pocket Manual in Obstetrics & Gynaecology
DESSIMINATED INTRAVASCULAR
COAGULOPATHY (DIC)
OVERVIEW:
WORK UP:
MANAGEMENT:
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MOH Pocket Manual in Obstetrics & Gynaecology
• Avoid hypothermia.
If severe bleeding :
Ø 6 units of PRBC
Ø 6 units of Platelets
Ø 10 units of Cryoprecipitate
Ø Antithrombin III
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MOH Pocket Manual in Obstetrics & Gynaecology
• Aim to maintain:
Ø Hb> 8 g/dl
Ø Platelet > 75 x 10 9
Ø Prothrombin < 1.5
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MOH Pocket Manual in Obstetrics & Gynaecology
• Complication of DIC:
Ø Renal failure
Ø Liver failure
Ø Pulmonary dysfunction
Ø CNS dysfunction
Ø Death
ALERT:
References:
• Up To Date 2012
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MOH Pocket Manual in Obstetrics & Gynaecology
OVERVIEW:
WORK UP:
• Keep I.V. line access.
• Send blood for urgent CBC and cross match of blood and
blood products.
MANAGEMENT:
1-oxytocin;
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MOH Pocket Manual in Obstetrics & Gynaecology
2-Ergot alkaloids;
2- Retained Placenta :
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MOH Pocket Manual in Obstetrics & Gynaecology
haematologist.
- Site IV line , take blood for CBC and cross match 2 units
of PRBCs.
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Extent of inversion:
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ALERT:
References:
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MANAGEMENT OF PATIENTS ON
ANTI - COAGULANT THERAPY
OVERVIEW:
WORK UP:
MANAGEMENT:
1. During Pregnancy:
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1. During Labour:
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MOH Pocket Manual in Obstetrics & Gynaecology
2-After Delivery:
Regional Anesthesia :
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ALERT:
References:
• Up To Date 2012
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INSTRUMENTAL DELIVERY
OVERVIEW:
WORK UP:
Preparation:
- Empty bladder
- Lithotomy position
- Adequate analgesia
needed in multigravid.
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MOH Pocket Manual in Obstetrics & Gynaecology
MANAGEMENT:
Instrumental Use:
• Forceps – Types:
1) Classical Forceps:
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MOH Pocket Manual in Obstetrics & Gynaecology
• Vacuum Extraction:
Ø The head, not just the scalp should descend with each pull.
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MOH Pocket Manual in Obstetrics & Gynaecology
- Slips 3x.
- 20 minutes elapsed.
3).Technique:
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MOH Pocket Manual in Obstetrics & Gynaecology
ALERT:
References:
• Up To Date 2012
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WORK UP:
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MANAGEMENT:
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• Pack the uterus with moist sponges. Remove lateral tilt. Con-
tinue ACLS throughout.
ALERT :
References:
• RCOG
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MOH Pocket Manual in Obstetrics & Gynaecology
• All pregnant women are ended the screening for HIV in-
fection, syphilis, hepatitis B and rubella in every pregnancy
at their booking antenatal visit, as part of the infectious Dis-
eases in Pregnancy Screening Programme and management
should be a multidisiplinary. Team including an HIV physi-
cian, specialist, midwife, and pediatrician.
WORK UP:
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MANAGEMENT:
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2-Management of delivery:
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Ø Prolonged pregnancy:
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ALERT:
Reference:
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ECTOPIC PREGNANCY
OVERVIEW:
WORK UP:
MANAGEMENT:
1. Expectant:
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Follow-up:
2. Medical Treatment:
stable patient and beta hCG < 5000 mIu/ml, no fetal cardiac activ-
ity and Ectopic mass size less than 3 to 4 cm.
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Follow-up:
3. Surgical Treatment:
Indications:
• Hemodynamic instability
• Contraindications to Methotrexate
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ALERT:
• Abdominal pain
• Amenorrhea
• Vaginal bleeding
References:
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WORK UP:
Vital Signs :
• Significant oedema
• Ileus
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• Thrombocytopenia
• Hyperbilirubinemia
• Imaging Test:
Ø Chest X – Ray
Ø Ultrasound Scan
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MANAGEMENT:
• Target:
3) Intravenous Fluid:
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5) Antimicrobial Regimen:
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6) Corticosteroid Therapy:
ALERT:
References:
• Up To Date 2012
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WORK UP:
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MANAGEMENT:
• suture materials:
• repair of the IAS muscle , fine suture size such as 3-0 PDS
and 2-0 Vicryl .
Surgical techniques:
• External Anal Sphincter:
(a) tear can only be repaired using an end – end repair while
the repair of
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• Educate the woman about the need for adequate fluid intake
when using bulking agents (1.5-2L /day).
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3) Other risk factors for sphincter damage (e.g. big baby, Oc-
cipito Posterior position)
4) Woman’s request
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ALERT:
References:
• Up To Date 2012
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WORK UP:
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MANAGEMENT:
series have found that there may be a role for second evacu-
ation in selected cases when the hCG is less than 5000 units/
liter.
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ALERT:
References:
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EPISIOTOMY
OVERVIEW:
WORK UP:
MANAGEMENT:
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• Timing of Episiotomy:
Ø Extended episiotomy
Ø Cervical tear
Ø Haematoma
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Ø Inelastic perineum
Ø Preterm delivery
Ø Breech delivery
Ø Instrumental delivery
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ALERT:
References:
• ACOG , 2006
• NICE, 2009
• Up to Date , 2011
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OVERVIEW:
WORK UP:
1- Antiphospholipid antibodies
2. Karyotyping
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3. Anatomical factors
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MANAGEMENT:
• Genetic Factors
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ALERT:
References:
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OVERVIEW:
WORK UP :
1. Clinical assessment:
complete abortion.
2. Ultrasonography :
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MANAGEMENT:
1. Threatened abortion :
should be managed by :
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MOH Pocket Manual in Obstetrics & Gynaecology
3) Complete abortion :
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Surgical Management :
(D&C ).
Medical Management :
WHO Guidelines :
• 13-22 weeks: 400 mcq vaginally every 3-4 hours ( max five
doses ) or 600 mcq vaginally every 12 hours.
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ALERT:
References:
• RCOG
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MENORRHAGEA
OVERVIEW:
WORK UP:
a) Patient age
b) Reproductive status of the woman
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MANAGEMENT:
( Norethisterone 5 mg.).
Second Line Drugs - when simpler measures have failed, are use-
ful in the management of severe anemia e.g. GnRH Analogue.
These approaches are limited to short term use because of their
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side effects.
ALERTS:
References:
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MANAGEMENT OF HEMATOMAS
RESULTING FROM DELIVERY
OVERVIEW:
WORK UP:
• Nulliparas
• Pre - eclampsia
• Vulval varicosities
• Common locations:
• Vulva
• Retroperitoneal
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of injury.
• Vulva Hematomas
• Vaginal Hematomas
- Rectal pressure
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MANAGEMENT:
Ø If hemodynamically stable:
crystalloid.
Ø If hemodynamically unstable:
(i.e. PRBC)
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antibiotics.
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MANAGEMENT:
Either:
1) Conservative Management:
e.g. - Lethargy
2) Surgical Intervention:
• Suction / irrigation.
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• Perineal hygiene with sitz baths and gentle cleaning with sa-
line rinse.
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ALERT:
References:
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ANTENATAL CARE
OVERVIEW:
WORK UP:
• All first visit patients will have a history and physical exam-
ination including those late booking needing consultant’s
opinion.
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• Laboratory Test:
3) Sickling Test
4) Rubella Antibodies
5) Hepatitis Screening
6) VDRL (RPR)
One Hour Glucose Challenge Test for all patients ( oral 50 gms
glucose) for non fasting ,
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MANAGEMENT:
• Subsequent visits
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• Prenatal Education:
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ALERT:
References:
•Nice 2009
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MANAGEMENT OF
DIABETES IN PREGNANCY
( GDM )
OVERVIEW:
WORK UP:
- Overt Diabetes > 126 mg/dl. > 200 mg/dl. > 6.5 %.
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MANAGEMENT:
3. Nutritional Therapy:
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The Goal:
- To prevent ketosis
5. Insulin Therapy:
Insulin Dose:
Note:
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7. Timing of Delivery:
- Hold AM dose
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MOH Pocket Manual in Obstetrics & Gynaecology
NOTE:
• Follow Up:
ALERT:
References:
• Up To Date 2013
• ACOG 2013
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M.O.H
DRUG LIST
ALPHAPITICAL
DRUG INDEX
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atorvastatin carbimazole
carboplatin cyclophosphamide
carboprost tromethamine cycloserine
carboxymethyl-cellulose cyclosporine
carmustine cyprotone acetate + ethinyl estradiol
carteolol hcl cytarabine for injection
carvedilol )D(
caspofungin acetate dabigatran
cafaclor dacarbazine
cefepime hydrochloride dactinomycin
cefixime dalteparin
cefixime sodium danazol
ceftazidime pentahydrate dantrolene sodium
ceftriaxone sodium dapsone
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cefuroxime darunavir
celecoxib dasatinib monohydrate
cephalexin monohydrate daunorubicin hcl
cephradine desmopressin acetate
cetuximab dexamethasone
chloral hydrate Dextran (dextran40) + sodium chlorid
chlorambcil dextromethorphan
chloramphenicol dextrose
chlordiazepoxide hcl diazepam
chlorhexidine gluconate diazoxide
chloroquine diclofenac
chlorpheniramine maleate didanosine
chlorpromazine hcl diethylcarbamazine citrate
chlorthalidone digoxin
dihydralazine mesilate or hydralazine
chlorzoxazone
hcl
)cholecalciferol (vitamine d3 diloxanide furoate
cholestyramine )diltiazem hcl (sustainad release
cincalcet hydrochloride dimenhydrinate
cinnararizine dinoprostone
ciprofloxacin diphenhydramine hcl
cispltin )diphetheria,tetanus,pertussis (dpt
citalopam hydrobromide diphetheria,tetanus vaccine for adult
diphetheria,tetanus vaccine for
clarithromycin
children
clindamycin diphetheria antitoxine
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cyclophosphamide carboplatin
cycloserine carboprost tromethamine
cyclosporine carboxymethyl-cellulose
cyprotone acetate + ethinyl estradiol carmustine
cytarabine for injection carteolol hcl
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(D) carvedilol
dabigatran caspofungin acetate
dacarbazine cafaclor
dactinomycin cefepime hydrochloride
dalteparin cefixime
danazol cefixime sodium
dantrolene sodium ceftazidime pentahydrate
dapsone ceftriaxone sodium
darunavir cefuroxime
dasatinib monohydrate celecoxib
daunorubicin hcl cephalexin monohydrate
desmopressin acetate cephradine
dexamethasone cetuximab
Dextran (dextran40) + sodium chlo-
chloral hydrate
rid
dextromethorphan chlorambcil
dextrose chloramphenicol
diazepam chlordiazepoxide hcl
diazoxide chlorhexidine gluconate
diclofenac chloroquine
didanosine chlorpheniramine maleate
diethylcarbamazine citrate chlorpromazine hcl
digoxin chlorthalidone
dihydralazine mesilate or hydralazine
chlorzoxazone
hcl
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corticorelin (corticotrophin-releasing
edrophonium chloride
factor,crf)
efavirenz cromoglycate sodium
electrolyte oral rehydration salt (ors) cyanocobalmin (vit b12)
emtricitabine cyclopentolate hcl
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tropicamide vigabatrin
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valsartan (Z)
vinorelbine
vitamine B complex
vitamine E
voriconazole
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Authors
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Illustration
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