Part 1

Common Drug untuk Gestational HPT :

- Rx start > 140/ +/- 90 mmHg
- NICE : 1st line – Oral Labetolol 100 mg BD, max 400 mg
- Protocol : 1st – Oral Methyldopa 250 mg TDS, max 1g TDS
---------- BP still poorly controlled lepas dah Max Methyldopa +/- Labetolol ->
Oral Nifedipine 10 mg TDS, max : 20 mg
---------- Acute hypertensive crisis ->
IV / IM Hydralazine (6.25 mg ~ 12.5 mg STAT in post partum)

Definition
- Gestational HPT : BP > 140/90 mmHg (2 occasions, 4 hrs apart) + > 20 wks + previously N
- Pre eclampsia : BP > 140/90 mmHg (2 occasions, 4 hrs apart) + > 20 wks + previously N +
proteinuria > 300 mg / 24 hrs
- Eclampsia : Preeclampsia + tonic-clonic convulsions
- Impending eclampsia : blurred vision, hyper reflexia *not reliable
- Hypertensive Crisis : BP > 160/110 mmHg (2 occassions) / MAP >12.5 mmHg

Eclampsia
- Why seizures occuss?
1. Cerebral vasospasm
2. Cerebral ischemia
3. Cerebral oedema

- DDx seizures in Pregnancy

1. Epilepsy
2. Ifx – cerebral malaria, meningitis
3. SAH / ICH
4. Cerebral tumour
5. Septicaemia

Induction of Labour

Syntocinon/Oxytocin : IM 10 IU + IV 10 – 20 IU placed in 500 – 1000m L of crystalloid and

run quickly
- Resembles normal contraction
- Rapid onset
- Shorter duration of action

Syntometrine ( Syntocinon 5 IU + Ergometrine 0.5 mg) at delivery of anterior shoulder

- C/I : PIH, eclampsia, heart disease
- Moderate onset
- Longer duration of action
 PPROM PROM SROM
Preterm Prelabour Spontaneous
Prelabour
Rupture of membrane Rupture of membrane Rupture of membrane at
before onset of labour before onset of labour the onset of labour
< 37 wks > 37 wks After contractions +/- show

Supportive Tx
1. V/S, if fever : chorioamnionitis
2. S/S chorioamnionitis
3. Pad chart : colour, smell, liquour
4. GBS Prophylaxis if 18 hrs of leaking : Oral erythromycin ethyl succinate 400 mg BD

Chorioamnionitis

Risk Factors
1. PROM > 18 hrs
2. Internal fetal monitoring
3. Freq VE during labour
4. Bacterial vaginosis
5. Transplacental hematogenous, 2 to maternal bacteraemia

Diagnosis :
1. Clinical
- Maternal tachycardia : >120 bpm
- Fetal tachycardia : 160 – 180 bpm
- Urine tenderness, irritability
- Foul smelling vaginal discharge
- Fever

2. Ix
- FBC : leukocytosis
- High vaginal swab : CnS
- AF analysis : CnS, glucose, AF esterase

Tx
1. Definitive : Immediate delivery
2. Antibiotic :
- First, IV Cefuroxime 1.5 g STAT, then 750 mg TDS + IV Metronidazole 500 mg STAT, then
TDS
- Second, Oral Cefuroxime 150 mg BD + Oral Metronidazole 400 mg TDS

HO on call tips :
1. Pt Hx suggestive?
2. Confirm leaking : High vaginal swab by perspeculum examination
3. Differentiate PPROM, PROM, SROM
4. VE – Bishop score, os ? 4 cm (active phase of labour) -> send to LR
5. If not in active phase :
- observation
- pad chart
- Temp
- chorioamnionitis?
- inform MO in charge
- Tx

Nak tengok apa Perspeculum examination kalau pt datang leaking liquour

PPH

Primary PPH
- Tone – uterine atony**
- Trauma
- Thrombin : DIVC 2 to PPH, chorioamnionitis
- Tissue

Secondary PPH
24 hrs ~ 6 wks post delivery
- Retained POC
- Ifx : endometritis
- Shedding of dead tissue after obstructed labour
- Breakdown of uterine wound, after c sec
- choriocarcinoma

Management

1. Intrapartum
- Call obstetric on call team, anaes
- Active mx of 3rd stage of labour
- Resuscitate : IV access 2 large bore needle, O2 by mask, elevate legs, blood (GXM, ABG,
FBC, CP)
- Foley’s catheter U/O
- V/S
- Volume replacement : IV Crystalloids 1L
- Blood transfusion if severe, look for DIVC and correct it** how??

Uterine Atony
- uterine massage
- empty bladder
- IV Ergometrine 0.5mg bolus
- bimanual compression
- aortic compression
---------- If failed :
- maintain bimanual compression, repeat blood transfusion
- increase IV Oxytocin IV 10 – 20 IU placed in 500 – 1000m L of crystalloid and run quickly
- pack the uterus
- keep tamponade in situ 24 hrs
----------- not controlled :
- Surgical intervention : uterine suturing, hysterectomy