CPG-BASED SUMMARY NOTES

PAEDS ONG

PART 1 : PREGNANCY
PART 2 : PREGNANCY RISK TO FETAL AND MOTHER
PART 3 : PAEDIATRICS

MD ZAKI MEDICAL NOTES 2022

PART 1 : PREGNANCY
ISCHEMIC STROKE
- Pregnancy itself is a risk
factor for stroke :
•Pro-thrombotic state
•Additional haemodynamic
demands
•Caesarean delivery
Main causes of ischaemic
stroke in pregnancy :
- Congenital heart
Diseases
- Valvular heart diseases
- Atrial fibrillation (AF)
- Inheritable coagulation
abnormalities.
Most common aetiologies of
cerebral haemorrhage :
- aneurysm
- arteriovenous
malformation
- pregnancy-induced
hypertension
- HELLP syndrome
Ix of Choice : MRI of Brain
GDM HEART FAILURE
1. Screening by OGTT: Common causes of HF in pregnancy :
- Women at risk to develop GDM: at booking/as early as possible I) Previous normal heart :
- Women age ≥25 with no other risk factors: at 24-28 weeks of - Hypertensive complications of pregnancy i.e.
gestation gestational hpt, preeclampsia, HELLP syndrome
- If normal OGTT at 24-28wk, no repeat at 4-6 weeks later - Peripartum cardiomyopathy.
- previously unrecognised genetic cardiomyopathy
2. Overt diabetes in pregnancy is diagnosed at any time during - latent cardiac viral infection
pregnancy with the presence of any one or more of the following II) Pre-existing heart disease : due to decompensation or
criteria: have HF previously and still has a depressed
o FPG ≥7.0 mmol/L myocardial function. (LVEF < 40%)
o 2-HPP ≥11.1 mmol/L
o Random plasma glucose ≥11.1 mmol/L with symptoms Physiology during pregnancy :
•Increase cardiac output by 30-50% (80% during labor
- NEED TO CONFIRM with Second test on another day and delivery)
- Managed as pre-existing Diabetes •Haemodynamic changes : return to baseline 2-4 weeks
(vaginal delivery) and up to 6 weeks (after caesarian
3. Capillary Blood Glucose / BSP 4 Hourly : delivery)
- Target 4-7mmol/L
- On Insulin / OAD should maintain above 4.0mmol/L (Prevent Hypo) - Contraindication of pregnancy :
- Also the target during labor and delivery •Severe Pulmonary Hypertension
•Eisenmengers’ syndrome
4. Oral Antidiabetic agents (OAD) - Metformin : •Cardiomyopathy class III and IV
- There are sufficient human data on the use of metformin in •Severe aortic stenosis, coartation, HOCM
pregnant women and it is considered to have low risk in pregnancy •Marfan syndrome with aortic root
- Should be offered when medical nutrition therapy fails (For 1-2 •Severe maternal cyanosis
weeks), but need consult with speacialist
- Antiplatelet : only Aspirin up
to 150mg OD can be used in
pregnancy
- Anticoagulant :
I) Warfarin is contraindicated
in 6th-12th week of pregnancy
and also near term. Need to
be substituted with UFH or
LMWH. At other weeks of
gestation, Warfarin can be
given
II) Similarly, High-risk
pregnancy on DOAC need to
be replaced with UFH or
LMWH between 6th-12th week
of pregnancy
Management :
- Blood pressure should be
reduced to < 160/110 mmHg
- Hemorrhage stroke : control
by Methyldopa, Labetalol and
long acting Nifedipine
- Ischemic stroke : Aspririn up
to 150mg OD
Prevention :
In preeclampsia or severe
hypertension with
neurological symptoms, the
aim is to achieve an urgent
and sustained reduction of
- OAD should be continued in women who are already on the
treatment before pregnancy
5. IV insulin infusion initiation rate
✓ T1DM: 0.01-0.02 unit/kg/hour
✓ T2DM / GDM: 0.05-0.07 unit/kg/hour
✓ If requirement exceed 0.1 unit/kg/hour, refer the
endocrinologist/physician
6. Medical Nutrition Therapy :
- Given to patient at risk , with pre-existing diabetes, with GDM and
as post-partum care
- Should be individualized according to nutrition needs and cultural
preferences
7. Exercise :
- All uncomplicated pregnant women encouraged to exercise150
min per week
- However, need to practice safe exercises (Eg. Swimming, brisk
walking, strength training)
- Absolute contraindications to aerobic exercise in pregnancy are:
✓ Haemodynamically significant heart disease
✓ Restrictive lung disease
✓ Incompetent cervix/cerclage
✓ Multiple gestation at risk for premature labour
✓ Persistent second or third trimester bleeding
✓ Placenta praevia after 26 weeks gestation
✓ Premature labour during the current pregnancy
✓ Ruptured membranes
✓ Pregnancy induced hypertension
8. Insulin :
- Can be initiated at outpatient setting
Preconception Counselling :
- Patients with LVEF < 30% and those in NYHA Class III and
IV should be
strongly advised not to get pregnant. If pregnant,
termination should be considered
Mx of HF in pregnancy :
- Should be manage by Multi-disciplinary Team
(Non Pharmacological-mild symptoms):
I)Rest and Limit strenuous exercise
II) Low salt diet
III)Tx anemia and infection
(Pharmacological Tx)
I) Afterload reduction : Nitroglycerine
II) Preload reduction: Digoxin, Diuretics (with caution)
III) B blocker, ACEi and ARB contraindicated
IV) If A fib : Cardioversion + Anticoagulant
- Mx during delivery :
I) Vaginal delivery with epidural anaesthesia preferred
II) Indication for C-Sec :
Obs reason, On warfarin, Severe P.HPT
III) Forcep and VAD beneficial (Shorten 2nd stage of
labour)
- Post partum care :
I) Haemodynamic monitoring 24hr post partum
II) Full cardiac assessment and appropriate contraception
blood pressure to less than
160/110 mmHg to reduce the
risk of maternal stroke
- Preferred choice : Multiple daily injection (Bolus)
- Continued during pregnancy in women with pre-existing diabetes
who are already on the treatment
- Type : 1st Choice – Human Insulin (Actrapid, Insulatard), Other
choice : Insulin Analogues (Lispro, Glargine, Premixed)
- Insulin Analogue have benefit in patient with frequent
Hypoglycemia
9. Ultrasound Scan (Fetal Surveillance) :
- Pregnant women with pre-existing diabetes :
o at 11-14 weeks of gestation : Dating(Crump-rump length) And
Major Structural Malformation (Acrania, Anencephaly)
o at 18-20 weeks of gestation : Detailed Structural Anatomy Scan (by
a trained fetomaternal specialist or ultrasonographer) - spine and
heart (four-chambers, outflow tract and three vessels)
- In women with pre-existing diabetes and gestational diabetes
mellitus : Serial Growth Scan every four weeks from 28 to 36 weeks
of gestation.
10. Timing of Delivery :
- GDM (No complication + Diet control): Before 40+0 weeks
- GDM (OAD / Insulin) : Before 37+0 and 38+6 weeks
- Pre-existing diabetes (No maternal or fetal complications ): Elective
delivery between 37+0 – 38+6 weeks
- Develop maternal or fetal complications (BOTH Pre-existing
diabetes & GDM) : Elective delivery before 37+0 weeks
11. Mode of delivery : Individualised (taking into consideration the
estimated fetal weight and obstetric factors )
12. Intrapartum Management :

CHRONIC KIDNEY DISEASE
I) All pregnant women with
CKD co-managed by a
multidisciplinary team
(nephrologists/
physicians and obstetricians)
II) Pregnancy may be
considered in women with
chronic kidney disease (CKD)
having mild renal impairment
(serum creatinine <124 μ
mol/L), well controlled blood
pressure and without
proteinuria
III) Pregnancy should be
counseled to avoid in women:
- moderate to severe renal
impairment (serum creatinine
>124 mmol/L)
- Monitor capillary blood glucose hourly if on insulin and 4 hourly if
not on insulin (4-7mmol/L)
- Use IV dextrose and insulin for women with :
o T1DM from the onset of established labour
o capillary blood glucose >7.0 mmol/L
13. Post partum GDM:
- OGTT after 6 weeks
- Annual screening of diabetes
- Use metformin and intensive lifestyle intervention as prevention
for diabetes
TUBERCULOSIS MALARIA DYSLIPIDEMIA
Prompt diagnosis and early Treatment of malaria has to
treatment of maternal TB is crucial be modified in pregnancy - Statin therapy is contraindicated in pregnancy, who
because it is associated with due to contraindication for intent to get pregnant and lactating mother. However
increased risk of maternal mortality use of certain antimalarials : bile acid sequestrants may be considered
and perinatal morbidity - Pregnancy can leads to elevated TG
- Riamet
Treatment : Standard anti- (artemether/lumefantrine) is
tuberculosis (TB) regimens should contraindicated in pregnancy,
be used in pregnant and as well as Artesunate
breastfeeding women with TB, /Mefloquine due to limited
along with Pyridoxine 30mg/day data on safety of Artemisnin
(Exception for Severe
I) Pregnancy : Plasmodium infection where
- Isoniazid, rifampicin, ethambutol IV Artesunate is used)
and pyrazinamide are safe to be - Thus, Quinine used
used recommended
- Streptomycin should be avoided - Primaquine is not given for
in pregnancy due to foetal lactating mothers
ototoxicity. Pyridoxine (25 mg
daily) should be given to all
- Poorly controlled pregnant women on isoniazid to
hypertension prevent foetal neurotoxicity
- Heavy proteinuria
- Active systemic disease II) Lactation :
- Lactating mother should receive
ACEi and ARB should be full course anti-TB
avoided in pregnancy - Rifampicin may cause yellow or
orange coloured-milk, which is
harmless
- Breastfeeding should be
continued in lactating mothers
because the amount of anti-TB
drug in breastmilk is minimal.
However, surgical mask should be
used if the mother is infectious
- First-line antiTB drugs are safe in
breast feeding + Pyridoxine
- Once active TB in the baby is ruled
out, if the mother treated more
than 2 months anti tb, then no
treatment needed to the baby and
can give BCG vaccine at birth as
usual
- However, if the mother treated
less than 2 month of anti TB, the
baby should be given six months
isoniazid prophylaxis and defer BCG
vaccine at birth
- Separation of the infant from the
mother should be considered if the
mother has MDR-TB or is non-
compliant to treatment

BRONCHIAL ASTHMA
Asthma is more likely to
become severe or to worsen
during pregnancy in women
with pre-existing severe
asthma
Dx : same as dx of any non-
pregnant asthma pt
-> CXR is NOT contraindicated
in pregnancy
Mx : Same for non-pregnant
patients ,with ICS being the
preferred long-term controller
medication
Exacerbation : oxygen, inhaled
β2-agonists (inhaled
anticholinergics may be added
when needed) and possibly
systemic corticosteroids
Prompt and adequate
treatment is important to
avoid foetal hypoxia
IV) Oral Contraceptive Pills :
- Patient on rifampicin should use
alternative contraception methods
other than oral contraceptives
RHEUMATOID ARTHRITIS
RA often affects women in their
reproductive years.
The disease activity may improve,
stabilise or become active during
pregnancy
Medication : Some contraindicated
in pregnancy and lactation due to
limited available safety data, for
example ;
✓ NSAIDs restricted to first
and second trimester , but
compatible with lactation
✓ Selective COX-2 inhibitor
should be avoided in
pregnancy
✓ Methotrexate and
leflunamide :
contraindicated in
pregnancy and lactation
Pre-conception counselling :
disease course and medication
safety during pregnancy and
lactation.
CHRONIC HEPATITIS C
Preconception Counseling :
- In patient on direct anting
ativiral (DAAs) for Hep C,
counsel to avoid pregnancy
for female patient and
female partner of male
patient during and six
months after completion of
treatment
Treatment of hepatitis C
should not be initiated until
pregnancy has
been excluded due to the
lack of safety and efficacy
data
DENGUE
An early diagnosis of dengue infection in pregnancy is
usually difficult due to the various physiological changes
of pregnancy :
✓ elevation of HCT in dengue is masked by
haemodilution
✓ Third space accumulation difficult to detect due
to gravid uterus
✓ Baseline BP is lower, while baseline HR is higher
Higher risk of severe dengue infection on pregnancy
- > both mother and the newborn with dengue infection
may be at an increased risk for haemorrhage in the
presence of DSS
Complication :
1. MATERNAL :
- First trimester : Abortion
- Third trimester : Preterm birth, bleeding, higher risk of
fetal distress
2. Fetal outcome :
- Low risk of vertical transmission to infant from mother
- Fetal death, Low birth weight, preterm delivery
Delivery method : SVD
- Instrumental delivery should be avoided where possible
and if indicated, the procedures should be done by an
obstetrician

A. TERMINOLOGY :
Hypertension in Pregnancy :
Blood Pressure of
140/90mmHg taken after a
period of rest on two
occasions.
OR
Rise of systolic blood pressure
(SBP) of 30mmHg and/or a rise
in diastolic blood pressure
(DBP) of 15mmHg compared
to pre pregnancy levels
Subclassification of
Hypertensive Disorder in
Pregnancy (HDP) :
I. Pregnancy Induced
Hypertension (PIH)
Hypertension after the 20th
week of pregnancy in a
previously normotensive
woman. It may be associated
with proteinuria. The
condition is expected to
return to normal after
pueperium.
• Gestational Hypertension
(GH) : PIH without proteinuria
HYPERTENSIVE DISORDER IN PREGNANCY (HDP)
HISTORY PREVENTION OF PRE- MANAGEMENT OF MODERATE HDP (+MILD HDP with
• Family history of hypertension ECLAMPSIA complicatons)
• History of pregnancy induced
hypertension 1. Dietary Supplementation
• Primigravida (Especially Calcium
• Associated conditions – multiple
supplement ≥1g/day)
pregnancy, DM, renal disease, SLE
2. Aspirin 75mg OD from 12
etc week
- For high risk of pre-
SYMPTOMS
eclampsia :
-Frontal headache
a. History of pre eclampsia
-visual disturbance/blurring of
especially if associated with
vision
-nausea and vomiting
an adverse event.
-epigastric pain b. Multiple pregnancy.
- hyperreflexia c. Chronic hypertension.
- severe hypertension d. Diabetes (Type I or II).
e. Renal disease.
COMPLICATION OF PRE-ECLAMPSIA f. Autoimmune disease (eg
SLE).
Central Nervous System =======================
• Cerebral oedema.
• Cerebral haemorrhage. MANAGEMENT OF MILD HDP:
• Transient cortical blindness.
• Serous retinal detachment. I) Criteria selection for
Outpatient mx :
Cardiovascular System • BP ≥140/90mmHg but less
• Hypertension. than 160/100mmHg.
• Acute pulmonary oedema. • No proteinuria.
• Cardiac failure. • No signs/symptoms of
impending eclampsia.
Pulmonary System • No excessive weight gain.
1. Indication for Admission :
• symptomatic patients.
• maternal or fetal complications.
• persistent diastolic blood pressure >100mmHg or
systolic >160mmHg for stabilization.
• abnormal biochemical PE profile.
• presence of severe proteinuria >2+.
2. Monitoring : PE CHART
• Four hourly blood pressure (BP) and pulse rate (PR)
monitoring.
• Daily urine for protein.
• Weekly weight.
• Sign and symptoms of impending eclampsia.
• Investigations eg: FBC, renal profile, serum uric acid.
• Fetal monitoring eg: fundal height, fetal movement,
CTG.
3. Antihypertensive Therapy :
- All moderate HDP should be started
- Drug of choice :
I) Alpha Methyldopa (Oral 250mg tds)
II) Labetolol (Oral 100mg bd)
-Start with monotherapy and increase gradually till
maximum dose
- Aim : diastolic BP around 90-100mmHg
• Pre-eclampsia (PE)—PIH
with proteinuria
• Eclampsia—PIH with
convulsions
II. Chronic Hypertension
III. Chronic Hypertension with
Superimposed Pre-eclampsia :
• Chronic Hypertension : as
the presence of hypertension
of at least 140/90 before 20
weeks of pregnancy OR
beyond 6 weeks postpartum.
• Chronic Hypertension with
Superimposed PE :
development of PE in women
who have pre-existing
hypertension.
B. SEVERITY OF HDP
MILD :
-SBP 140-149mmHg and or
DBP 90-99 without
albuminuria OR a rise in SBP
30mmHg or a DBP 15mmHg
from pre pregnancy blood
pressure.
MODERATE :
SBP 150-159mmHg and or DBP
100-109mmHg.
• Acute pulmonary oedema.
• Aspiration pneumonia.
Liver
• Congestion.
• Haemorrhage.
• Infarction.
• Rupture.
Kidney
• Glomeruloendotheliosis.
• Nephrotic syndrome.
• Acute renal failure.
Blood
• Thrombocytopenia.
• Microangiopathic haemolytic
anemia.
• Disseminated intravascular
coagulation.
Uterus, Skin & Mucosa
• Placental abruption.
• Oedema.
• Petechia, ecchymosis.
• Laryngeal oedema.
Foetus
• Intrauterine growth retardation.
• Prematurity.
• Intrauterine death.
• No signs of intrauterine
growth retardation.
• Normal biochemical
investigation.
II) Ix : Plt, HCT, Uric Acid,
Creatinine, Urine Protein + 24
hour urine protein (if
necessary)
III) Fetal surveillance : Fundal
height, fetal heart, fetal kick
chart, Serial USG (if available)
IV) AntiHypertensive therapy
- BP of 140/90mmHg,without
any complications may not
require meds
- Consider meds if Diastolic BP
persistently above 100mmHg
V) Referral to Hospital :
• If there is any deviation
observed from the above
criteria.
•Delivery : All cases of mild
HDP must deliver in hospital.
=====================
INVESTIGATION FOR
ECLAMPSIA :
• Haemoglobin.
- Consult the specialist if there is a need to add the
second drug medication.
4. Timing of Delivery
- For chronic hypertension which BP lower than
160/110mmHg, timing of birth should be agreed between
the woman and the senior obstetrician
- Not be allowed post date unless complication
- Maternal and fetal condition compromised : early
delivery is mandatory and appropriate corticosteroid
usage
5. Intrapartum management :
I) Maternal surveillance:
• Labour should be monitored using partogram.
• Antihypertensives should be continued
• I.V. hydralazine (2.5-5mg bolus / infusion) should be
considered if DBP is more than 110mmHg.
• Shorten second stage of labor. Use only Syntocinon
during third stage of labour.
• Others : IV line, Adequate analgesia, fluid regime
therapy
II) Fetal surveillance:
• Auscultation of fetal heart rate every 15 minutes.
•CTG continuously or intermittently as indicated.
6. Immediate postpartum management :
- Observed in labour suite about one hour. If the BP
remain high (diastolic >100 or systolic >160) then such
patient should be observed at Obstetric HDU before
transfer to the high risk postnatal ward

SEVERE :
- Progressive deterioration in
both
maternal and foetal condition.
It is characterised by:
• SBP ≥160mmHg or DBP
≥110mmHg on two occasions
6 hours
apart.
• Proteinuria of (3+) or >3g/L.
• Oliguria (<400ml/24 hours).
• Headache.
• Cerebral or visual
disturbances.
• Epigastric pain.
• Hyper-reflexia.
• Pulmonary oedema.
• Impaired liver function tests.
• Increased serum creatinine
(>1.2mg/dl).
• Retinal haemorrhage,
exudates or papilloedema.
• Thrombocytopenia.
• IUGR.
C. MOTHER AT RISK :
• Maternal age <20
years and >35 years
• Primigravida
• Previous history of
HDP
• Multiple gestation
• Platelet count.
• Coagulation profile.
• Transaminases (liver
function test).
• Renal profile, uric acid.
• CT scan in the presence of
neurological deficits or
recurrent fits.
4 STAGES OF ECLAMPSIA
1. Premonitory stage (10-20s):
• the eyes roll or stare.
• face and hand muscles
twitch.
• LOC
2. Tonic stage (10-20 s) :
• the muscles go stiff or rigid.
• the diaphragm is in spasm
so that breathing stops and
skin becomes cyanosed.
• the back may be arched.
• the teeth are clenched.
• the eyes bulge.
3. Clonic stage (1-2 min) :
• violent contraction and
relaxation of muscles.
• increased saliva causes
“foaming” at mouth.
• deep noisy breathing.
- First 24 hours : Monitor VS 4 hourly, cont antiHPT, early
immobilization
MANAGEMENT OF SEVERE HYPERTENSIVE
I) Aim : prevent a cerebro-vascular accident to the
mother whilst trying to achieve a clinically useful
prolongation of the pregnancy
II) Initial Management in different healthcare center :
a) From Home or Health Clinic :
- Sent to Hospital STAT (Code Red)
- IV Drip, IM MgSO4 10g bolus (5g each buttock) and Oral
nifedipine 10mg stat/ IM Hydralazine 6.25mg stat
- During transfer , monitor BP, HR and FHR every 15 min
b) Hospital without OnG Specialist :
- HDW area -> while waiting to transfer to hospital with
specialist
- IV drip, monitor U/O, do urine protein, cont oral
antiHPT
- IV MgSO4 4g slow bolus over 10 min if not given earlier,
followed by maintenance IV infusion of MgSO4 1g per
hour
- Monitor BP, HR,RR and FHR every 15 min
- Consult the O&G Specialist in the nearest hospital
- If the fetus is preterm, dexamethasone should be
administered (between 24-36 weeks gestation)
- If diastolic BP ≥110mmHg, set up an IV infusion of
hydralazine 20mg in either 500ml of Hartman’s solution
or normal saline. Starting at 5 drops per minute (dpm),
• Polyhydramnios • inhalation of mucous or
• Non-immune foetal saliva.
hydrops • face looks congested and
• Underlying renal swollen.
disease • tongue is bitten by violent
• Chronic hypertension action of jaws.
• Diabetes mellitus
• Gestational 4. Coma stage (min or hours) :
trophoblastic disease • there is a deep state of
(molar pregnancy) unconsciousness.
• Low socio-economic • breathing is noisy and rapid.
group • cyanosis fades but face
• Pregnancies with remains congested.
different partners • further fits may occur.
• Excessive weight gain ======================
MANAGEMENT OF HELLP
• Rh incompatibility
SYNDROME :
I - Diagnosis :
• Microangiopathic
haemolytic anemia.
• Thrombocytopenia ≤100 x
109/L (principal and earliest
coagulation abnormality
Detected)
• Hepatic dysfunction
enzyme:
–– AST or ASOT ≥70IU/L
–– LDH ≥600IU/L
II – Complication :
increase by 5dpm every 15 minutes until the diastolic BP
is around 90mmHg
c) Hospital with OnG Specialist :
- Same management , but faster referral with OnG
Consultant
III) Deliver Options :
Timing :
- <34 weeks : Try prolong pregnancy to as near 36 weeks
as possible
- >34 weeks : Consider delivery if crisis recur
- Maternal or fetal complication : Deliver stat once
stabilized
Deliver method :
-No Obstetrics complication : Vaginal Delivery
- o/w Caesarean section recommended
IV) Intrapartum Management :
• Adequate analgesia preferably epidural
• To complete MgSO4 infusion to at least 24 hours
postpartum
• Strict input/output chart
• Monitor magnesium toxicity
• Paediatrician to standby at delivery
V) Postpartum care :
• Observed at Obstetric HDU.
• Continue oral antihypertensive agent.
• Diastolic BP controlled between diastolic 90-100mmHg.
• MgSO4 continue at least 24 hours after delivery.
i. Disseminated intravascular
coagulation.
ii. Abruptio placenta.
iii. Acute pulmonary oedema.
iv. Acute renal failure.
v. Intracerebral
haemorrhage/stroke.
vi. Subcapsular liver
haematoma.
vii. Retinal detachment.
viii. Death.
III- Treatment :
- LDH, SGOT, platelets, PCV,
BUSE every 12-24 hours and a
further 48 hours after delivery
- Control BP
- Correct Thrombocytopenia
- Manage complication (Eg.
spontaneous hemorrhage ,
DIVC)
- Labor and delibery : Aim for
vaginal delivery and avoid
episiotomy if possible.
Caesarean section done only
for obstetric indication and
vertical skin incision preferred
to pfannensteil incision2
MANAGEMENT OF ECLAMPSIA :
A. In Health Clinic :
I) Call for help
II) Place pt in lateral position. Put on nasal
prong/ventimask, IV drip with NS
III) MgSO4 10gm 50% solution (20mls) intramuscularly.
One half is injected into upper outer quadrant of each
buttock in zigzag manner
IV) IV AntiHPT (Hydralazine or Labetolol) / Nifedipine
V) Suck secretion, insert foley catheter, monitor U/O
VI) Monitor BP,HR, RR,FHR every 15min
VII) Transfer immediately to Hospital - Prepare IV MgSO4
2g (or 5g for IM) in a syringe in case patient threw
recurrent seizure during transfer
B. In Hospital without OnG specialist :
Additional Management :
- Red Alert
- IV MgSO4 4g diluted in normal saline slow bolus,
followed by maintenance IV infusion of MgSO4 1g per
hour
- If the diastolic BP ≥110mmHg, hydralazine infusion
20mg in 500ml of NS or Hartman’s solution, starting at
5dpm and increasing by 5dpm every 15 minutes until the
diastolic BP is about 90mmHg
- Transfer to Hospital with specialist
C. In Hospital with OnG specialist :
Additional Management :
• Continue MgSO4 infusion 1g/hour and to be continued
till 24 hours after delivery or convulsion whichever is
later
• Alert the anaesthesiologist for possible operative
procedure, and the need for ICU or HDU care.
• Reassess the pregnancy to decide the timing and mode
of delivery.

Obstetrics Management :
- Mainstay : Immediate delivery after patient stabilization
irrespective of gestational age
-> If Cephalic presentation and os 8cm above, and no
fetal or maternal complication : Vaginal Delivery
-> Otherwise : Caesarean Section

Postpartum Care :
- Monitored in the high dependency area (HDU) for at
least 24 hours

DISCHARGE CRITERIA :
• Diastolic blood pressure has settled below 100mmHg
• NO end-organ dysfunction
• Patient:
–– understand the disease and its complication
–– compliant to medication
–– accessible to a health center
–– has good support from family
• From KK postnatal follow up, Consider postnatal
referral to hospital if :
- BP >150/100mmHg with proteinuria and/or with
- signs and symptoms of impending eclampsia
- If hypertension and proteinuria persist beyond six
weeks postnatal period.
 CPG HEART DISEASE IN PREGNANCY
RISK STRATIFICATION : HISTORY
- NYHA class
A. NYHA -Past medical hx (Cardiac murmur,
cardiac surgery/ intervention)
Class I : -Family history (Cardiac disease,
Ordinary physical Activity - No arrhythmias, sudden death)
sx
Class II : PHYSICAL EXAM
Ordinary physical Activity - -HR snd BP should be measured
fatigue, palpitation, dyspnoea, manually by mercury
angina sphygmomanometer
Class III : -Physiological flow murmur is
Less than ordinary physical normal, but need monitor new
activity - fatigue, palpitation, onset /change in murmur
dyspnoea, angina
Class IV : INVESTIGATION
Symptoms of CCF present at -ECG
rest -ECHO
B. Modified WHO Maternal CV PRECONCEPTION COUNSELLING :
risk : -Indicated for all women in
Refer pic below reproductive age group who have
cardiac disease
MATERNAL CV RISK (Based on
risk stratification) : - Counselling Assessment :
I) Started early at puberty and re-
I) Low Risk : WHO class I,II & emphasized at age 16-18 and prior
NYHA I,II to marriage
II) Moderate Risk : WHO class II) Thorough history of
II-III, III comorbids,cardiac events
III) High Risk : WHO class IV & /interventions with detailed clinical
NYHA III,IV examination
ANTENATAL
-Once pregnancy confirmed, need to go
nearest antenatal clinic for booking.
Patient should be referred as soon as
possible for cardiac assessment and risk
stratification
A. Low risk - Local health facility
B. Moderate Risk :
-Follow up tertiary center at least 1 visit
per trimester
- Close maternal-fetal surveillance :
i)Nuchal translucency scan 11 to <14w, if
indicated
ii)Genetic karyotyping, if indicated
iii)women with CHD - offer fetal echo at
18-22 w
-Manage meds/ anticoagulation if any
-Correct factors that contribute to
cardiac compensation
- Anaesthesia review in advance
- Advance plan : detail labor and delivery
plan, and postpartum plan
C. High Risk :
-Advice early termination , consider up
to 22 weeks
-If patient chooses to continue
pregnancy :
COMMON ENCOUNTERED CARDIAC DISEASE
IN PREGNANCY
I) Valve Disease :
- Most patient tolerate pregnancy well
-Patient with severe obstructive lesion
(severe mitral and severe aortic stenosis)
should undergo cardiac intervention prior
pregnancy
- Severe Mitral stenosis features:
Mitral valve area <1.0 cm2
NYHA functional class III & IV
Pulmonary Hypertension
Development of atrial arrhythmias
-Severe Aortic stenosis :
Aortic valve <1.0cm2
Mean gradient of <40mHg
Peak velocity of >4m/s
II) Congenital Heart Disease :
-Most acyanotic and repaired/ corrected
patient tolerate pregnancy well
- Patient with pulmonary hypertension and
eisenmenger syndrome : High risk
(Termination pregnancy should be
considered)
III) Peripartum Cardiomyopathy :
-Predisposing factors :
Maternal age >30y/o
Multiparous
Eclampsia

PREDICTORS OF POOR
NEONATAL/FETAL OUTCOME :
-NYHA class III & IV
-Cyanosis (spo2 <85%)
-Mechanical prosthetic valve
-Use of heparin / warfarin
during pregnancy
-Left heart obstructive lesion
-Smoking during pregnancy
- Twin/multiple pregnancy
III) Review of medications
-Clinical Counselling :
I) Appropriate optimisation of
cardiac condition (e.g valvuloplasty
for mitral stenosis, cardiac surgery
for congenital cardiac lesion)
II) Encourage planned pregnancy
with emphasis on timing to be early
in disease process
III) Others :
-Dental review
- Folic Acid at least 3-6 month prior
conception
-Rubella vaccine at least 3 month
prior conception
- Early referral for cardiac
assessment and risk stratification
IV) Appropriate contraceptive
advice for high risk patient
LEVEL OF CARE MANAGEMENT :
I) Low risk : Local center by FMS/
physician or cardiologist
II) Moderate risk : Tertiary center
by multidisciplinary team with
cardiac expertise
III) High risk : referred early to
tertiary center for assessment. If
termination of pregnancy is
I)Detailed medical counselling
II)Careful documentation
III)Close monitoring and +/- early
hospitalisation (Manage as per mod risk)
INTRAPARTUM
-Monitoring :
i) ECG, BP,strict I/O
ii) Spo2
iii) Continuous fetal monitoring
-Preterm labor :
i)Atosiban (1st line tocolysis)
iI)Corticosteroid should be considered
-Mode of delivery :
i) Vaginal delivery preferred with
assisted second stage
ii) Indication of Caesarean section :
->Woman on anticoagulant who not
switched to heparin at least 2 weeks
before delivery
->Patient with Marfan syndrome with
aortic diameter >45mm
->Patient with acute /chronic aortic
dissection
-> Functional class NYHA II & IV
-> LVEF <30%
-> Severe obstructive cardiac lesion
-> Severe pulmonary hypertension and
eisenmenger syndrome
Twin pregnancy
Hypertension
Nutritional deficiency
Racial origin (Black)
-Sx : new onset HF
-ECG : non-specific ST/T wave changes,atrial
or ventricular arrythmia and conduction
defects
-Obstetrics and cardiac risk will depend upon
baseline LV function
- Anticoagulant therapy recommended to all
patinet with peripartum cardiomyopathy
- Most patients recover within 6 months of
diagnosis
IV ) Patient on anticoagulant due to
mechanical heart valve :
- Balance between risk of warfarin
embropathy on 1st trimester and risk of high
thrombosis if using UFH or LMWH
- All high risk patient with mechanical heart
valve : Warfarin throughout pregnancy up to
36 weeks
- Alternative : Warfarin in 2nd and 3rd
trimester up to 36 weeks with bridging
heparin based therapy (IV UFH or LMWH) in
1st trimester
- At 36 weeks : Warfarin switched to LMWH
or UFH (LMWH switched to UFH at least 36H
before IOL or Caesarean section)
- Post delivery : Oral anticoagulation can be
resumed after 24 hours if no bleeding
concerns
considered, it can be performed up -> Obstetrics indication
to 22 weeks
- Other consideration :
i)Avoid prolonged labor
ii) Epidural analgesia - analgesia of
choice in labor
iii) Antibiotic prophylaxis in high risk
patient
iv) Paeds team present during delivery
V ) Patient on anticoagulant for other
indication :
- 2 Optional Regime :
Regime A : Warfarin throughout pregnancy
till 36 weeks OR
Regime B : UFH or LMWH therapy in 1st
trimester and warfarin in 2nd and 3rd
trimester

POSTPARTUM

A.Moderate and High risk:

- Monitor in HDW / ICU for first 24-72H

- Minimum hosp stay 3-5 days is
recommended , except if have
pulmonary hypertension (7-14 day)
- Monitor RR, SpO2,I/O Chart

B. For All patient :

- Oral anticoagulant , if indicated, should
be restarted and therapeutic INR should
be achieved before discharge
- Cardiac review/follow up appointment
should be given at 6 weeks postpartum
- Contraception should be given prior to
discharge
 CONSENSUS TREATMENT OF HYPEREMESIS GRAVIDARUM
DEFINITION : RISK FACTOR INVESTIGATION MANAGEMENT

I) Nausea and Vomiting in -Multiple pregnancy A. Lab : A. NON-PHARMACOLOGICAL:

Pregnancy : Symptoms of
nausea and/or vomiting
during early pregnancy
where there are no other
causes (Diagnosis of
exclusion)
II) Hyperemesis Gravidarum
: -Severe form of nausea
and vomiting in pregnancy
-Protracted nausea and
vomiting in pregnancy
associated with triad of
weight loss >5% of pre-
pregnancy weight,
dehydration and electrolyte
imbalance
Complications of
hypermesis gravidarum :
I) Maternal Complication :
-Nutritional deficiency
-Electrolyte imbalance
-Venous thromboembolism
-Wernicke encephalopathy
-Esophageal rupture or
Mallory weis tear
-Molar pregnancy
-Previous hyperemesis /
previous molar
-Depression or anxiety
-Pre pregnancy underweight
-Younger age
-Allergies (eg Asthma)
-GI disorder
-Female fetus
-Higher BMI
HISTORY
Peak incidence at 12 weeks of
pregnancy.Symptoms of
vomiting usually resolved by 20
weeks (90%)
-Hx of persistent vomiting
-Hx of nausea and vomiting in
previous pregnancy
-Hx to exclude other causes :
Abd pain, infection, UTI sx,
Hyperthyroid sx
- Ptyalism (Overproduction of
saliva)
-Modified Pregnancy-Unique
Quantification of Emesis/Nausea
(PUQE) Score :
1. UFEME :
-UTI, Ketonuria
2. FBC :
-HCT, WBC
3. Urea and Electrolyte :
- Hyponatremia
- Hypokalemia
- Mag/Phosphate
4. LFT (40% have moderately
increased transient transaminatitis)
5. Others as needed :
Eg . TFT - Only if there are pre-
pregnancy symptoms , HCG level if
suspect molar, Amylase if suspect
pancreatitis
B. Imaging :
- Pelvic USG (USS) : Rule out multiple
pregnancy / Molar pregnancy
========================
ADMISSION CRITERIA
-Abnormal urea and electrolyte
- Change of environment /avoidance of
trigger
- Dietary :
a.Eliminate greasy/fried
food/coffee/spicy/very sweet food
b.Small frequent meals
c.High protein diet/salty/low flat/bland
diet/dry toast
d.Peppermint tea
- Supportive psychotherapy
- Acupressure (applied by wrist
band/finger at pericardium 6)
-Ginger capsule 1-1.5g/day orally
B. FLUID THERAPY
-First line : Normal saline + KCL
-Fluid required = Maintenance fluids (25-
30mls/kg/day) + replacement fluid
(Based on clinical and lab monitoring)
-Tailor KCL according to potassium
deficit
- Avoid dextrose / dextrose infusions -
Precipitate Wernicke’s encephalopathy
-Avoid rapid infusion of normal saline ->
too rapid correction in sodium -> May
cause central pontine myelinosis
-Depression and social How long feel nauseated/sick ,
isolation frequency of vomiting and
retching
II) Fetal Complication :
-Low birth weight SCORE
-Small for gestational age (Mild NVP </=6, Mod 7-12,
Severe NVP >/=13)
EXAMINATION
-Weight loss trend
-Hydration status
-Muscle wasting/weakness
-Abd palpation
-Loss of 5% body weight
-Haematemesis
-Persistent vomiting /ketonuria after
day case hydration
- Suspected other cause for vomiting
- Diabetes Mellitus
- Severe hyperemesis (Modified PUQE
score >/=13)
-Confirmed or suspected comorbidity
========================
INPATIENT CARE :
I) IV Fluid :
-Maintenance (25-30mls/kg/day) +
Replacement (Clinical dehydration) +
Potassium replacement (based on
Serum K)
- Insulin sliding scale (DM Patient)
II) Antiemetic :
FIRST LINE :
-> Meclozine 25mg/Pyridoxine 50mg 1-
2 tab 2-3 times daily
-> Prochlorperazine 5-10mg 6-8 hourly;
deep IM/IV 12.5mg 8 hourly)
-> Promethazine Deep IV/IM/PO 12.5-
25mg 4-8 hourly (Max 100mg)
-> Chlorpromazine (10-25mg 4-6 hourly
PO/IV/IM or 50-100mg 6-8 hourly)
SECOND LINE :
-> Metoclopramide 10mg IM/IV/PO
TDS
C. PHARMACOLOGICAL
1) Antiemetic :
i. Antihistamine :
-Meclozine 25mg/Pyridoxine 50mg PO 1-
2 tabs 2-3 times/day
-Prometazine IM/PO/IV/PR 12.5-25mg 4-
8 hourly
ii.Dopamine Antagonist
iii. Serotonin inhibitors 5-HT3 antagonist
:
iv.Steroid (Refractory) : IV Hydrocort
100mg BD -> Oral prednisolone 40-50mg
OD
2) Vitamin Supplementation :
-Thiamine (PO 25-50mg TDS if tolerating
orally) - For all women with prolonged
vomiting especially before administration
of dextrose or parenteral nutrition
-Folic Acid (PO 5mg OD once tolerating
orally)
3) Anti-reflux medication :
-GERD/Esophagitis/gastritis
-Alginate (PO 10-20mls TDS)
-Ranitidine (IV 50mg TDS/PO 150mg
BD)
- Omeprazole (IV/PO 40mg BD)
4) Thromboprophylaxis :
-TED Stocking
-Anticoagulant as per VTE score
-> Ondansetron 4-8mg 6-8 hourly, IV
8mg over 15 min 12 hourly
-> Domeperidone 10mg 8H, PR 30-
60mg 8 H
THIRD LINE (Refractory Cases):
-> Steroids (IV Hydrocortisone 100mg
BD) -> Taper to Oral prednisolone 40-
50mg OD once improve
III) Vitamin :
-Thiamine (IV 100mg bolus in 100cc
NS, then 100mg OD 2-3 days; PO 25-
50mg TDS)
- Folic acid (PO 5mg OD)
IV) Gastric Prophylaxis :
-Alginate (PO 10-20mls TDS)
-Ranitidine (IV 50mg TDS, PO 150mg
BD)
-Omeprazole (IV/PO 40mg BD)
V) Thromboprophylaxis :
- Consider antenatal prophylaxis
with LMWH
VI) Dietary advice :
-Stop iron therapy (resumes once
nausea settle)
-Refer non pharmacological
management
5) Enteral/Parenteral : Refractory to all
pharmacological/ non-pharmcological
measures
D. BASED ON PUQE SCORE :
I) Score 3-12 & No complication :
- Antiemetic
- Lifestyle and dietary changes
II) Score >/=13 & No complication :
- Ambulatory daycare management until
no ketonuria
->IV Hydration , Antiemetic, Thiamine
III) ANY score with complication/
unsuccessful ambulatory daycare
management :
- Inpatient management (Ambulatory
daycare mx + Thromboprophylaxis,
steroids consideration and
multidisciplinary team)
E. DISCHARGE PLAN
-Antiemetic PRN
-Safety netting (Knows when to seek
medical attention)
-Follow up under KK
-Serial growth scan (For severe NVP/
Hyperem gravidarum who have sx into
late 2nd and 3rd trimester)
F. COMPLICATION OF HYPEREMESIS
GRAVIDARUM

a) Wernicke’s Encephalopathy :

-Potentially reversible yet serious

neurological complication from Vit B1
deficiency
- Precipitated by glucose containing
fluids before thiamine supplementation
- Clinical Features :
i) Classical Triad (47%) : Confusion,
Ocular abnormalities
(nystagmus,opthalmoplegia,6th nerve
palsy), Ataxia (gait, finger nose ataxia)
ii) Other sx : memory loss, apathy,
decreased consciousness, blurred vision
- Diagnosis : No specific lab test. MRI
highly specific (compared to CT scan).
Rapid clinical improvement after
Thiamine administration.
-Tx : IV Thiamine 100mg Bolus in 100mls
NS , then 100mg OD 2-3 days.
Subsequently oral thiamine 50mg OD
until normal diet intake

b) Malory Weiss Tear :

-Repeated bouts of vomiting -
> laceration of esophageal mucosa ->
hematemesis
- Tx :
i) Anti-reflux medication (empirical)
ii) If symptoms persist after vomiting
subsided , significant drop in Hb level

HYPOTHYRODISM IN PREGNANCY
DEFINITION
Maternal Hypothyroidism
: elevated serum TSH
during pregnancy beyond
the upper limit of the
pregnancy-specific
reference range.
Overt maternal
hypothyroidism :
decreased TSH AND serum
fT4 below the lower limit of
the pregnancy specific
reference
Range
Subclinical Hypothyroidism :
isolated high TSH with fT4
TREATMENT
A.WHEN TO START
I) Overt Hypothyrodism :
-Start with Levothyroxine (LT4)
II) Subclinical Hypothyroidism :
a) Pregnant women with
negative TPO Ab:
– LT4 is recommended if TSH
is >10 mIU/L
– LT4 maybe considered if
TSH is above the pregnancy
specific reference range or 4.0
mIU/L
b) Pregnant women with positive
TPO Ab:
HYPERTHYRODISM IN PREGNANCY
DEFINITION
Maternal hyperthyroidism :
suppressed serum TSH level with
elevated free tri-iodothyronine (fT3)
and/or free thyroxine (fT4)
Subclinical Hyperthyroidism
: suppressed serum TSH with normal
fT4 and/or fT3 levels
CAUSES :
-2 most common causes :
I) Gestational transient thyrotoxicosis
(GTT) :
-> non-autoimmune transient disorder
that occurs in the first trimester of
pregnancy and is caused by the peak
in hCG levels during early pregnancy
and suspicion of other sinister causes ->
Endoscopy
c) Venous Thromboembolism
-Pregnancy + Immobility + Dehydration :
risk of thrombosis
-LMWH : Pharmacological tx of choice
d) Termination of pregnancy :
-Maybe considered in women with
severe hyperemesis gravidarum
complicated with life threatening physical
and mental conditions
B. Graves Disease :
PRECONCEPTION :
-Education : Importance of maintaining
euthryoid state
-Consider all tx options for achieve
euthyroid state first before getting
pregnant (RAI, thyroidectomy and ATD
therapy)
- Patient well-controlled on carbimazole,
could switch to PTU before trying to
conceive
-The major period of teratogenicity due to
ATD was gestational weeks 6–10, the
period of organ formation
MANAGEMENT :
-Anti-thyroid drugs (mainstay tx)
-During early pregnancy, consider
discontinuation of antithyroid drugs in a
patient who is euthyroid on low dose of
within the pregnancy-
specific reference range.
(TSH upper limit references
: 4 mIU/L)
CAUSES :
-Hashimoto’s Thyroiditis
(Most common)
- Other causes : previous
surgery, radioiodine
ablation, congenital
hypothyroidism and rarely,
lymphocytic hypophysitis
TARGET TFT :
1. 1Preconception :
TSH </= 2.5 mIO/L
2. Second and Third
Trimester : TSH </=
2.5 mIO/L
SCREENING
-TSH should be tested in
patient with :
i) Hx of thyroid dysfunction
ii) Goitre
iii) Known thyroid Ab
positive
iv) Age >/= 30 y/o
v) Type 1 diabetes or other
autoimmune disease
vi) Hx of recurrent
pregnancy loss or preterm
delivery
– LT4 is recommended if TSH
is above the pregnancy
specific reference range or 4.0
mIU/L – LT4 may be
considered if TSH is >2.5 mIU/L
B. DETAILS
i) If patient already treated with
LT4 before pregnant, it is
recommended to have their LT4
dosage increased by 30%–50%.
Consider higher percentage
being considered for post
ablative hypothyroidism and
lower percentage for
autoimmune hypothyroidism
ii) TFT monitor every 4 weeks
from conception until mid-
gestation and at least once
during middle of 3rd trimester
iii) After delivery, LT4 dosage
generally re-adjusted to
prepregnancy requirement
ADVERSE OUTCOME :
-Pregnancy loss, pre-eclampsia,
low birth weight (LBW),
intrauterine growth restriction
(IUGR) and impaired foetal
neurocognitive development
-> No prior hx of thyroid disease and
stigmata of Grave disease
-> Generally asymptomatic, mild and
self limiting
II) Graves’ disease :
-> Have goitre and opthalmopathy
-> Thyroid receptor antibody positive
- Other causes : toxic multinodular
goitre, toxic adenoma and thyroiditis,
multiple pregnancy,molar pregnancy
COMPLICATION OF
HYPERTHYROIDISM IN
PREGNANCY
I) Maternal : miscarriages, preterm
delivery, hypertension, heart failure,
and thyroid storm
II) Fetal : Fetal hyperthyroidism which
lead to IUGR , stillbirth, low birth weight
Management :
A. Gestational Transient Thyrotoxicosis
(GTT) :
-mainly symptomatic, depending on the
severity of symptoms
- Rehydration and hospitalisation if
needed in the presence of hyperemesis
gravidarum; and beta-blocker if very
symptomatic
CMZb (≤10 mg daily) or PTU (≤100 mg
daily), due to the potential teratogenic
effects
- Consider continue ATD in patient :
>women who were started on ATD
therapy recently (<6 months)
>still have suppressed TSH
>relatively high serum T3
>high levels of TRAb
>large goitre
>active ophthalmopathy or other signs of
active disease
- Based on above :
->If decide to CONTINUE : PTU is
recommended in early trimester (dose
ratio of 1:10 e.g. 200 mg PTU per day to
replace 20 mg CMZ)
->If decide to STOP : TFT and clinical
exam monthly to ensure euthyroid
- Ix : TFT, TRAb
Past hx of grave disease tx with ablation
or on ATD for graves : TRAb early in
pregnancy → If low or undetectable early
pregnancy, no further test BUT If
maternal TRAb is elevated /treated with
ATD, repeat TRAb 18-22 weeks → If
maternal TRAb is elevated/mother taking
ATD in 3rd trimester, repeat TRAb at 30-
34 weeks
-The lowest effective dose of ATD should
be used during pregnancy, targeting fT4
at or just above the reference range,
monitor every 4-6 weeks
FETAL SURVEILLANCE
vii) Infertility -Adverse outcome assoc - Antithyroid drug (ATD) not indicated - Done in uncontrolled hyperthyroidism
viii) Hx of Thyroid surgery or strongly with presence of TPO patient in the second half of pregnancy
head and neck radiation Ab positivity and elevated TRAb levels at
ix) Morbid obesity any time during pregnancy (>3x upper
x) Use of lithium or limit of normal).
amiodarone
xi) Recent administration of
iodinated radiologic contrast
xii) Residing area of
moderate to severe iodine
deficiency
xiii) FHx of thyroid disorders
xiv) 2/more prior
pregnancies

POSTPARTUM THYROIDITIS (PPT)

- Def : Thyroid dysfunction in first postpartum year in women who were euthyroid prior pregnancy
- Classical Form : Transient thyrotoxicosis (2-6 month postpartum) is followed by transient hypothyroidism (3-12 month) with a return to the euthyroid
state by the end of the initial postpartum year (Although 20-40% will have permanent hypothyroidism in 3-12 years)
- Versus in Graves disease : Usually PPT negative TSH Receptor antibodies, no goitre with bruit, no opthalmopathy, Radioiodine uptake elevated or
normal in GD and low in PPT
- Screening for PPT :
• Women with hx of autoimmune disease (T1DM, SLE etc)
• Women with history of PPT in previous pregnancy or with positive thyroid antibody titre
-Management :
• Thyrotoxic Phase (Symptomatic) : Treated with beta blockers. ATD are not recommended
• Hypothyroid Phase (Symptomatic) : Treated with LT4
• Women who’s not treated : Repeat TFT every 4-8 weekly until euthyroid state is restored

Pre Pregnancy Care
• Advise weight loss (Target
BMI <30)
• Lifestyle modification
• Good control of co-
morbids
• Educate on Maternal and
Fetal complication related
to maternal obesity :
Maternal Complication : Increased
risk of miscarriega, GDM, pre-
eclampsia, VTE, induced labor,
dysfunctional/prolonged labor,
LSCS and anaesthetic
complication, PPH, Wound
infection and mortality
Fetal complication : Increased risk 3rd Trimester :
of congenital anomalies, stillbirths,
prematurity, macrosomia,
neonatal death
• Medication :
I) Folic Acid 5mg OD one month
before conception
II) Consider Vit D (1000iu)
• Bariatric Surgery (For BMI
>40/ >35 with metabolic
disease
OBESITY CONSENSUS GUIDELINE IN PREGNANCY
Antenatal Postnatal Care
ANTENATAL I) Higher risk of infection -
post op abx
A. Maternal : II) VTE , TED stocking,
adequate hydration,
1st Trimester : encourage early
• Comprehensive hx and risk factor assessment mobilization
• Cuff size 13cm x 24 cm III) Aspiration risk caution
• VTE risk scoring IV) Encourage and assist
• Dietician referral in breastfeeding
• Exercise mild - mod intensity, 30min/5 times per week V) Encourage weight
management, counsel
2nd Trimester : regarding bariatric
• T Aspirin 150mg OD from 12 th week to gestation (Women with more surgery
than one moderate risk factor: BMI >35, primigravida,maternalage VI) Contraception (LARC
>40y/o, Fhx pre-eclampsia and multiple pregnancy) preferred) : Copper IUCD
• Repeat GDM Screening 24-26th Week first line, followed by
implanon and mirena
-Refer table below
• Refer for anaesthetic assessment (Recommended to refer during 28-
34 months, sp for BMI >40)
• Risk of PPH -Active 3rd stage mx
FETAL
• Dating scan (may require TVS)
• BMI >40 -> Nuchal scan between 11-13th weeks
• If difficulty in measuring SFH : Need USG for proper featl surveillance
• Fetal weight assessment at term
• Risk of stillbirth in postdatism (Recommend Elective Caesarian in
patient 39 weeker if pre-pregnancy BMI >30, but need to consider
patient as a whole )
 Timing of Delivery and Intrapartum care :

A. Timing of delivery :
• Obesity alone is not indication for Caesarean section or IOL
• Can consider IOL if macosomia suspected
• IOL at term may reduce chance if Caesarean section without increasing risk of adverse outcome

B. Intrapartum Care :
• Difficulty in monitoring fetal heart - may need internal monitoring
• Consider H2 receptor antagonist
• Second stage similar with normal person

Caesarean section :
• Anticipated difficulty - required experienced surgeon
• Need to suture S/C tissue (>2cm) - reduce risk of wound infection and wound separation
• Require higher dose of antibiotics
• Skin incision : pfannenstiel incision
• Type of incision : maybe difficult due to excessive fat or soft tissue
• Syntocinon dosage : In ot BMI >40 most likely need twice of normal dose

BMI VALUES :

BMI Total weight gain (kg) Rate of weight gain in 2nd and 3rd trimester [mean (range) in kg/wk]

<18.5 12.5-18 0.51 (0.44-0.58)

18.5-24.9 11.5-16 0.42 (0.35-0.50)

25-29.9 7-11.5 0.28 (0.23-0.33)

>/=30 5-9 0.22 (0.17-0.27)

 Obesity with infertility
1. Higher risk of menstrual
dysfunction and anovulation
cycle
2. How obesity lead to infertility :
-Impaired ovarian follicular development
Pregnancy of post bariatric surgery
Few Important points regarding pregnancy post bariatric surgery :
PRECONCEPTION
1. Delay conception 12-18 months from surgery with effective contraception
2. Pre-conception supplementation (Folic acid, Vit B12, Ca and iron supplement )
-Qualitative and quantitative
development of oocyte ANC
- Lower implantation and pregnancy rate 3. Antenatally, need to managed by multidisciplinary team with early antenatal appointment
3. Also have increase maternal and 4. Monitor GM and screen for neural tube defects
fetal complications during pregnancy, 5. VTE each trimester
lower risk of life birth
POSTPARTUM

6. Adequate pain control, early mobilization, thrombo-prophylaxis , physiotherapy

7. Encourage BF
8. Follow up with nutritionist and guide for weight loss
PART 2 : PREGNANCY RISK TO FETAL AND MOTHER

Illness DIABETES MELLITUS HYPERTENSION CKD HEART DISEASE IN PREGNANCY

Risk Fetus : Fetus: Fetus: Fetus:
- Multiple congenital malformations (VSD, - Placenta abruption - Premature birth - 5-10% Increase incidence of
NTD, skeletal malformation) - IUGR - Low birth weight congenital heart disease in the fetus of
- Fetal macrosomia - Neonatal death mother with congenital heart disease.
Mother:
- SGA/IUGR
- Stroke
Mother: - Still birth - Higher risk of IUGR in cyanotic heart
- Renal failure
- Pre-eclampsia disease
- Cardiac failure
- Urinary tract infection Mother:
- Cardiac failure
- Candidiasis - Gestational hpt Mother:
- Pre-eclampsia
- Sepsis - Pre-eclampsia - Primary Pulmonary Hypertension and
- Eclampsia Eisenmenger Syndrome have high risk
- Maternal death of maternal mortality and should avoid
pregnancy.
- Increased risk of
pulmonary embolism, stroke and SBE
more common in prostatic valve.
Pre-pregnancy - For poorly controlled Diabetes Mellitus, - ECG at least - Assess kidney function - Symptomatic mother should be seen
Intervention insulin should be initiated early before annually. and blood pressure. by a cardiologist/physician.
pregnancy. - Aim BP below - Pregnancy reasonably - Mother with mechanical valve change
- Blood glucose and HbA1c monitoring and 140/90. safe if renal function is to LMWH.
control should be done prior to embark on - Avoid angiotensin normal. - Detail scan for fetal anomaly during
a pregnancy. converting enzyme - Target BP less than pregnancy.
- Folic acid supplementations. (ACE) inhibitors, 140/90 - Serial growth scans.
- Screening diabetes complications at least angiotensin receptor - Advice against pregnancy - Contraception continued until
annually. blocker, anti-lipid for severe renal optimization of the heart condition.
- Appropriate management of agents and diuretics. insufficiency. - Specific disorders should be managed
complications and co-morbid conditions. by the cardiologist
 - Referral to appropriate secondary or
tertiary centers when indicated
WHAT - Combination Antiretroviral
therapy (ART) is used to prevent
mother to child transmission
WHO - ART must be started in all
pregnant mothers who are HIV+
regardless of CD4 count
WHEN - Ideally ART should be
started at 14 weeks of pregnancy.
Women who present after the 28
weeks must commence ART without
delay
Choice of ART :
- 2 NRTIs plus either a NNRTI or a
boosted PI or an integrase strand
transfer inhibitors
- Preferred : TDF + FTC + EFV
(TDF+FTC+RAL/TDF+FDC+RAL
preferred for late presenters >28w)
**If patient already been on ART ,
the ART need to be continued
throughout pregnancy and after
delivery, unless taking a regimen
that is contraindicated in pregnancy
(eg. Tenofovir Alafenamide)
- May need to - For specific renal
consider aspirin from disorders refer
12 weeks onwards nephrologist or physician.
- Low dose aspirin should
be given in first trimester
CPG HIV : PREVENTION OF MOTHER-TO-CHILD TRANSMISSION
MODE OF DELIVERY
- A viral load must be done between weeks 32–36 to determine ongoing risk of transmission to the foetus.
Mode of delivery Viral Load (32-36w)
SVD <50 copies/mL
ELLCSC Recommended 50-399 copies/mL
ELLCSC >400 copies/mL or unknown viral load
IN LABOR
- Intrapartum IV Zidovudine Infusion :
✓ Recommended for women with viral load >1000copies/mL who present in labor/ruptured membrane/ELLSCS
✓ IVI Zidovudine 2 mg/kg for the 1st hour followed by 1 mg/kg/h subsequently
✓ Viral load <1000 copies : No added benefit in reducing risk of transmission during late pregnancy & near
delivery
- If HIV+ve woman presented in labor with no prior ART :
✓ Intravenous (IV) AZT stat
✓ Start ART (fixed-dose AZT and 3TC with Raltegravir)
✓ After delivery, the ART can be switched to recommended first line ART regimen for non-pregnant patients
✓ The HIV exposed infant should receive 6 weeks of oral AZT and 3 doses of NVP at birth, 48 hours later and 96
hours after the 2nd dose
- Pre labor ROM (PROM):
✓ Expedite delivery as there is increased risk of perinatal HIV transmission of 2% per hour
✓ If HIV viral load <50copies/mL : Vaginal Delivery
If HIV viral load >/= 50 copies/mL or unknown viral load : Caesarian Section
BREAST FEEDING
- Not recommended as it is associated with risk of transmission up to 14% if not virally suppressed, 1% if suppressed
- For women on ART, compliance must be stressed if they insist on breast-feeding their baby
PART 3 : PAEDIATRICS

ISCHEMIC STROKE DM TYPE 2 OBESITY HEART FAILURE HYPERTENSION

STROKE OF THE YOUNG TYPE 2 DIABETES IN CHILDHOOD AND HEART FAILURE IN INFANTS HYPERTENSION IN NEONATES,
ADOLESCENTS ADOLESCENT OBESITY AND CHILDREN CHILDREN AND ADOLESCENTS
- Before the age of 45
- Better prognosis than elderly Risk Factors : - Common cause : - Causes (I and II most PART 1 : Neonates & Infants
- Need more comprehensive - usually occur in the second unhealthy eating common) :
investigation to determine cause decade coinciding with patterns, lack of I) Congenital Heart Disease - More common in neonates
physiologic pubertal insulin physical activity, II) Cardiomyopathy and infants with antenatal
- Causes : resistance genetic factors, or a III)Tachyarrhythmia steroids, bronchopulmonary
I) Atherothrombolic (Uncommon) - more common in female combination of these IV)Acquired disease dysplasia, patent ductus
- Large artery atherosclerosis - increased adiposity factors (Rheumatic carditis, arteriosus or in those with
- Cardiogenic embolism - family hx of diabetes Endocarditis) indwelling umbilical arterial
- Small vessel disease - low socioeconomic status - Evaluation : catheters
II) Non-atherothrombotic/ Stroke of I) BMI (Using cut-off - Clinical Feature :
other determined cause - multiples of Compared to adult, T2DM in points based on - Measurement : arterial pulse
causes including : children most likely : national centiles) I) Infant & young children: pressure wave form
- Hematological causes - more severe and rapidly II) Adolescent : cut-off Difficulty in feeding
- Coagulation disorders progressive disorder points of 25 and 30 (interrupted feeding, - Protocol in measurement :
- Illicit Drug use - expected to have long kg/m 2 for adult prolonged feeding time) • Measure by oscillometric
- Arterial dissections disease duration and overweight and Tachypnoea , diaphoresis, device
- Vasculitis/inflammatory arteriopathy accumulation of glycemia- obesity at age 18 pallor • use appropriate sized BP cuff
- Others related complications years • use right upper arm
IV) Cryptogenic Stroke/ embolic stroke III) Children : II) Children and • 3 successive BP reading at 2
of undertermined source (ESUS) – Dx of Misdiagnosis of T2DM in overweight is defined adolescence: min intervals
exclusion adolescents : as a BMI greater than Shortness of breath,
• Non-obese adolescents with the 85th percentile Dyspnoea, Decrease effort - Reference point : 95th & 99th
- Ix : diabetes and obesity as a BMI tolerance, Abdominal pain, percentile value
•Classical vascular risk factor screening nausea, and vomiting
•Special (Fasting homocysteine, Anti- •Ketosis/ketoacidosis is
phospholipid present at onset
antibodies, Coagulation screening) •When pancreatic
•Radiological autoantibodies are positive
- Mx : - Screening and Dx :
•If cause not identified -> Aspirin I) Who to screen :
•If cerebral venous thrombosis -> Overweight (>/=85th
anticoagulation with adjunctive therapy percentile) or Obese (BMI
to prevent associated complications ≥95th percentile)+ 2 or more
risk factor below :
•Family history of T2DM
•Signs/ condition assoc. of
insulin resistance (acanthosis
nigrican, hypertension,
dyslipidaemia, PCOS)
•Maternal Hx of GDM during
child’s gestation
II)Test :
- glucose load of 1.75 g/kg
body weight (max. 75 g) for
OGTT is used
- Pancreatic Autoantibodies
(TRO T1DM)
III) Period : Screen every 2
years starting at the age of 10
or at onset of puberty, if
earlier
- Mx :
greater than the 95th - Tx : Diuretics, ACEi, B Blocker
percentile To determine severity of HF and CCB
-> Modified Ross
- Management : classification : PART 2 : Children and
I) Weight loss : Adolescents
Prolonged weight I.Asymptomatic
maintenance II. - Def : Average systolic or
II) Diet : Specifiying Infant : Mild tachypnoea or diastolic BP > 95th percentile
total number calories diaphoresis during feeding for age, gender and height
per day and % from ,No growth failure or failure percentiles on at least 3
fat, protein d carb to thrive separate occasions
III) Physical Activity : Older children: Dyspnoea
>60min per day of on moderate exertion - Goal of therapy :
moderate exercise III. I) Uncomplicated : <95th
IV) Behaviour : Salf- Infant : Marked tachypnoea percentile for age, sex and
monitoring, or diaphoresis during height
nutritional education feeding, Growth failure or II) Secondary HPT/TOD/DM :
V) Family Involvement failure to thrive <90th percentile for age, sex and
Older children: Dyspnoea height
*15-40% of T2DM on mild or minimal exertion
patients have T1DM- IV. Tachypnoea, - Mx :
associated pancreatic diaphoresis or respiratory I) Non-pharmacological :
auto-antibodies. These distress at rest Dietary changes, exercise and
patients are less
weight reduction
overweight, younger,
- Ix :
have higher A1c and
more rapid development
I) CXR : II) Pharmacological :
of insulin dependence - First line ix Indication :
- Look for size of heart, • DM T1/2
**Symptoms contours, pulmonary • TOD
associated with vasculature, and signs of • Stage II hypertension
hypertension include fluid overload • Symptomatic HPT
headache, nausea, II) ECG : • Secondary HPT
I) Lifestyle changes and
education on self management visual disturbances
II) Pharmacotherapy (hbA1c
>9%):
•Only Metformin and Insulin
approved for tx
•Metformin : 500mg daily for
7 days -> Gradual increment ->
500mg once a week for 3-4 w -
> Max dose 1000mg bd
•Insulin :
- May needed in initial
metabolic control, then
change to metformin
- Long/intermediate acting
may be added (0.5u/kg) at bed
time
- Consider starting if HBA1c
>/= 8.5%
- Target :
A1c <7.0%
SMBG :
› Premeal: 4.0 mmol/L-7.0 mmol/L
› Post meal: 5.0 mmol/L-10.0 mmol/L
› Prebed: 4.4 mmol/L-7.8 mmol/L
- Monitoring :
•Complication (Albuminuria,
Retinopathy, Neuropathy)
•Dyslipidemia testing
•NAFLD evaluation
vomiting, seizures and - Always abnormal in • Persistent HPT despite non-
children with HF pharmacological tx
- However, finding are non
specific (Eg sinus Drugs : diuretics, B blocker,
tachycardia and left ACEI, ARBs and CCBs
ventricular Hypertrophy)
III) Echocardiogram : Method : Begin with
- Structural Cardiac defects, recommended dose
chamber sizes, Cardiac monotherapy -> Up until max ->
function Add 2nd meds -> 3rd class
- Mx : - Once a child is diagnosed with
(I) General measures : hypertension, he should be
•Oxygen therapy referred to a paediatrician for
•Correct acidosis/ further evaluation and
hypoglycemia/ anemia management
•NG Tube
•Tx infection / GERD
• Fluids should be carefully
administered - the goal of
therapy is to return the
patient to a euvolemic
state with good perfusion
• Anaemia should be
treated cautiously. If
indicated, blood
transfusion should be
given in small volumes (5-
10ml/kg) to avoid
worsening symptoms
II) Anti failure meds :
•Frusemide (Volume
overload)
In decompensated HF, a
slow intravenous infusion
of frusemide would avoid
worsening the hypotension
as compared to
intermittent bolus
injection
•ACEi (Reduce Afterload )
Captopril is commonly used
in infants. In those more
than 2 years of age,
enalapril can also be used
•Spironolactone :
avoids the need for
potassium supplements. It
has the additional
beneficial effect of
attenuating the
development of
aldosterone-induced
myocardial fibrosis and
catecholamine release
•Inotropic agents
(Dopamine, Dobutamine)
and vasopressors) - acute
decompensated HF

III) Definitive transcatheter

/ surgical intervention
(Depends on diagnosis)
 The ultimate therapy for HF
that is unresponsive to
treatment is cardiac
transplantation
MALARIA
- Treatment regime is SAME as adult except that drug dose is adjusted Uncomplicated P. falciparum malaria : Treatment of chloroquine-resistant P.
according to body weight - Artesunate / mefloquine Fixed Dose vivax, knowlesi or malariae :
- Doxycycline is contraindicated in children <8 years old Combination (ASMQ) - ACT (Riamet or ASMQ) with 14 day
- Primaquine should only be given once screened for G6PD deficiency - 2nd line : Artemether/Lumefantrine (Riamet) primaquine therapy

Tx for P Vivax, knowlesi or malariae: Treatment for Complicated Plasmodium

Total chloroquine 25mg base/kg divided over 3 falciparum :
day D1: IV artesunate 2.4 mg/kg on
admission, then repeat again at 12h
D2-7: IV artesunate 2.4 mg/kg OD or
switch to oral ACT
CONGENITAL MALARIA
- Uncommon
- acquired by transmission of parasites from mother to child during pregnancy or perinataly during labour
- Cause : P. vivax is more commonly reported in Asia whereas infection from P. falciparum is mainly described in African countries
- Clinical Symptoms (Most present with symptoms between 10 and 30 days of age) :
✓ Anemia
✓ Fever
✓ Liver and Spleen Enlargement
✓ Poor feeding/lethargy/irritability
✓ Severe thrombocytopenia
TUBERCULOSIS
TUBERCULOSIS IN CHILDREN
Intro :
- Commonest presentation : Pulmonary TB and Lymph node TB
- A positive TB contact history (usually an adult index TB case) would be a strong clue for TB in a
symptomatic child
- The risk factors for rapid TB progression in children are age <5 years old, malnutrition and HIV infection

Symptoms :
- any cough, fever, night sweats, haemoptysis, weight loss, chest pain, shortness of breath or fatigue
- In children <5 years old, it should also include anorexia, failure to thrive, poor feeding, decrease activities or playfulness
- In HIV Children :
✓ <10 years old: any current cough, fever, history of contact with TB, reported weight loss, confirmed weight loss >5% since last visit or growth curve
flattening or weight for age < -2 Z-scores
✓ ≥10 years old: any current cough, fever, weight loss or night sweats
ACTIVE TB LATENT TB
1. Diagnostic Test : M. tuberculosis confirmed by culture or Xpert MTB/RIF 1. High Risk group to progress to active TB from Latent TB :
- Child contact of bacteriologically confirmed PTB
- 3 smears for AFB : one sample each for Xpert Ultra and mycobacterial culture be - Children below 2 - 4 years of age with LTBI have the highest
obtained to increase the diagnostic yield in children with TB risk of progression to active TB including disseminated and
- In children who are symptomatic with more severe TB, GA and bronchoalveolar lavage central nervous system TB
(BAL) have significantly better yield than NPA in both smear for AFB and mycobacterial - Infant and children living with HIV
culture
- Gastric lavage/aspiration or nasopharyngeal aspirate should be performed in children 2. Diagnostic test : (No Golden standard test)
who cannot expectorate I) Tuberculin skin test (TST)
- In newborn, TST is often negative at presentation and should be repeated after 3 - >10mm induration
months by which time it is frequently reactive - Children may take 8 - 12 weeks to develop a positive TST
- CXR findings in children can be non-specific result after exposure to TB
- Smear Negative TB : Lateral Flow Lipoarabinomannan Assay, LF-LAM may be considered II) IGRA
as an adjunctive test, if Xpert Ultra negative intrathoracic TB in children - similar sensitivity but greater specificity
- Preferable if available for children > 2 years old
2. Treatment :
I) Regime : Either a positive IGRA or TST result should be considered
The TB treatment regimen in children for both PTB and EPTB are the indicative of M. tuberculosis infection. A negative IGRA or TST
same as in adults results cannot conclusively exclude the diagnosis of LTBI and
II) All children with tuberculosis should be given standardised treatment regimens and should be interpreted in the context of other clinical data
dosages (Note : Children have higher dose than adult as in children, serum concentration
is lower & eliminate drug faster) II) Other test :
III) Precaution : CXR : usually normal , but may have dense
 - Ethambutol : Monitor complication (Esp. optic neuritis) regularly nodules with calcifications, calcified non-enlarged regional
- Isoniazid : Supplemental pyridoxine (5 - 10 mg/day) is recommended lymph nodes, or pleural thickening (scarring).
- Medication dose requires recalculation every two to four weeks as children gain weight
rapidly, particularly in neonates and young children 3. Treatment :
Preferred Regimens :
- 4R for all children >28 days of age or 3HP for children aged
>2years.
- 6H for all newborns aged 28 days and below.

Alternative regimes : 3HR, 6H or 9H.

In HIV-infected children with LTBI, 6H is the preferred regimen

for:
- children <2 years of age.
- children ≥2 years of age on antiretroviral treatment with
rifamycin drug interaction.

Complication from vaccination -> BCG LYMPADENITIS

- Occur 2 - 4 months after vaccination and suppuration can occur in 30 - 80% of lymphadenitis
- Usually self-limiting within 4-6 months (If suppuration – heal via rupture -> Scarring)
- Children with unusually large, suppurative BCG lymphadenitis with constitutional symptoms, generalised lymphadenopathy and hepatosplenomegaly should be
referred to the Infectious Disease
DYSLIPIDEMIA
Cholesterol levels are low at birth, increase in first 2 years, peak prior to adolescence and reduce during Mx :
adolescence (Age <18)
Non Pharmacological :
Risk Factors : - Health lifestyle with appropriate diet
- Genetic dyslipidemia - Maintenance of “desirable weight”
- Overweight/Obese - regular exercise
- Kawasaki disease
- Nephrotic Syndrome Pharmacology :
- CKD
- Type 1 & 2 DM
- Chronic inflammatory disease such as SLE
- HIV
- Cigarette smoking
- Screening
I) Assessment of Family Hx for CVD or genetic dyslpidemia
II) If obese/overweight -> full lipoprotein profile, BP measurement and fasting glucose
DM Diagnostic Criteria
i. Classic symptoms of diabetes or
hyperglycaemic crisis, with plasma
glucose concentration ≥11.1 mmol/L
OR
ii. Fasting Plasma Glucose ≥7.0
mmol/L (At least 8 hours)
OR
iii. 2 hour post-load glucose ≥11.1
mmol/L in OGTT
OR
iv. HbA1c >6.5% (Unclear role)
The diagnosis must be confirmed by
repeat blood glucose testing in
the absence of unequivocal
hyperglycaemia
________________________
Risk Factors :
- Genetic susceptibility
- High birth weight (>4 kg)
- Early introduction of cow’s milk
before 3 months old
- In patient with famililal Hypercholesterolemia , statins
are the drug of choice
- All statin can be used as an adjunct diet , in children >10
y/o
- Need for life long therapy and its assoc health risk and
drug exposure during unplanned pregnancy in individual
with child bearing age need to be considered
CPG DM TYPE 1
Clinical Features IX & Monitoring Insulin Tx
Classical Symptoms Screening : TFT & AntiTPO at dx -> Repeat every 2 Common insulin regimen:
over 2 – 6 weeks (Or years A. Intensive insulin therapy (4 or more
months) insulin injection/day)
OR HBA1C : <7.5% for <18 y/o (Individualized : Close as - Basal-bolus regimen (Mimics physiological
Rapid onset of normal while avoiding hypo) insulin secretion)
symptoms within days - Pump therapy [Continuous Subcutaneous
and present in diabetic SMBG : Insulin Infusion (CSII)] – Proven To slow
ketoacidosis (DKA) - 4-6 times/day down progression of complication
- Optimal control : - Sensor-augmented therapy with basal-
Classical Symptoms : ✓ 4-8 mmol/L (Fasting) bolus regimen or pump Therapy (Expensive)
- Polyuria (or Recent ✓ 5-10 mmol/L (Post-prandial)
onset of enuresis in ✓ 6.7 – 10 (Bedtime) B. Less intensive insulin therapy
previously toilet- - Three injections daily :
trained children), Biochemical features to support for the diagnosis of (Mixture of 1) Rapid-acting/short-acting
Polydipsia, Recurrent T1DM includes: and intermediate-acting insulin pre-
infection (skin – Eg. ✓ Low or undetectable C-peptide levels breakfast, 2) Rapid-acting /short acting pre-
Vaginal Candidiasis) ✓ Presence of diabetes-associated dinner and 3)Intermediate-acting insulin
and weight loss (Or autoantibodies pre-bed)
failure to gain weight (GAD/IAA/ICA512/IA2/ZnT8) - Two injections daily :
in growing children) ___________________________ (Mixture of rapid-acting/short-acting and
Sick Day : intermediate-acting insulin pre-breakfast
- Rapid growth within first two years
of life
- Enterovirus infection
- High energy food intake
Associated Autoimmune dz : Thyroid
(Graves dz) , Coeliac Disease, MG,
Pernicious anemia
Emergency - Complication : DKA, dehydration, uncontrolled and pre-dinner (Not recommended because
presentation hyperglycaemia and hypoglycaemia fixed ratio)
- Moderate to severe - General principle :
dehydration 1. DO NOT STOP INSULIN. Insulin dosage :
- Frequent vomiting 2. Monitor BG and ketone (urine or blood) more - Prepubertal children : 0.7-1.0 IU/kg/day
- Abdominal pain frequently. - During puberty and higher : 1.2-2
- Continuing polyuria 3. Monitor and maintain electrolytes and water IU/kg/day
despite the presence of balance.
dehydration 4. Patients and their caregivers should be taught on Short Acting Insulin :
- Weight loss due to sick day management guidelines soon after • in combination with intermediate-acting
fluid loss, and loss of diagnosis and periodically thereafter. insulin in twice daily regimen
muscle and fat 5. Treat the underlying precipitating illness. • as pre-meal bolus injections in basal-bolus
- Acetone-smelling 6. Urgent medical attention if : Persistent fever, regimen together with intermediate-acting
breath weight loss due to dehydration, persistent vomiting insulin/basal analog once or twice daily
- Hyperventilation for 2 hours, Altered mental status • as rescue insulin during crisis
- Decreased level of
consciousness Exercise : Monitoring of Complication :
- Hypotension - Prevention of hypoglycemia during exercise: 1. Retinopathy :
- Shock I) Avoid strenuous physical activity if pre-exercise ✓ Start at age 10 / onset of puberty (If
BG is high (>14) with ketonuria / ketonemia earlier) after 2-5 years diabetes
Age : 6months to II) Increase intensity / duration of physical activity duration -> Annually
Young Adult in progressive manner ✓ Fundoscopy
III) Do not inject insulin in site heavily activity (Eg. 2. Nephropathy :
Thigh before cycling) ✓ Start at age 10 / onset of puberty (If
IV) Monitor BG in evening and night after physical earlier) after 2-5 years diabetes
activity to avoid duration -> Annually
nocturnal hypoglycaemia. ✓ ACR or 1st morning urinary albumin
V) Carry some sugar and drink more water conc or Albumin excretion rates
(AER)
- If hypoglycemia during exercise : 3. Macrovascular disease :
I) Stop physical activity immediately ✓ After age 10 years
II) Consume a rapid-acting 15 g carb ✓ Lipid profile every 5 years , BP
anually

PHASES
3 IMPORTANT STAGES OF DENGUE :
A. FEBRILE PHASE (Day 2-7)
- Abrupt high-grade fever
- Sx : Facial flushing, skin erythema,
generalised body ache, myalgia,
arthralgia, retro-orbital pain,
photophobia, rubeliform exanthema
and headache, Anorexia, nausea and
vomiting + Bleeding tendency
- Earliest abnormality : Drop in WBC
- Complication : Dehydration and
febrile seizure
B. CRITICAL PHASE (Day 3-8 day of
illness) :
- typically occurs around the time of
defervescence (temperature drops to
and remains below 38oC).
- Plasma leakage may occur as a result
of increased capillary permeability and
is manifested by warning signs -> High
HCT -> Hypovolemic Shock (DSS) ->
Severe organ involvement
- Lasts 24-48H
C . RECOVERY PHASE (24 – 48H after
the onset of plasma leakage) :
III) Take additional carbohydrate if hypoglycaemia
persists
IV) Monitor BG level until it is normal
DENGUE IN CHILDREN
SX INVESTIGATION MANAGEMENT
Fever and 2 or following 1. Dengue rapid combo test : I) FEBRILE PHASE
criteria : I) Acute and Recent Dengue infection : - PCM
- Nausea, Vomiting Either NS1 Ag positive or IgM positive - Tepid sponging
- Rash (Regradless of the IgG result) - Don’t prescribe Aspirin, ibuprofen or other NSAIDs
- Aches and pains II) Probable secondary dengue infection or IM injection
Leukopenia / past dengue infection : Only IgG - Outpatient Mx : Daily V/s , FBC and I/O monitoring
Any warning signs positive until resolution of critical phase
III) Unlikely dengue : All NS1/IgM/IgG - Outpatient Mx :
WARNING SIGNS : negative ✓ Criteria : Age<12 mth, Warning sign, severe
-Abdominal Pain/ dengue, present of co-morbidities
Tenderness (Continous) 2. Serology (ELISA) : ✓ Review daily (twice a day for critical phase)
-Persistent Vomiting (>/= - If Negative rapid combo test, but ✓ Clinical (CCTVR) + Lab (FBC, + RP/LFT if in
2 episode that amounts highly suspicious of dengue critical phase, ABG/VBG/Lactate if in shock
to fatige or IV Fluid - NS1 Ag Elisa : if sx </= 5 days
- Clinical fluid - igM/IgG ELISA : If sx >5days or if NS1 II) CRITICAL PHASE
accumulation (Plueral Ags serology negative in sx </= 5 days - 3 main priority :
effusion / ascites) ✓ Replacement of plasma losses
- Mucosal bleed (Eg. 3. RT-PCR : ✓ Early recognition and tx of hemorrhage
Nose/gums/vaginal - Sent if serology/NS1 Ag negative in ✓ Prevention of fluid overload
bleed) suspected severe dengue or mortality - Tx : Judicious IV fluid usually is the only
Lethargy, restlessness cases intervention required to maintain effective
- Liver enlargement >2cm circulation for 24 - 48 hours during the critical phase
- Lab : Increase HCT (20%) Other Ix : ✓ Based on clinical hemodynamic state
concurrent with decrease - Viral Isolation ✓ Decompensated Shock : 20ml/kg boluses
in platelet (>/=100x103) over 15-30 min, Compensated Shock : 10-
Under the Prevention and Control of 20ml/kg over 1 hour
Severe dengue Infectious Diseases Act, 1988 (Act 342),
- General condition improves (Eg
improve appetite, reduce sx,
hemodyanamically stabilized)
- HCT may decrease due to dilutional
effect which does not warrant further
action
- Complication : new onset respiratory
distress due to fluid overload
INTRO
Congenital hypothyroid screening
using cord blood collected at birth
Primary TSH measurement
supplemented by FT4 is preferred
strategy.
All cord blood is assayed for TSH. In
babies with borderline high TSH,
free
T4 is assayed from the same blood
sample
Long Term Outcome/ Complication :
• Neurodevelopment
• Growth and puberty
I) Severe plasma notification of dengue is mandatory and ✓ Type of fluid : Isotonic crystalloid solution.
leakage(Eg. Shock) failure to notify is compoundable Colliod is used if persistent shock despite
Ii) Severe bleeding ============================== resus with crystalloid
III) Severe organ DISCHARGE CRITERIA ✓ Detail i/o ,urine output would be at least
impairment : I) Clinical Criteria : 0.5 - 1 ml/kg/hour
-Liver AST or ALT >/= • No fever for 24 - 48 hours ✓ Blood transfusion indicated in massive
1000 • Improvement in clinical status bleeding or occult bleeding in shock
(general well-being, appetite,
**It is important to see haemodynamic status, urine output) III) RECOVERY PHASE
signs of dehydration in • Absence of respiratory distress - Discontinue IV fluid early to avoid fluid overload
dengue patient • Resolution or recovery of organ - Fluid overload : Small doses of IV frusemide 0.1 -
dysfunction 0.5 mg/kg/dose twice or thrice daily or a continuous
II) Lab Criteria : infusion of frusemide 0.1 mg/kg/hour may be
• Increasing trend of platelet count indicated
• Stable HCT without IV fluids
CONGENITAL HYPOTHYROIDISM
SX INVESTIGATION MANAGEMENT
Risk factors : Cord TSH blood taken for ALL baby at LT4 treatment should be started as soon as diagnosis is
- Maternal history of birth (SCREENING) : made.
thyroid disease
- Use of anti-thyroid I) Cord blood TSH >60 mIU/L (HIGH): • An initial dose of LT4 at 10-15 mcg/kg/day (maximum 50
drug; excessive iodine Patient is recalled for venous TFT (see mcg/day) is
intake e.g. seaweed below) recommended, the lowest dose for mild disease and
- Maternal iodine II) Cord blood TSH (20-60) mIU/L higher dose for severe
deficiency; parental (BORDERLINE): disease.
consanguinity Cord blood FT4 is measured. › Mild CH (FT4 >10 pmol/L) 10 mcg/kg/day
- Family history of › Cord FT4 ≤15 pmol/L: Patient is › Moderate CH (FT4 5-10 pmol/L) 10 mcg/kg/day
thyroid disease recalled for clinical evaluation and › Severe CH (FT4 <5 pmol/L) 15 mcg/kg/day
- Prematurity venous TFT. › Subclinical CH 5-10 mcg/kg/day
- Low birth weight › Cord FT4 >15 pmol/L: No further
infant actions are required • LT4 is better if :
- Use of iodine III) Cord blood TSH <20 mIU/L ✓ Branded rather than generic
antiseptic solutions -> Normal
• Metabolic, cardiovascular and
bone health
• Health-related quality of life (QOL)
• Fertility & future pregnancy
outcome
============================== ✓ Dispensed in Tablet form (can be crushed, but not
Features suggesting Abnormal result ( cord TSH >60 mIU/L, to be served in milk bottle)
congenital or (20-40) mIU/L AND cord FT4 ≤15 ✓ Consistent timing every day to ensure compliance
hypothyroidism : pmol/L) -> recalled at day 4-6 ✓ Avoid soy, iron, calcium supplementation within
• Sluggishness for a detailed clinical evaluation and an hour of LT4 administration
• Constipation re-testing of FT4, TSH for confirmation
• Hoarseness of voice of thyroid status : • Monitoring :
• Poor weight gain - After 2 weeks of intiation (if initial dose 15mcg/kg/day or
• Dry skin I) Day 4-6 venous TSH >40 mIU/L : 50mcg/day, then 1 week) -> Every 2 weeks until TSH
• Prolonged neonatal Treatment should be started normalizes -> 1-3 months until age of 12 months -> 2-4
jaundice immediately regardless of FT4 months (1-3 years old) -> 3-6 months until growth
• Macroglossia concentration. completed
• Umbilical hernia - More frequent follow up if abnormal FT4/TSH or
• Cold extremities II) Day 4-6 venous TSH 20-40 mIU/L, compliance issue
• Wide posterior and :
fontanelle A - FT4 < 12 pmo/L : treatment should • Re-evaluation :
(normal 0.5cm x be started - Done for all patients which aetiology and permanence of
0.5cm) B - FT4 > 12 pmol/L, FT4, TSH is CH has not been established before initiation of thyroxine
• Goitre repeated on day 8-14 If the repeat replacement (thyroid scintigraphy has not been done
TSH on Day 8-14 is persistently >20 prior tx)
mIU/L, treatment should - Done at 3 years old (Myelination of CNS completed)
be started. - Thyroxin is stopped for 4 weeks or phased out over 4-6
weeks duration. At the end of this period, venous FT4 and
III) Day 4-6 venous TSH 6-20 mIU/L : TSH are measured
Venous TFT is re-checked after 1-2 - Thyroxine replacement is indicated if :
weeks: ✓ Structural abnormality of the thyroid gland is
A -> Treatment is indicated if repeat present
venous FT4 falls below age-specific ✓ TSH increases to >10 mIU/L (Permanent
reference range. Congenital Hypothyroidism)
B -> If repeated TSH remains static ✓ FT4 falls to below the reference range for age
within 6-20 mIU/L after the age of 21 ✓ Symptoms and signs of hypothyroidism. –
days in a healthy neonate with a Resume LT4 and consider but Thyroid USG to
determine etiology

RISK FACTORS
Multifactorial and complex
aetiology :
a) Biological factors
- Male
- Genetic
b) Environment factors
- Prenatal factors : Hypertensive
disorder, maternal diabetes,
maternal psychosocial stress,
maternal drug abuse/alcohol
abuse
c) Perinatal Factors
-Low apgar score, Preterm birth
and low birth weight
- Traumatic brain injury
3 CORE SYMPTOMS
• Inattention
• Hyperactivity
• Impulsivity
In adolescence and adulthood :
hyperactivity and impulsivity
normal FT4, options should be
discussed
IV) Day 4-6 venous TSH < 6 mIU/L: No
further action is required
ADHD
HISTORY
- Information from parents/carers and
teachers should be sought to increase
accuracy of assessment
- Explore history in terms of :
•Perinatal History
•Behaviour in school and home
•Activities of daily living and behaviour,
with their impac on individual and family
•Family structure and family history
PHYSICAL AND MENTAL
EXAMINATION
Focus of mental status examination :
• general appearance and behaviour
• activity level and social interaction
• speech and language
• mood and affect
• thought process
• attention and concentration
• intelligence and academic skills
RATING SCALES
- useful adjuncts to the clinical interview
in gathering more information about the
individual
- If FT4 & TSH are within the normal reference range
without thyroxine replacement for 4 weeks, this likely
indicates transient CH -> Stop LT4
SEVERITY OF ADHD PHARMACOLOGICAL
I) MILD : TREATMENT : Stimulants/ Non-
- Few symptoms in excess to make stimulants
diagnosis
- Minor impairment in social or A. Children ≥6 years and
occupational functioning adolescents :
II) MODERATE : -Offer Methylphenidate (MPH) if
-Symptoms or functional impairment symptoms are persistent and
between “mild” and “severe” are causing significant impairment in
present at least one domain despite
III) SEVERE : behavioural and environmental
-Many symptoms in excess to make interventions
diagnosis
-Marked impairment in social or Atomoxetine (ATX) maybe given
occupational functioning as alternative
TREATMENT/MANAGEMENT B. Children <6 years old
======================= - If medication indicated, it
MILD symptoms and functional should be initiated by a child
impairment : psychiatrist or a paediatrician
->Psychoeducation and non- with expertise in managing
pharmacological treatment ADHD
(Can be managed in primary care
setting by FMS) COMBINATION TREATMENT
OTHERS : -Combination treatment
Refer psychiatrist/paediatrician if: (pharmacological and non-
becoming less evident,while
inattention symptoms remain
When to suspect ADHD:
- Any child or adolescent
presenting with academic
difficulties, behavioural
problems, mood disturbances,
substance use or personality
disorders
Additional Support that can be
offers for children with ADHD
-Registration for Orang Kurang
Upaya (OKU)
- Special needs education
including inclusive education in
the mainstream setting
- Examination and classroom
accommodation (e.g. extra time,
reduced distraction)
- Common behaviour rating scales
used are:
->Conners’ Rating Scales (CRS)
->Child Behavior Checklist (CBCL)
->Vanderbilt ADHD Rating Scale
->ADHD Rating Scale-5
->Strengths and Difficulties
Questionnaire (SDQ)
DIAGNOSIS :
-DSM-5 or Hyperkinetic disorders from
ICD-10
-Core symptoms of ADHD are:
• inattention
• hyperactivity
• impulsivity
In order to meet diagnostic criteria, the
core symptoms should:
• be persistent
• be pervasive (present in two or more
setting)
• have caused significant functional
impairment
• not better accounted for by other
mental disorders (e.g. pervasive
developmental disorder, schizophrenia,
other psychotic disorders, depression or
anxiety)
[Onset of symptoms : 5 years ADHD,for
hyperkinetic ds,12 years for ADHD]
-Moderate / severe symptoms /
functional impairment
- Pre-schoolers
- Indication for referral
- Presence of co-morbidities
- Persistent impairment despite
intervention of patient with mild
symptoms
=======================
NON PHARMACOLOGICAL
TREATMENT
I) Psycho-Education :
Contain the following :
->good patient-healthcare
relationship
->disorder-related information e.g.
symptoms, negative effects in the life
course
-> treatment-related information
barriers to adherence and coping
skills parenting skill
II) Occupational therapy :
Method include sensory motor
activities, motor training, social skills
training, cognitive interventions,
behaviour intervention and play-
based interventions
III) Organisational skills training
IV) Psychological Intervention
• Cognitive behavioural therapy-
based interventions : include
modules on psychoeducation,
pharmacological) should be
considered in children ≥6 years
of age and adolescents with
ADHD when the symptoms
persist and cause functional
impairment
- Also helps lower use of lower
stimulant dosages
=========================
REFERRAL TO
PSYCHIATRIST/
PAEDIATRICIAN
-All pre-schoolers (below six
years of age) with suspicion of
ADHD
- Uncertainty of diagnosis
- Lack of response to non-
pharmacological treatment
- Indication to start
pharmacotherapy
- Severe side effects of
medication
- Co-morbidities (e.g. substance
abuse)

ACQUIRED THYROID DISORDER IN CHILDREN AND ADOLESCENCE
ACQUIRED HYPOTHYROIDISM
Most common cause : Autoimmune
Thyroiditis (Hashimoto’s Thyroiditis)
CLINICAL SYMPTOMS
- Most common : declining height
velocity that result in short stature
- Other symptoms : altered school
performance, sluggishness, lethargy,
cold intolerance,
constipation, dry skin, brittle hair, facial -First choice : Levothyroxine
puffiness and muscle pain
Physical Examination :
- Most common : diffusely enlarged
thyroid gland/goiter
- Other : short stature;
apparent overweight; puffy facies with
dull, placid expression; bradycardia;
pseudohypertrophy of the muscles and
delayed deep tendon reflexes
Risk Factors :
- Turner Syndrome (Annual TFT)
- Down syndrome (TFT 6,12 month and
then annually)
- Klinefelter Syndrome (TFT every 1-2
years after age of 10)
- Prader-Willi syndrome
INVESTIGATION
- Antithyroid antibodies (Serum
TPO antibody and ATG antibody
level)
- USG and isotope scan not
recommended
TREATMENT
(LT4)
-Aim : restore normal growth,
development, and normal
pubertal progression
-Dose :
i)Age 1–3 years: 4–6 mcg/kg
body weight
ii)Age 3–10 years: 3–5 mcg/kg
body weight
iii)Age 10–16 years: 2–4 mcg/kg
body weight
- Target range :
• TSH : 0.5–2.0mIU/L
• FT4 : Upper half of
reference range
For euthyroid Hashimoto’s
thyroiditis : Tx with thyroxine is
recommended if present of
goitre
organisational/ planning skills,
impulsivity and motivation
management, and relapse
ACQUIRED HYPERTHYROIDISM
Most common : Graves TREATMENT
disease - First line : Carbimazole / MMI
- Dose : 0.2–0.5 mg/kg daily
CLINICAL FEATURES : - Avoid PTU
I) School age children and - Consider Beta blocker if significant
adolescents : poor tachycardia
concentration, - Monitoring : After 2–4 weeks, when
deterioration in school thyroid hormone levels have normalised,
performance, irritability, the initial dose is gradually reduced by
fatigue, palpitations,heat 30%–50%. Hypothyroidism may occur if
intolerance, fine tremor, the ATD dose is not reduced as serum fT4
and goiter levels normalize
II) Younger prepubertal - Blood : FBC, LFT at baseline
children : poor weight gain - Definitive Therapy of Graves Disease :
and frequent bowel I) Indication : relapse after an appropriate
movements, increase in duration of ATD, compliance issues, or
height velocity adverse effects of ATD)
II) Options : RAI or Thyroidectomy
Physical Exam : III) RAI
- Symmetrical goiter • Preferred treatment for children
- Ophthalmic abnormalities between 5 and 10 years of age
: less severe in children • Recommended when when a child
than in adults has developed a reaction to ATD,
proper surgical expertise is not
Ix : available, or the patient is not a
1.TFT suitable surgical candidate
2.If dx not apparent : TSH • Must achieve euthyroid first using
receptor antibody, RAIU MMI/ beta blocker
IV) Thyroidectomy :

Definition : group of inherited
(X-Linked recessive) blood
disorders in which there is
life-long defect in the clotting
mechanism
Most common type :
-Haemophilia A (factor VIII
deficiency)
-Haemophilia B (factor FIX
deficiency)
X-Linked recessive : Males are
more commonly affected,
females are carriers
Clinical Features :
a) Newborn/ Infant :
spontaneous
intracranial bleed.
b) Early childhood : Easy
bruising (Eg. hematoma post-
vaccine or Vit K injection)
Common site :
-Joints (70 - 80%)
especially hinged joints (e.g.
ankles, knees and elbows)
HAEMOPHILIA
Severity of Hemophilia :
a)Mild (5-40 IU/dL): Severe
bleeding with major trauma or
surgery
b) Moderate (1-5 IU/dL) :
Occasional spontaneous
bleeding; prolonged bleeding
with minor trauma or surgery
c) Severe (<1IU/dL):
Spontaneous bleeding into
joints or muscles
Investigation
1.Screening Test :
-FBC : Platelet (Normal)
-Coagulation Profile :
Prolonged APTT and normal
PT
2. Diagnostic :
I) If prolonged APTT + NO fhx
of hemophilia : Mixing Test
-> Likely factor deficiency if
mixing result is corrected both
for immediate and 2-hour
incubation
-> If it is not corrected,
Bethesda or Nijmegen assay
3. USG : Thyroid gland
asymmetry or palpable
nodule
NON PHARMACOLOGICAL:
• Rehabilitation :
-Offer during acute or sub-acute bleeds and
those with chronic arthropathy.
• First aid measures) :
a. Acute (within 72H) :
-Protection, Rest, Ice therapy, Compression,
Elevation (PRICE)
b. Subacute (<3 days) :
-Hydrotherapy
-Mobilising exercise
-Strengthening exercise
-Mechanical exercise
c. Chronic (>6 month) :
-Hydrotherapy
-Mobilising exercise
-Strengthening exercise
-Mechanical exercise
-Weight bearing exercise
======================
Detail regarding PRICE :
A.Protection (P)
• Avoidance of weight bearing
• Restriction of activities until swelling and
temperature of the joint return to normal
• Use of a sling, removable splint and
compressive bandage for the affected joint
• Preferred treatment for GD in young
children (<5 years)
• Total or near-total thyroidectomy
MUSCULOSKELETAL
COMPLICATION
I) Synovitis :
-painless chronic swelling of the
affected joint due to hypertrophy
and hypervascularity of synovium
- Imaging : US and/or MRI
-Additional tx option :
Synovectomy including
radiosynovectomy; a local
radiotherapy indicated for patient
with recurrent joint bleeding
II) Joint arthropathy and
contracture :
-Chronic haemophilic arthropathy
-Additional tx option : Surgical
intervention (Eg prosthetic joint
replacement) considered if these
conservative measures fail
IV) Pseudotumor :
-encapsulated haematoma with a
thick, fibrous capsule
-Symptom : painless, firm,
expanding masses
- Treatment options : Surgical
resection, Irradiation
INHIBITOR :
-Others : Muscles (esp deep
compartment),Mucous
membrane (Mouth,gums,nose)
-Life threatening : Neck/ throat,
intracranial, gastrointestinal
should be done to determine
the factor inhibitor level
II) If prolonged APTT + positive
fhx of hemophilia : Factor VIII
or Factor IX assay
4. Mutation analysis : affected
male and his mother
5. Cascade screening : Offer to
at least 1st and 2nd degree
female relative if mother of
person with hemophilia is a
confirmed carrier
B. Rest ( R)
• Immobilisation of the affected joint until pain develop following factor
resolves
• Use of crutches when ambulating
C.Ice Therapy (I)
• Should not be applied directly to the skin
and should not exceed 20 minutes at 2-
hourly intervals
• Always be guided by levels of pain and
discomfort
D. Compression (C)
• Configuration follows the limb/joint shape
• Provision of a graduated compressive force - Screening for inhibitor : done in
which is comfortable for the individual
E. Elevation (E)
• Elevation when sitting and lying in supine
position
PHARMACOLOGICAL TREATMENT :
• Prophylaxis - Prophylactic clotting factor
infusion :
-for all severe haemophilia patient as primary
prophylaxis
-Start following intracranial haemorrhage, first
joint bleed, severe intramuscular bleed or by
3 years old, whichever comes first
- Preferred therapy regime : Malmo protocol
(high dose)
• Adjunct :
i)Desmopressin (DDAVP) :
-Inhibitor : antibodies that
neutralise clotting factors which
replacement therapy -> making
factor replacement therapy
ineffective
- Risk factor : high intensity tx of
clotting factor, FVIII genotype, and
family history inhibitor
- Should be suspected when :
poor response to replacement
therapy,recovery assays are not
as expected and increase
bleeding episodes despite optimal
prophylaxis
all persons with haemophilia
exposed to factor replacement
therapy (at regular intervals, after
intensive tx for >5 days, prior to
surgery)
-Acute bleeding in patient with
inhibitor : Bypassing agents (e.g.
rFVIIa or aPCC) which bypass
coagulation pathway that normally
utilises FVIII.
- Immune tolerance induction (ITI)
to eradiacte inhibitor : consider if
inhibitor titre below 10BU within 1-
2 years, or severe life threatening
bleeding event
MONITORING :
-Annual Bleeding Rate
- Inhibitor screening
-boosts plasma level of FVIII and vWF in mild
to moderate haemophilia A
- relatively contraindicated in children less
than two years old who may be at risk of
seizure secondary to cerebral oedema due to
hyponatremia
ii)Tranexamic acid :
-control bleeding from skin and mucosal
surfaces e.g. oral bleeding, epistaxis and
menorrhagia
• Analgesia : for pain relief according to its
severity in haemophilia.(PCM->Celecoxib->
Mild Opioid->Strong opioid)
- Annual Haemophilia Joint Health
Score
- Ultrasound of knee, ankle and
elbow when feasible
OTHERS :
-All injectable vaccinations in
haemophilia should be given
subcutaneously
-Comprehensive and routine oral
health care should be initiated
early within six months after the
first tooth erupts and no later than
12 month.

•Acute Bleeding in specific site :

Acute bleeding should be treated preferably
within 2 hours. Haemostatic agents e.g. TXA
should be given concurrently except in
genitourinary bleeding

I) Medical Emergency : Bleeding in head,

neck and GIT. Factor replacement should
precede investigation

II) Joint (Hemarthrosis)

-Symptoms : Rapid lose of ROM, Pain, warm
and swollen joint
-Besides factor replacement therapy, pain
relief and rehab, Joint aspiration
(arthrocentesis) can be considered if no
improvement 24 hours after conservative
treatment

III) Muscle Bleeding


Route of Transmission :
1. Person to person via
aedes mosquito bite
2. Vertical transmission in
neonate
Pathophysiology :
Dengue infection disrupt the
EGL and thus increased
capillary permeability ->
Plasma leakage into extra
vascular component ->
Haemoconcentration and
hypovolemia/shock
Risk factor for severe
dengue :
• lethargy
• abdominal pain
• bleeding tendencies
• hepatomegaly
DENGUE CPG IN CHILDREN
Asymptomatic or present with a
broad range of clinical
manifestations from [mild febrile
illness (known as DF) to life-
threatening shock syndrome]
—---------------------------------------
Warning signs of dengue
• Abdominal pain - abdominal
tenderness and continuous pain
(not intermittent)
• Persistent vomiting - ≥2 episodes
of vomiting that amounts to fatigue
or requires intravenous (IV) fluids
• Mucosal bleed - bleeding from
nose, gums, conjunctiva, vagina,
gastrointestinal/respiratory/ urinary
tract
• Lethargy, restlessness
• Liver enlargement >2 cm
• Clinical fluid accumulation -
pleural effusion and ascites
-Symptoms : Painful when stretched or
actively contracted,tenderness upon
palpation,swelling and specific posture of the
affected limb to avoid pain
- Ix : US and MRI to confirm diagnosis
Provisional Diagnosis :
1. Live in/travel to dengue endemic
area
2. Fever and TWO of the following
- nausea or vomiting
- leukopenia
- rash
- any warning signs
- aches and pains
INVESTIGATION
Lab Criteria for suspicion of dengue:
• Increasing trend of platelet count
• Stable HCT without IV fluids
I) FBC
Febrile Phase : The earliest
abnormality in full blood count (FBC) is
a gradual drop in
MANAGEMENT
1. FEBRILE PHASE:
-Paracetamol 10mg/kg/dose TDS/QID
-Tepid sponging in high fever
-DO NOT aspirin/NSAIDs/ Intramuscular
injection
Outpatient Criteria :
- Daily Vital sign and FBC until critical
phase resolved
- Urine output target 4-6 times/day
-Safety netting : Eg. TCA STAT if
presence of warning sign
Admission Criteria :
-Age <12 months
-Presence of warning signs
-Features of severe dengue
-Presence of co-morbidities
-Consider in Social factors
• haemoconcentration of
>22% of baseline
• thrombocytopenia of <100
PREVENTION ON
MOSQUITO BITE : :
• clothing that minimises
skin exposure during
daylight hours when
mosquitoes are most active
• repellents on exposed skin
or to clothing in strict
accordance with label
instructions
• insecticide-treated
mosquito nets during
sleeping
• household insecticide
aerosol products, mosquito
coils or other insecticide
vaporisers
• household fixtures e.g.
window and door screens
and air-conditioning
• Laboratory: increase in
haematocrit (HCT) concurrent with
decrease in platelet - HCT raised
by 20% from the baseline value
with concurrent decrease in
platelet count ≤100 x 103 cells/mm
=======================
A.Febrile Phase (2-7 days)
• abrupt high-grade fever
• facial flushing, skin erythema,
generalised body ache, myalgia,
arthralgia,retro-orbital pain,
photophobia, rubelliform
exanthema and headache
• anorexia, nausea and vomiting
• Haematological manifestations
are mild e.g. petechiae,
mucosal membrane bleeding
(nose, gum), easy bruising or
bleeding at venepuncture sites
Complications : dehydration and
febrile seizures
B. Critical Phase (After 3rd day -
8th day, when temp drops to and
remains below 38) :
-Usually lasts 24 - 48 hours
-May have plasma leakage
- Complication :
-> Hypovolemia, Shock, Severe
dengue , severe organ
involvement
white cell counts, which should alert
the doctor to a high probability of
dengue.
Critical Phase : Initiation of plasma
leakage is signalled by an elevated
HCT and rapid onset of
thrombocytopenia
Hematocrit Interpretation :
-Interpretation need to corresponds
with hemodynamic state
- Rise of HCT level beyond 20% of the
baseline during critical phase indicates
significant plasma leakage and the
need for
IV fluid therapy
- Range of HCT different according to
age groups
- HCT FORMULA :
I) NOT STABLE + High/Rising HCT :
Active Leakage, need further fluid
resus
II) Stable Vital Sign + High/Rising HCT
: Monitor closely
III) Shock patient + HCT Decrease :
Bleeder , consider packed cell
transfusion
IV) Stable patient + HCT Decrease :
Hemodilution/R eabsorption of
extravasated fluid, stop fluid
-In infant , they have relatively low
HCT (28-42%) and even lower in IDA
patient
Inpatient monitoring :
I) Clinical : General well being, Warning
sign, I/O , u/o
II) Hemodynamic Status : CCTVR, BP,
HR
III) Others : GCS, Spo2, sign of bleeding
IV) Blood ix
2. CRITICAL PHASE :
Key management :
• replacement of plasma losses
• early recognition and treatment of
haemorrhage
• prevention of fluid overload
Fluid type :
-Isotonic Crystalloid (Eg 0.9% NS)
-Colloid may be used in persistent shock
Treatment of warning sign : Fluid
resuscitation + maintenance based on
level of hydration
=> Refer Below for Management of
Shock
3. RECOVERY PHASE :
- Discontinue IV Fluid early to prevent
fluid overload which can lead to resp
distress from pleural
effusion/ascites/Pulmonary edema
- Tx of Fluid overload : Can consider IV
or IVI frusemide
======================
C. Recovery Phase :
-24 - 48 hours after the onset of
plasma leakage -> reabsorption of
extravascular compartment in the
next 48 - 72 hours)
Important signs to be considered
are:
-General condition improves
-HCT may decrease due to
dilutional effect which does not
warrant further action
- New onset respiratory distress
due to fluid overload
======================
INFANT
-May similar with older children :
coryza symptoms e.g. cough,
nasal congestion and runny nose.
-Important Atypical sx in infant :
presence of febrile convulsion,
vomiting, diarrhoea and petechial
rash
(Shock Patient + Normal HCT :
Consider Bleaker (Bleeding + Leaking)
)
DIAGNOSTIC INVESTIGATION
I) Acute (1-5 days of fever) :
Detection of DENV
• Viral Isolation (Mosquito cell culture
inoculation)
• Nucleic acid detected (PCR)
• Antigen detection (NS1)
II) Viral Serology :
• Paired Sero ( Acute 1-5 days and
second serum 15-21 Days after) : IgM
/ IgG seroconversion
• Serum after day 5 of fever : IgM and
IgG Detection
Commonly used : DENGUE RAPID
COMBO TEST
(NS1 Antigen/IgM/IgG) :
**MUST NOTIFY DENGUE WITHIN
24 HOURS**
Primary vs Secondary Infection :
NS1 / IgM positive - Likely Primary
Infection
MANAGEMENT OF ORGAN
INVOLVEMENT IN DENGUE
A. Neurological Involvement :
-Acute encephalopathy :
•most common neurological
complication
•present with reduced level of
consciousness
•Cause by multifactorial (Eg. shock,
organ failures)
• Ix : CSF analysis usually normal
• Mx : Management of u/l cause
-Encephalitis :
•Clinical features : reduced
consciousness,headache, altered mental
status and seizures.
•Ix : Presence of DENV by PCR,
NS1 Ag or dengue IgM antibody in CSF.
CT/MRI brain : Cerebral Edema
•Mx : Supportive management
B. Liver Involvement :
• Usually in severe dengue
• Clinical Features : Usually
asymptomatic with mild and transient
elevation transaminitis, although rarely
develop into acute liver failure
• Ix : LFT : AST > ALT
• Mx : Supportive management
C. Cardiac Involvement :
•Clinically significant cardiac involvement
including myocarditis is uncommon
 IgG positive only - Likely Secondary
infection
ALL positive - Likely Secondary
infection with High viral load of DENV
Other bloods in shock patient/ as
indicated :
-RP/LFT/Blood Sugar
-VBG/ABG/Lactate
-Coag Profile
======================
DISCHARGE CRITERIA
Clinical Criteria :
• No fever for 24 - 48 hours
• Improvement in clinical status
(general well-being,
appetite, haemodynamic status, urine
output)
• Absence of respiratory distress
• Resolution or recovery of organ
dysfunction
MANAGEMENT OF SHOCK AND ITS COMPLICATION : D. Monitoring patient in Shock :
•Tx : Supportive mx
D. Kidney Involvement :
• Proteniuria may developed in day 5-7
day of fever, will resolved as patient
recover
• AKI may developed in prolonged shock.
Tx : supportive
• If RRT required, CVVH is preferred
mode of RRT
E. Blood Transfusion :
• Indication :
-Massive bleeding
-Occult bleeding
• Type : Fresh Packed red cell
• How much :
-Children : 10 - 20 ml/kg/dose
-Neonate : 5 - 10 ml/kg

A. Criteria for PICU/HDW : • consciousness level

• prolonged and/or decompensated shock • vital signs
• severe bleeding with severe DIVC • peripheral perfusion (every 15 - 30 minutes until the patient is out of
• fluid overload shock, then 1 - 2 hourly)
• respiratory distress and failure • continuous ECG and spo2 monitoring
• severe organ impairment (hepatic damage, renal • Urine output (each hour until the patient is out of shock, then every 1 - 2 hours).
impairment, cardiomyopathy, encephalopathy or encephalitis)
E. Glucose Control :
B. Treatment of compensated shock :
• IV/IO access within five minutes.
• IV fluid resuscitation 10 - 20 ml/kg over one hour. Both hyperglycaemia and hypoglycaemia may occur in the same dengue patient at
(infusion/syringe pumps) different periods.If oral intake is still inadequate, blood glucose should be monitored
• Reassess the patient’s condition (vital signs, CRT, HCT and frequently during the critical and recovery phase.
urine output):
• If the condition of the patient improves, reduce IV fluid I) Hyperglycemia :
accordingly (Reduced earlier If oral fluid intake -Causes :
improves) •Neuroendocrine stress response
• Stop IV fluid if patient shows signs of reabsorption, •Diabetes Mellitus
usually 48 hours after entering critical phase. •Inappropriate large quantities of glucose-fluids administered in resuscitation
• If vital signs are still unstable (i.e. shock persists), -Effect :
check HCT urgently after the first fluid bolus: •Osmotic diuresis which worsens the hypovolaemic shock
=> Increasing HCT or still high with evidence of shock, repeat • Gives a false impression of a “good urine output”
crystalloid solution at 10 - 20 ml/kg over an hour. -Treatment : Most resolve with appropriate (isotonic, non-glucose) and adequate fluid
=> Consider changing to colloid solution at 10 - 20 ml/kg over resuscitation
an hour after resuscitation with 40 ml/kg of crystalloid
solution. II) Hypoglycemia :
=> Decreasing HCT with unstable vital signs indicates -Causes :
bleeding which may be occult. Transfuse patient with fresh •Starvation in young children
whole blood or packed cells. •Diabetic patients on hypoglycaemic agents
• Boluses of crystalloid or colloid solution may need to be •Severe liver impairment
repeated if shock recurs. -Effect :
•Seizures, mental confusion
C. Treatment of Decompensated (Hypotensive) Shock •Increased sympathetic drive

• IV/IO access within five minutes. F. Electrolytes and Acid-Base Imbalances

• IV fluid resuscitation 20 ml/kg bolus over 15 - 30 minutes
(infusion/syringe pumps)
• Colloid solution may be considered if the BP has to be
restored urgently, i.e. in those with pulse pressure <10
mmHg.
• Monitor vital signs closely and urine output hourly with an
indwelling Catheter.
• Children with decompensated shock should be admitted to
the HDW or ICU and managed by senior staffs.
I) Hyponatremia :
-Common observation in severe dengue
-Related to GI losses or Hypotonic solutions used for resus
-Treatment : Isotonic solution for fluid resus
II) Hyperkalemia :
-association with severe metabolic acidosis or acute kidney injury (AKI)
-Management (3 levels) :
•First line- Appropriate fluid resuscitation to reverse met acidosis

DEFINITION of diarrhoea :
passage of unusually loose or
watery stools, usually at least
3 -Several hours to days
times in a 24-hour period.
Not considered as diarrhoea :
->Frequent passing of formed
stools is not considered as
diarrhoea
->Baby pass loose, 'pasty'
stools sometimes up to 6 to 7
•Life threatening- Lytic cocktail (infusions of calcium gluconate, sodium bicarbonate
and/or insulin-dextrose)
•Failed medical tx-renal replacement therapy (RRT)
III) Hypokalemia :
-associated with gastrointestinal fluid losses and stress-induced hypercortisol state
-usually happens towards the later part of the critical phase
-Treatment: corrected with potassium supplements in the IV fluids
G. Metabolic Acidosis :
-Early sign of hypovolaemia and shock
-Cause :
•Most common cause in critically ill dengue patients is lactic Acidosis which is due to
tissue hypoxia and hypoperfusion
-Differential of Lactic Acidosis (High lactate >2.2) : acute renal failure and acute liver
failure secondary to severe dengue. Also consider co-infections e.g. leptospirosis,
salmonellosis or other superimposed bacterial sepsis.
•Hyperchloraemic acidosis with normal lactate levels : administration of large volumes
of 0.9% NS (chloride concentration of 154 mmol/L)
DIARRHOEA IN CHILDREN
CLINICAL TYPE : DIFFERENTIAL DIAGNOSIS OF MANAGEMENT
AGE
1.Acute Watery Diarrhoea : A.REHYDRATION :
• Acute appendicitis
-Main concern is dehydration • Strangulated hernia i) No signs of dehydration (<3%) :
-Weight loss if feeding withheld • Intussusception or other causes -If BF, cont breastfeeding
too long of bowel obstruction -If formula fed, cont usual feeding and offer
• Urinary tract infection extra water
2.Acute Bloody Diarrhoea • Meningitis and other types of -Older children : Cont Normal diet with extra
(dysentery) : sepsis fluid
-When blood and mucous • Any cause of raised intracranial
present in stools pressure ii) Some signs of dehydration (3-9%) :
• Diabetic ketoacidosis
times a day which should not
be considered as diarrhoea
Volume of fluid loss can vary
from 5ml/kg body weight/day
to ≥ 200 ml/kg body
weight/day. Dehydration and
electrolyte losses associated
with untreated diarrhoea are
the main causes of morbidity
and mortality of
childhood AGE.
Causative agents :
A.WATERY :
i) </=2 years : rotavirus,
astrovirus, calicivirus, enteric
adenovirus, enteropathogenic
Escherichia coli (EPEC),
enterotoxigenic Escherichia
coli (ETEC), Vibrio cholerae
ii) 2-5 years : Enterotoxigenic
Escherichia coli (ETEC),
rotavirus, Shigella, Vibrio
cholerae
B.MUCOUSY/BLOODY :
i) </=2 years : Shigella, shiga-
toxin producing Escherichia
coli (STEC), Campylobacter
jejuni
-Main concern : intestinal
mucosa, sepsis and malnutrition.
Dehydration may also occur.
3.Persistent Diarrhoea :
-Diarrhoea lasts 14 days or
longer
-Main concern : malnutrition,
serious infection with or without
dehydration
-3 Most common cause
:Bacterial infections, lactose
intolerance and food protein
allergy (cow milk and soy
protein)
4.Diarrhoea with severe
malnutrition :
- Serious condition and warrants
special attention to exclude
severe systemic infection,
dehydration, severe electrolyte
imbalance, heart failure and vit
and mineral deficiencies
======================
ASSESSMENT
I) History :
-Onset, frequency, quantity and
character of both vomiting
(presence of bile, blood) and
diarrhoea (presence of blood or
mucous)
-Reduce oral intake
• Inborn error of metabolism
• Haemolytic uraemic syndrome
• Inflammatory bowel disease
If Infection is suspected :
-high fever (>39°C), overt
faecal blood, abdominal pain, CNS
involvement -> Suggest Bacterial
aetiology
-significant vomiting and
respiratory symptoms -> Suggest
viral aetiology
INVESTIGATION
-Most child does NOT need lab
investigation (Clinical Diagnosis)
A) Stool C+S :
Indicated in :
-> Bloody Diarrhea (Consider
dysentry)
-> Severe watery stools (Consider
cholera)
-> Severe and prolonged diarrhea
-> Immune-compromised child
B) Urine FEME :
-> See specific gravity : May hep in
monitoring response to therapy in
children with severe hydration
C) Blood test :
-Urea, Na, K, pH, HCO3
-ORS : 30-90ml/kg within 2-3 hours. After
every diarrhoea episode: ORS 10ml/kg
(Note : 100 plus is inappropriate to be used
in rehydration therapy)
- Small and frequent feeds with regular
assessment
-Refer hospital if persistent vomiting,
worsening dehydration despite adequate
therapy
iii) Severe dehydration (>9%) :
• Resuscitation (normal saline / Ringer’s
lactate)
• Frequent monitoring
• Immediate referral to hospital for admission
B. ANTIBIOTICS :
Indicated in certain condition only:
• Shigella dysentery - in cases of bloody
diarrhoea, these should be treated with an
antimicrobial effective for Shigella
(Azithromycin/Ceftriaxone)
• When cholera is suspected
(Doxycycline/Azithromycin)
• When diarrhoea is associated with another
acute infection such as pneumonia and UTI
• May be indicated for Salmonella
gastroenteritis in very young babies (< 3 m),
immune-compromised, immuno-suppressed,
systemically ill,achlorhydia
(Amoxicillin/Ceftriaxone)
Others :
ii) 2-5 years : Shigella, shiga-
toxin producing Escherichia
coli (STEC), non-typhoidal
Salmonella, E. histolytica
=======================
Major enteric viruses:
ROTAVIRUS, norovirus, and
enteric adenovirus
Major enteric bacteria : non-
typhoidal SALMONELLA,
Campylobacter, Shigella and
E.coli.
DEHYDRATION :
-U/O
-Assoc sx (Eg Fever, change in
mental status)
-Past medical hx
-Social Hx
II) Physical Examination :
• Accurate body weight
• Vital signs (temperature, heart
rate, respiratory rate, blood
pressure)
• General conditions
• Eyes: sunken eyes, presence /
absence of tears
• Mucous membrane :moist/dry
• Respiratory pattern
• Bowel sounds
• Extremities (perfusion, capillary
filling time)
• Skin turgor (anterior abdominal
wall)
• Inspection of stool (presence of
blood or mucous)
- FBC : if bacterial sepsis
suspected
-Consider glucose monitoring (girls
younger than 5y/o with vomiting)
-Consider Ca and Mg in young
infants
======================
REFERRAL TO HOSPITAL
• Severe dehydration (> 9% of
body weight), shock
• Neurological abnormalities
(lethargy, seizures, etc.)
• Persistent or bilious vomiting
(even if no dehydration)
• Treatment failure with oral
rehydration salts (ORS)
• Presence of systemic illness (high
fever, toxic looking)
• Underlying medical conditions
(heart failure, significant
neurodevelopment disabilities)
• Caregivers unable to provide
adequate care at home or
other social/logistic concerns
• Suspected surgical condition,
uncertain about diagnosis
• Uncertain about degree of
dehydration (obese children)
Though commonly used, most of the anti-
diarrhoeal agents and other therapies have
no
practical benefits and are never indicated for
the treatment of acute diarrhoea in children.
PREVENTION :
1.Rotavirus vaccine
-Recommended to take
- 2 vaccine available in Malaysia : RotaTeq
and Rotarix
-First dose of primary vaccination should be
given between the age of 6 and 12 weeks,
and the full schedule (RotaTeq 3 doses
and Rotarix 2 doses) should be completed
by the age of 8 months for RotaTeq and 6
months for Rotarix
LACTOSE INTOLERANCE
-Clinical Features : Abd pain, nausea,
persistent diarrhoea,watery stool, abd
distension
-Mx : temporary change to
lactose-free formula, either cow milk-based
or soy protein-based
-Refer if patient malnourished
COW MILK PROTEIN ALLERGY
-Potentially serious complication following
acute gastroenteritis.
-Children suspected with cow milk protein
allergy should be referred to a specialist
A. Severity of dehydration :
-The best measure of dehydration is by the percentage loss of body weight.
-Most useful signs for significant dehydration are:
• Prolonged capillary refill time (normal < 2 seconds)
• Reduced skin turgor
• Abnormal respiratory pattern

B.SIMPLEST WAY CLASSIFYING DEHYDRATION

Classification Fluid deficit as % of body Fluid deficit in ml/kg of body

weight weight

No signs of dehydration <3% <30ml/kg

Some signs of 3-9% 30-90ml/kg

dehydration

Severe dehydration >9% >90ml/kg