o&g4 notes - obstetrics additional protocol (2009)
TRANSCRIPT
Obstetric Protocols (supplementary)-Downloaded on 27-02-2009 from OG departmental website, obtained during IV
rotation OG 2008/2009
-Similar arrangement to previous version
-A Reminder from Prof. Tam: Materials included are only meant for reference, and
may be idiosyncratic and not the ideal management
-Some references and citations were re-included
-Prepared by medic 2010 Rashid Lui (I deleted all the parts that were redundant, but if
you find anything missing or you want all the original downloads, feel free to find
me.)
Table of Contents
APH............................................................2
Preterm labour...............................................3
Maternal medicine..........................................8
Fetal medicine.............................................34
Labour.......................................................38
Drugs........................................................43
Misc..........................................................55
CUHK medic 2010 1
APH
APH of unknown origin Updated:7/14/2008
Diagnosis and Management of Antepartum Haemorrhage of Unknown Origin
Rule out other causes: placenta praevia, abruptio placentae, genital tract lesions
Document the amount of bleeding by history and speculum examination.
Perform CTG if >= 26 weeks.
Consider induction of labour or caesarean delivery if CTG is abnormal.
If gestation < 34 weeks of gestation:
o Perform TVS cervical length assessment, and give corticosteroid if cevical
length <15mm, or manage as a case of threatened / preterm labour when
there are uterine contractions.
Discharge if no more vaginal bleeding or abdominal pain for 2 days.
Remark:
o No need for routine weekly CTG assessment or induction of labour in cases
with history of APH of unknown origin.
CUHK medic 2010 2
Preterm labour
TVS cervical length
Updated:7/14/2008
Indications
To assess the immediate risk of preterm delivery when patients present with
symptoms of threatened preterm labour
To predict, in long term, the chance of preterm delivery in asymptomatic patients
present at antenatal clinic at 20-24 weeks of gestation
Method of assessment
Patient must empty bladder before scan
Use 5-MHz transvaginal transducer
Put TVS probe 3 cm proximal to the cervix to avoid any cervical distortion of its
position or shape
Obtain a good sagittal view of the cervix, with the echogenic endocervical mucosa
along the length of the canal
Magnify the view as much as possible
Measure the length of the straight line between the internal os and the external os
CUHK medic 2010 3
Interpretation of Result
For cases present with threatened preterm labour:
o a positive result (cervical length <15mm) indicates indicates 37% chance of
delivery within 7 days and hence corticosteroid and tocolytic may be
indicated
o a negatiave result indicates 99% chance that delivery would not occur within
7 days and hence corticosteroid and tocolytic are not necessary
References
Tsoi E, Akmal S, Rane S, Otigbah C, Nicolaides KH. Ultrasound assessment of
cervical length in threatened preterm labor. Ultrasound Obstet Gynecol. 2003
Jun;21(6):552-5.
Cervicovaginal fibronectin test Updated:7/14/2008
Introduction
Fetal fibronectin (fFN) is an extracellular matrix protein found in the decidua basalis
next to the placental intervillous space. It acts like a ‘glue’ attaching the fetal
membranes to the uterine decidua.
Mechanical or inflammatory mediated damage to the placenta or membranes may
result in its release into the cervico-vaginal fluid.
Fibronectin is often found in cervico-vaginal fluid before 18 weeks’ gestation and at
the end of term pregnancy; however, it is not normally present from 22 to 37 weeks,
and hence its presence is associated with an increased risk of preterm birth.
Indication of cervico-vaginal fibronectin test
To assess the immediate risk of preterm delivery when patients present with
symptoms of threatened preterm labour
Method of assessment
The test must be done before any digital examination of the vagina and cervix
After insertion of speculum into the vagina, a Dacron polyester swab is put into the
posterior vaginal fornix, and roll across to absorb fluid
CUHK medic 2010 4
The Dacron swab is then inserted into a collection tube for bedside monoclonal
antibody assay (available in Ward 7E)
Remark: blood and amniotic fluid in the vagina will give false positive result and
hence the test should not be done in case of APH or ROM
Interpretation of Result
For cases present with threatened preterm labour:
o a positive result (fibronectin level >=50ng/ml) indicates 24% chance of
delivery within 7 days and hence corticosteroid and tocolytic may be
indicated
o a negatiave result indicates 98% chance that delivery would not occur within
7 days and hence corticosteroid and tocolytic are not necessary
References
Tsoi E, Akmal S, Geerts L, Jeffery B, Nicolaides KH. Sonographic measurement of
cervical length and fetal fibronectin testing in threatened preterm labor. Ultrasound
Obstet Gynecol. 2006 Apr;27(4):368-72.
Preterm labour
Updated:7/14/2008
Definition of preterm labour
Onset of labour after 24 weeks and before 37 weeks of gestation
Onset of labour can be diagnosed when there are the cervix started to dilate or has
totally effaced, associated with regular painful uterine contractions
Onset of labour is suspected (threatened preterm labour) when there are uterine
contractions plus one of more of the following:
o Show of mucus
o rupture of membranes
o shortening of cervical length as measured by transvaginal scan
o cervicovaginal fibronectin test is positive
Initial assessment
Inform on-call Medical Officer
Ascertain gestation
Look for causes of preterm labour eg.
CUHK medic 2010 5
o Abruptio placentae or APH
o Chorioamnionitis (check for rupture of memrbanes and take HVS)
o Urinary tract infection (check MSU)
o Polyhydramnios
o Multiple pregnancy or fetal anomalies
Depending on the gestation and clinical presentation, TVS cervical length,
cervicovaginal fibronectin test result, decide the use of corticosteroid, tocolytic agent,
time and mode of delivery with Mid-1 or above
Management of threatened / preterm labour before 34 weeks
Inform Mid-call 1, and Mid-call 2 if < 26 week
To labour ward, NPO, X-match, iv access
Continous fetal monitoring when gestation >= 26 week
Invite Neonatalogists to counsel the patient
Give corticosteroid and tocolytic agent in the following conditions:
o preterm labour (cevix is dilated or effaced)
o threatened preterm labour with cervical length <15mm, or +ve cervicovaginal
fibronectin test
Withhold corticosteroid and tocolytic agent if the above conditions are not fulfilled.
However, when uterine contractions persist, reassess TVS cervical length to make
decision accordingly.
If immediate delivery is required or unavoidable, decide mode of delivery according to
clinical situation
Management of preterm after 34 weeks
Allow delivery and manage as for term pregnancy
No need for corticosteroid or tocolytic agent,
Management of threatened / preterm labour with special conditions
Extreme prematuirty less than 26 weeks
Discuss with patient:
o Prognosis (together with Neonatalogists)
o Different modes of fetal monitoring (continuous vs intermittent ascultation)
o Different modes of delivery (classical CS and vaginal delivery) in case of fetal
malpresentation and fetal distress
Antepartum Haemorrhage
Rule out abruption which requires immediate delivery
CUHK medic 2010 6
Tocolytic agent s may be used to suppress labour in mild case of APH. Atosiban is the
preferred choice.
Prolonged rupture of membranes
Labour that starts after prolonged ROM may be a result of evolving chorioamnionitis.
Use of tocolytic agents to suppress labour should only be considered with strong
indications (e.g. extreme prematurity, for completion of corticosteroid), and should be
decided by specialists
Drugs for the mothers
Entonox for labour pain relief
Pethidine for labour pain relief
syntometrine or syntocinon iv or im injection for management in the third stage of
labour.
Sodium citrate
o Purpose:
premedication prior to emergency caesarean section
o Regimen:
30ml of 0.3M po once
Panadol
o Purpose:
for post-delivery pain relief
o Regimen:
500mg po QID prn
Potassium permaganate (KMnO4), Zinc oxide, hirudoid, sitz bath
o Purpose:
for local treatment of perineal wound
o Regimen:
local application bd
Drugs for the newborns
Vitamin K 1 for routine prophylaxis against neonatal haemorrhagic disease.
Naloxone (Narcan) for treatment of neonatal respiratory depression as antidote to
maternal narcotic effect.
Hepatitis B immunoglobin (hyperhep) to reduce the risk of vertical transmission of
hepatitis B.
Hepatitis B vaccine, polop and BCG vaccine
o Purpose:
for routine newborn immunization
o Regimen:
CUHK medic 2010 7
hepatitis B vaccine 0.5ml imi
polio 0.25ml po
BCG vaccine
Zinc oxide, Drapolene cream, Penatan cream. For treatment and prevention of nappy
rash, Apply cream after every nappy change. Drapolene: contain benzalkonium
chloride 0.01% and cetrimide 0.2% in a water miscible base
Maternal medicine
Ovarian cyst
Updated:11/10/2004
Antenatal management
Perform USG to assess the size and characteristics of the cyst
Look for any symptoms related to complications of the cysts
Confirm gestation
Management will depend on the nature of the cysts, presence of any symptoms and
gestation as stated below.
Simple unilocular ovarian cysts
Before 16 weeks of gestation and size <= 6cm:
o Most likely physiological cyst that will resolve spontaneously by 16 weeks.
o Adopt conservative management during antenatal course unless the patient
develops complication.
Before 16 weeks of gestation and size > 6cm:
o Unlikely to be physiological cyst.
o Counsel patient on the pros and cons of operation on ovarian cysts during
pregnancy.
o Surgery should be preferably performed at around 14 weeks of gestation
unless complication arises, earlier if the cyst is larger.
o Contact endoscopy team for arrangement of operation.
Between 16 - 20 weeks of gestation:
CUHK medic 2010 8
o Unlikely to be physiological cyst.
o Counsel patient on the pros and cons of operation on ovarian cysts during
pregnancy.
o Contact endoscopy team for arrangement of operation.
After 20 weeks of gestation:
o Unlikely to be physiological cyst.
o Adopt conservative management during antenatal course unless the patient
has symptoms.
Ovarian cysts with ultrasonic features of benign pathological cysts
Before 20 weeks of gestation:
o Counsel patient on the pros and cons of operation on ovarian cysts during
pregnancy.
o Surgery should preferably be performed around 14 weeks unless
complication arises, earlier if the cyst is larger.
o Contact endoscopy team for arrangement of operation.
After 20 weeks of gestation:
o Adopt conservative management during antenatal course unless the patient
develops complication.
Ovarian cysts with ultrasonic features suggestive of malignancy
Contact oncology team for assessment.
Intrapartum management
Presence of asymptomatic ovarian cysts should not be an indication for caesarean
section.
However, operation on ovarian cysts can be performed opportunistically during
caesarean section.
Acute complications during pregnancy
When there is clinical features suggestive of complications such as rupture, torsion or
haemorrhage, arrange surgical treatment.
No indication of Caeserean delivery at the same time unless:
o there is other obstetric indication, or
o the gravid uterus causes surgical difficulty (should be decided by Mid-call 2).
Postnatal management
For ovarian cysts in which conservative management is adopted during antenatal
period:
CUHK medic 2010 9
o Arrange an ultrasound examination of pelvis at radiology department to be
performed 3 months after delivery.
o Arrange a follow-up appointment at Pelvic Mass Clinic in the cluster at 4
months after delivery to review the report of ultrasound examination. (Need to
state the reason of the arrangement of a gynaecology follow-up on the
inpatient record)
For patients with ovarian cysts removed at caesarean section:
o Arrange a routine follow-up appointment at general gynaecology clinic in the
cluster for review of pathology report. (Please state the reason for gynaecology
follow-up on the in-patient record).
o
Fibroid
Updated:5/23/2005
Antenatal management
Counsel the patient:
o It is a bengin lesion and would not cause any risk to the mother and the fetus
in most of the cases
o Small chance of red degeneration that may lead to abdominal pain
o May cause fetal malpresentation if the fibroid is situated at the lower pole of
the uterus
No need to arrange serial ultrasound examination routinely throughout the antenatal
period, unless there is difficulty in monitoring fetal growth by fundal height
measurement.
For fibroid locating at the lower pole of the uterus, arrange follow-up at 37 weeks of
gestation (+/- USG) to assess the fetal presentation and engagement and decide
mode of delivery:
Allow vaginal delivery unless the uterine fibroid is situating at the lower segment AND
affect engagment of fetal head or cause malpresentation.
Intrapartum management
If Caesaerean section is indicated for any reason, DO NOT perform myomectomy at
the same time.
After delivery, no need for routine prophylactic syntocinon infusion unless the uterine
fibroid larger than 5 cm. Give syntocinon infusion (40 units in 500 ml of cystalloid
solution over 4 hours) if it is required.
CUHK medic 2010 10
Postnatal follow up
For patients who are asymptomatic before the pregnancy (no menorrhagia or
pressure symptoms):
o It is not necessary to give gynaecology follow-up after delivery
o Advise patient to seek medical advice when she has symptoms
For patients who has symptoms before the pregnancy:
o Arrange a follow-up appointment at Pelvic Mass Clinic in 6 months with
pictorial chart given to patient to document the menstrual pattern
o It may be necessary to postpone the follow-up appointment if the patient
would have long period of breast feeding and remains amenorrhoea.
Bacterial vaginosis Updated:7/14/2008
Diagnostic Test
Nugent’s method and classification of result (based on Gram stain and a scoring system):
normal vaginal flora
intermediate
indicative of bacterial vaginosis
Indications of Treatment
Treatment is only for patient with result 'indicative of BV':
o For symptomatic relief, or
o For asymptomatic pregnant woman before 20 weeks of gestation
risk of preterm delivery significantly reduced if treated before 20
weeks but not after 20 weeks
Routine treatment of sex partners is not necessary
Treatment regimen
Clindamycin 300 mg bd po * 7 days; or
Metronidazole 400 mg tds po * 7 days:
o Metronidazole can be used throughout pregnancy as multiple studies and
meta-analyses have not demonstrated an association between metronidazole
use during pregnancy and teratogenic or mutagenic effects in newborns
CUHK medic 2010 11
o Advise against drinking alcohol during metronidazole treatment and up to 24
hours afterwards
Screening
Evidence does not support routine screening, even in high risk groups
Discussion / Justification
Risk of preterm delivery before 37 weeks significantly reduced RR 0.63 (95% CI: 0.48 – 0.84)
if patients who have bacterial vaginosis receive treatment before 20 weeks. However, studies
do not show any benefits when treatment is started after 20 weeks
Haematuria
Updated:5/7/2001
Routine antenatal screening
Urine hemostix for all NEW obstetric cases
If positive, perform urine culture to exclude infection
If persistent haematuria (haematuria persists in two visits):
Refer to renal physician with special referral form
Perform
o urine cytology,
o RFT and
o 24 hour urine for protein and creatinine clearance.
If all other investigations are normal, patient can have routine AN care.
If the renal function is abnormal, refer to Medical OBS.
Note: #Trace# of RBC should be considered as positive
Sample of referral letter:
o I would like to refer the above lady for your further assessment whom we
detected persistent microscopic hematuria during antenatal check-up.
CUHK medic 2010 12
o She is now _______________ weeks pregnant. Her EDC is
___________________
CUHK medic 2010 13
Cardiac arrest Updated:5/7/2001
Cardiopulmonary resuscitation for cardiac arrest in obstetric patients
Nursing staff start cardiopulmonary resuscitation before doctors arrive, and mark the
time of all events:
1st nurse
Secure airway
Apply Ambu bag with 100% O2
2nd nurse
Call Junior obs and gynae on call M.O.s and midcall 1 using emergency code
9996/7/8/9
Call resuscitation team 2468
Call labour ward
Display uterus to left side by:
o Putting the wooden board underneath the patient"s back
o wedging the board to tilt the patient to left lateral position at about 30 degrees
Apply ECG electrodes to the chest
Perform external cardiac massage
3rd nurse or nursing Officer
Deploy nurses from other wards.
Assist in resuscitation +/- Perimortem Caesarean section
Other labour ward nurses
Inform paediatrician, NNU
Inform house officers, midcall 2 and consultant
Inform anaesthetist on call
Assist MO in the perimortem Caesarean section
Assist resuscitation of the baby
Prepare Caesarean section set for suturing
Medical staff to decide perimortem Caesarean section and continuation of resuscitation:
1st Medical officer who arrives
CUHK medic 2010 14
Enquire the duration of cardiac arrest from nursing staff
Check the patient"s carotid pulse and ECG tracing when nurse withholds cardiac
massage
Decide to proceed with perimortem Caesarean section if the duration of cardiac arrest
is greater than 4 minutes without response to CPR
Instruct the nurse to stop cardiac massage during perimortem Caesarean section
2nd doctor (medical officer or intern) who arrives
Establish IV line
Prepare for defibrillation in case of Ventricular fibrillation (300 J from the start)
Mid-call doctors
Assist in the CPR or the rest of the caesarean section
Decision on Perimortem Caesarean section
Avoid undue delay
Aim to deliver within 4 minutes of cardiac arrest which will optimise neonatal outcome
and facilitate maternal CPR
Liaise with anaesthetist for ICU transfer if resuscitation is successful and after
completion of Perimortem Caesarean section
Perimortem CS
Updated:5/7/2001
Indication
Obstetric patients with sudden cardiac arrest
Procedure
Put on the gloves and mask
Skip unnecessary steps: scrubbing, draping of operation site, bladder catheterization
Antiseptic is not required
Midline subumbilical incision and classical Caesarean section
Antibiotic cover with 1.2 gram IV Augmentin if patient responded to resuscitation
Close the wound
CUHK medic 2010 15
DM-antenatal managementUpdated:10/11/2007
Initial management of pre-existing IGT/DM
In patient management is preferred
Early admission to start diet control and h’stix monitoring
Stop any oral hypoglycaemic drug and change to insulin
Check HbA1c and investigate for diabetic complications
Arrange morphology scan at second trimester
Refer to ophthalmologist for retinal assessment
Initial management of newly diagnosed GDM
Mild (fasting glucose < 6.1mmol/l or 2nd hour < 11.1 mmol/l)
Outpatient management is preferred for most GDM
Refer DM education class to see dietitian for DM diet and DM education
Start outpatient H’stix monitoring
Follow up in Thursday medical obstetric clinic
Routine growth scan is not necessary
Severe (fasting glucose >= 6.1mmol/l and/or 2nd hour glucose >=11.1 mmol/l)
Early admission to start diet control and h’stix monitoring
Check HbA1c and investigate for diabetic complications
Fetal growth scan
Start insulin as indicated
Diet control:
Pregnancy 1st trimester 2nd trimester
singleton 1500kcal/day 1800kcal/day
multiple 1500kcal/day 2000kcal/day
CUHK medic 2010 16
Reference for glycaemic control
H'stix Normal Borderline Abnormal
Fasting (mmol/L) <= 5 > 5 - 5.5 > 5.5
Postprandial (mmol/L) <= 7 > 7 - 7.5 > 7.5
Subsequent Outpatient management for DM/GDM
GDM/DM on diet control
H'stix monitoring one to two days per week (4 times/day: Fasting, PB, PL, PS)
Check compliance and revise dietary plan if glycaemic control is borderline
Admit to consider insulin if glycaemic control is persistently borderline or abnormal
Uncomplicated GDM not requiring insulin can be followed up by midwives diabetic
clinic (MCDM) on Thursday morning
GDM/DM on insulin
H'stix monitoring two to five days per week (4 times/day: Fasting, PB, PL, PS)
Adjust insulin dosage if persistently borderline or abnormal glycaemic control
Admit if glycaemic control is difficult
Growth scan every 4 weeks
CTG weekly from 36 weeks for GDM/DM on insulin
Indications for blood sugar series
Routine blood sugar series is not necessary for all GDM cases
Blood sugar series would be used as a reference for the commencement of insulin,
the final insulin dosage for individual cases and when the h’stix result is in doubt
Timing of delivery
GDM on diet with good control: await spontaneous labour and induction at 41 weeks
gestation
GDM requiring insulin or pre-existing DM/IGT with normal H'sitx: consider induction at
40 weeks
GDM or pre-existing DM/IGT with poor glycaemic control and/or any complication:
consider induction at 38 weeks or earlier if indicated
Mode of delivery
CUHK medic 2010 17
Discuss elective caesarean delivery if the EFW > 4 kg
Take precaution of shoulder dystocia if mother with a macrosomic fetus (AC > 97
centile) undergoes vaginal delivery:
Doctor standby at fetal head delivery
Mid-call doctor assess before instrumental delivery
Measurement of blood pressure in pregnancy
Patient should be rested and sitting at 45-degree (or in lateral recumbent position while in
labour)
BP cuff should be of the appropriate size [standard cuff for arms 33 cm circumference,
large cuff (15 33 cm bladder) for larger arms].and placed at the level of the heart
Be aware that BP obtained using automated BP recording devices may differ significantly
from those using mercury sphygmomanometry in pregnancy
DINAMAP can be used for BP monitoring provided that it has been cross checked with
sphygomanometer at the time of diagnosis
Use Korotkoff sounds K1 (systolic) and K5 (diastolic) to record the blood pressure while
using mercury sphygmomanometer
References:
Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, et al. The detection,
investigation and management of hypertension in pregnancy: executive summary. Aust N
Z J Obstet Gynaecol 2000;40(2):133-8.
The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No. 10
A, March 2006.
Diagnostic Criteria
Diagnostic criteria for hypertension in pregnancy
SBP 140 mm Hg or DBP 90 mm Hg on 2 occasions at ≥ 4 hours apart, or
SBP 160 mm Hg or DBP 110 mm Hg at any occasion
CUHK medic 2010 18
Diagnostic criteria for significant proteinuria in pregnancy
Urine protein 0.3 g/d (24-hour urine collection should always be used for the
diagnosis of significant proteinuria unless the clinical urgency dictates immediate
delivery)
Spot urine protein to creatinine ratio 30 mg/mmol which usually equivalent to > to 0.3 g
proteinuria / 24 hours can be used as an alternative
Urine albustix 2 + usually suggest significant proteinuria but should always be confirmed
by 24 hour urine or spot urine protein to creatinine ratio
Urinary tract infection should be excluded by MSU
References:
Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, et al. The detection,
investigation and management of hypertension in pregnancy: executive summary. Aust N
Z J Obstet Gynaecol 2000;40(2):133-8.
Roberts JM, Pearson G, Cutler J, Lindheimer M, Pregnancy NWGoRoHD. Summary of
the NHLBI Working Group on Research on Hypertension During Pregnancy.
Hypertension 2003;41(3):437-45.
The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No. 10
A, March 2006.
Classification
Classification of hypertensive disorder in pregnancy
Gestational hypertension
o De novo hypertension without proteinuria onset after 20 weeks gestation
Pre-eclampsia/eclampsia
o Pre-eclampsia is de novo hypertension accompanied by new onset significant
proteinuria after 20 weeks
CUHK medic 2010 19
o If gestational hypertension is associated with headache, abdominal pain, or
abnormal laboratory tests (especially, thrombocytopenia < 100 or ALT), the
diagnosis of pre-eclampsia should be considered
o Eclampsia is diagnosed as convulsion superimposed on a case of pre-eclampsia
Chronic hypertension
o Hypertension before pre-conception or diagnosed before 20 weeks gestation
Essential hypertension: hypertension without an apparent cause
Secondary hypertension: hypertension associated with renal,
renovascular and endocrine disorders and aortic coarctation.
o Gestational hypertension that fails to normalize at 12 weeks after delivery would
be re-classified as chronic hypertension
Pre-eclampsia superimposed on chronic hypertension
o The following clinical conditions will suggest pre-eclampsia in women with chronic
hypertension
De novo proteinuria occurs after 20 weeks gestation
A sudden increase in the magnitude of hypertension or sudden increase
in proteinuria in women who have proteinuria early in gestation
Appearance of thrombocytopenia <100, and /or raised ALT
N.B. ‘White-coat’ hypertension
o It is not real hypertension and hence not under the classification of hypertensive
disorder It is a common condition in which blood pressure elevates in the presence
of a clinical attendant (e.g. in clinic) but returns normal in the normal environment
(e.g. home BP monitoring, after rest in ward, or ambulatory blood pressure
monitoring)It should replace all other terms for the diagnosis of condition
CUHK medic 2010 20
References:
Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, et al. The detection,
investigation and management of hypertension in pregnancy: executive summary. Aust N
Z J Obstet Gynaecol 2000;40(2):133-8.
Brown MA, Lindheimer MD, de Swiet M, Van Assche A, Moutquin JM. The classification
and diagnosis of the hypertensive disorders of pregnancy: statement from the
International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertens
Pregnancy 2001;20(1):IX-XIV.
Roberts JM, Pearson G, Cutler J, Lindheimer M. Summary of the NHLBI Working Group
on Research on Hypertension During Pregnancy. Hypertension 2003;41(3):437-45.
Severe pre-eclampsia
Diagnostic criteria of severe pre-eclampsia
Severe hypertension (SBP 170 mmHg or DBP ≥ 110mmHg on 2 or more occasions)
with significant proteinuria, or
Moderate hypertension and significant proteinuria, with any symptom or sign of
impending eclampsia, such as
o Neurological: ankle clonus, severe headache, persistent visual disturbances,
papilloedema
o Hepatological: epigastric pain +/- vomiting, liver tenderness, impaired liver function
(ALT > 70)
o Haematological: thrombocytopenia < 100, disseminated intravascular coagulation;
haemolysis
Other clinical features which also indicate the severity of the clinical condition and may be
an indication of earlier delivery
o Renal insufficiency – plasma creatinine 90 µmol/l or oliguria (< 500 ml/24 h)
o Fetal growth restriction or features of utero-placental insufficiency
CUHK medic 2010 21
In case the clinical conditions warrant delivery in a case of severe pre-eclampsia, MgSO4
is indicated for the prophylaxis of eclampsia
Early onset pre-eclampsia
Pre-eclampsia with onset 34 weeks
Investigate for underlying cause: e.g. anticardiolipin antibody and lupus anticoagulant
Aspirin prophylaxis (80 mg daily) is indicated in a previous early onset pre-eclampsia
resulted in preterm delivery
References:
The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies,
benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled
trial. Lancet 2002;359:1877-90.
von Dadelszen P, Magee LA, Roberts JM. Subclassification of preeclampsia. Hypertens
Pregnancy 2003;22(2):143-8.
The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No. 10
A, March 2006.
CUHK medic 2010 22
Peripartum management of Pre-eclampsia
General management in pre-eclampsia
Manage patient in the labour ward
NPO
IV fluid: Hartmann solution at 80 ml/hr
Use infusion pump for syntocinon infusion and adjust maintenance fluid accordingly
Check CBP, RFT & LFT (clotting profile is not required routinely if platelet count is normal)
Monitor BP/P every 15 minutes
Monitor hourly urine output
Continuous fetal heart monitoring
Advise on epidural anaesthesia for pain relief if no contraindication
Give slow IV syntocinon 5 units injection at third stage of labour and avoid IM syntometrine
Special management in severe pre-eclampsia
MgSO4
o Indicated for the prophylaxis of eclampsia if the clinical conditions warrant
delivery
o Loading dose: IVI 4 g over 20 min (8 ml of 50% MgSO4 diluted with normal saline
into 20 ml)
o Maintenance dose: IVI 1 g per hour (20 ml of 50% MgSO4 diluted with normal
saline into 50 ml)
Use a lower dose at 0.5 g per hour in case of renal impairment
o Monitoring while on MgSO4
Hourly urine output
Check deep tendon reflex hourly (e.g. biceps reflex if patient is /has been
on regional anaesthesia)
Check respiratory rate hourly
CUHK medic 2010 23
Continuous SaO2
Routine serum Mg level monitoring is not necessary but it should be
monitored every 6 hourly if MgSO4 is used in patient with renal
impairment
o Caution
MgSO4 should be used with caution in patient with renal impairment,
neuromuscular disease or respiratory depression
Antihypertensive
o Indicated when SBP ≥ 160 mmHg or DBP ≥ 100 mmHg or at a lower threshold if
there symptom and sign of impending eclampsia, or serious condition like HELLP
syndrome
o IV Labetalol
First line for intrapartum BP control
Bolus regimen: give iv 20 mg over 1 min; increase dose to 40 or 80 mg
every 10 min if indicated (until a maximum cumulative dose of 300 mg)
Infusion regimen: start at 20 mg/hr (dilute 100 mg into 100 ml with normal
saline), increase by 5-10 mg/hr every 30 min, (maximum 100 mg/hr)
Stop labetalol if maternal heart rate falls below 70/min
Avoid in the presence of pulmonary edema, heart failure or with asthma
o IVI Hydralazine
Second line for intrapartum BP control if labetalol fails or is
contraindicated
Bolus regimen: give 5 mg IV over 1 min and repeat at 20 min if indicated
(maximum cumulative bolus dose: 20 mg)
Infusion regimen: use if fail to control BP with 4 bolus doses, start at 5
mg/hr (dilute 100 mg into 100 ml with normal saline) increasing by 5
mg/hr every 30 minutes as indicated (usual dose varies between 5 to 20
mg/hr)
Consider other alternative antihypertensive if hydrallazine fails to control
CUHK medic 2010 24
BP or causes maternal side effects (e.g. tachycardia >120/min)
Caution: Maternal hypotension may occur with bolus or infusion regimen
o Oral nifedipine
Nifedipine should only be given as oral and preferably used in
postpartum
Regimen: Nifedipine (Adalat®) 5mg orally for acute hypertension while
nifedipine slow release (Adalat®retard) starting at 20 mg bd for
maintenance in postpartum
o Oral labetalol
Start at 200 mg bd for BP control in postpartum
Management of oliguria (U/O < 20 ml/hr for ≥ 2 hrs)
o Fluid replacement (250 ml of Hartmann solution over 1 hour) in the absence of
fluid overload
o Stop MgSO4
o Give IV diuretics (furosemide 20-40 mg) if there is pulmonary edema
o Consult anaesthetist for CVP to guide fluid management if persistent oliguria after
fluid replacement
Management of magnesium toxicity
Slurred speech, double vision, absent deep tendon reflexes and respiratory depression
may be symptoms and signs of toxicity
Absence of deep tendon reflexes
o Stop MgSO4
o Check for respiratory depression
o Continue cardiac monitoring
o Check urgent serum Mg level
o Give IV 1 gram (10 ml of 10%) Calcium gluconate over 10 min
Respiratory depression (respiratory rate < 10/min)
o Stop MgSO4
o Give O2 via mask to maintain SaO2 > 95%
CUHK medic 2010 25
o Continue cardiac monitoring
o Check urgent serum Mg level
o Give IV 1 gram (10 ml of 10%) Calcium gluconate over 10 min
o Consult anaesthetist for the need of respiratory support
Serum Mg level and toxcity
Serum level (mmol/l)
Normal pregnancy 1
Therapeutic 2-4
Loss of patellar reflex 5
Prolonged AV conduction 6
Respiratory failure 7.5
Cardiac arrest 12
References
The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No. 10
A, March 2006.
Sidhu H. Pre-eclampsia and Eclampsia. In: Johanson R, Cox C, Grady K, Howqell C, ed.
Managing Obstetric Emergencies and Trauma: The MOET Course Manual. London:
RCOG Press; 2003 p.133-147.
Management for eclampsia
General measure
o Call for help
o Lie patient in left lateral position
o Maintain airway and give 100% O2
o Documentation of the event and duration of convulsion
Anti-convulsant
o Diazepam is used to terminate any ongoing convulsion
Regimen: 5-10 mg slow IV bolus (given over about 1 minute)
o MgSO4 is used to prevent further recurrent convulsion
CUHK medic 2010 26
If eclampsia occurs before commencement of MgSO4, start loading dose
infusion over 5 min
If eclampsia occurs during initial loading dose, complete the loading dose
over 5 min
If eclampsia occurs during MgSO4 maintenance infusion, additional 2
gram bolus of MgSO4 (4 ml of 50% MgSO4 diluted with normal saline
into 10 ml) given over 5 minutes
o Recurrent eclampsia can be managed with a further 2 gram bolus of MgSO4 but
alternative anti-convulsant or intubation should be considered if a total 10 gram of
bolus has been given
A consultant or specialist in maternal medicine should be involved in case of eclampsia
Reference
The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No. 10
A, March 2006.
CUHK medic 2010 27
Postpartum management for pre-eclampsia
Investigate for underlying cause if the case is an early onset pre-eclampsia
Oral antihypertensive can be used as to control BP if indicated
o Use Adalat®retard: 20 mg - 40 mg bd and/or labetalol 200 mg bd - 400 mg tid
o Avoid methyldopa as it may increase the risk of postpartum depression
o Consult physician for refractory case
At discharge from postnatal ward, antihypertensive drugs can be tailed off gradually over
2-4 weeks with dose revision at weekly to biweekly interval with BP monitored at ward
follow up.
Postnatal follow up in General clinic at 6 to 8 weeks to review blood pressure and
proteinuria by urine albustix
o Renal function and 24 hour urine collection are not required routinely except renal
impairment at the diagnosis of pre-eclampsia or persistent positive albustix at
postnatal follow up
o CBP and LFT at 1 week before follow up as indicated in case of HELLP
syndrome
Refer patient to physician if hypertension or proteinuria still persists after puerperium
Flow chart for management of eclampsia
CUHK medic 2010 28
CUHK medic 2010 29
Antibiotic for heart diseases Updated: 2007
Intrapartum antibiotic prophylaxis is indicated in:
Prosthetic cardiac valve
Previous infective endocarditis
Congenital heart disease (CHD) limited to the following conditions:
o Unrepaired cyanotic CHD, including palliative shunts and conduits
o Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the
first 6 months after the procedure
o Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibit endothelialization)
Cardiac transplantation recipients who develop cardiac valvulopathy
Antibiotic Regimen
No allergy Allergy to ampicillin
At onset of labour/ rupture of
membranes Ampicillin 2.0g ivi Vancomycin 1.0g iv infusion
Intrapartum Ampicillin 500mg ivi Q6H Vancomycin 1.0g iv infusion Q12H
Postpartum Not required Not required
Remarks
Risk of infective endocarditis under an ordinary elective or pre-labour caesarean
section is very low so that antibiotic cover is not indicated for the above cardiac
conditions
Vancomycin infusion guideline
o reconstitute in 20 ml water, and dilute with 200 ml NS
o infuse over at least 100 min
Consult physician
o for the vancomycin dosage in case of severe renal impairment
o for opinion if patient allergic to both ampicillin and vancomycin
Discussion / Justification AHA has reviewed the topic and updated the guideline on antibiotic
prophylaxis in May 2007. Reference: AHA Prevention of Infective Endocarditis. A guideline
from the American Heart Association Rheumatic fever, endocarditis, and Kawasaki disease
committee, council on cardiovascular disease in the young, and the council on clinical
cardiology, council on cardiovascular surgery and anesthesia, and the quality of care and
outcomes research interdisciplinary working group. Circulation. published online, Apr 19,
CUHK medic 2010 30
2007.
Management of acute VTE
General management
VTE should be suspected in women at risk
ECG abnormalities are frequently transient and the commonest abnormality is sinus
tachycardia
Start anticoagulant once the clinical diagnosis of VTE is made in women at risk
Clinical assessment of deep vein thrombosis (DVT) and pulmonary embolism (PE)
could be unreliable
Perform USG Doppler lower limbs in suspected DVT
Perform spiral CT in suspected PE
Perform USG Doppler lower limbs if PE confirmed
Spiral CT has higher sensitivity & specificity and lower radiation to the fetus than V/Q
scan, but it increases the life time risk of breast cancer
V/Q scan can be performed if spiral CT is inconclusive
D-dimer should not be used for the diagnosis in pregnancy or puerperium
D-dimer is raised during pregnancy, especially in pre-eclampsia
A positive test is not useful in the diagnosis, only a negative test can make the
diagnosis of VTE less likely
Thrombophilia screening
Anticardiolipin antibody (AC) and lupus anticoagulant (LA) at the time of diagnosis
while Protein C, protein S, antithrombin III when anticoagulant has been stopped
for at least 2 wk and at least 6 weeks postpartum
Initial treatment of DVT
Both above knee or below knee DVT require anticoagulant treatment
Encourage mobilisation with graduated elastic compression stockings
CUHK medic 2010 31
Elevate the affected leg at rest in the first few days in order to reduce leg oedema
Start therapeutic dose of LMWH
SC enoxaparin (1mg/kg early pregnancy weight) Q12 hour
Use the nearest dose as charted:
Early pregnancy weight Initial dose of SC enoxaparin
< 50 kg 40 mg Q12 hr
50 - 69 kg 60 mg Q12 hr
70 - 89 kg 80 mg Q12 hr
90 kg 100 mg Q12 hr
Routine anti-Xa level and platelet count monitoring while on LMWH treatment is not required
except in
patient is at the extreme weight (< 50 kg or 90 kg)
renal impairment
recurrence on treatment
For antenatal above knee DVT
Arrange USG Doppler of lower limbs at 2-4 weeks after the initial treatment to assess
interval changes and repeat later if indicated
Initial treatment of PE
Mild PE Therapeutic dose of LMWH as for DVT
Severe PE Consult physician or cardiologist for the need of IVI heparin
Massive PE Consult ICU and cardiothoracic surgeon for the need of embolectomy
Anticoagulant regimen and duration
Antenatal VTE
Anticoagulation should be continued throughout pregnancy till at least 6 weeks
postpartum and the total period should last for 3 months at minimum
Postnatal VTE
CUHK medic 2010 32
Start warfarin 2 days after delivery if there is no excessive bleeding and stop
enoxaparin when INR reach the target range
Severe/ massive PE
Regimen as decided by physician or cardiologist
Intrapartum management
Spontaneous labour or ROM
Advise patient to withhold next dose at onset of labour or rupture of membranes and
admit for assessment
Withhold enoxaparin during labour till delivery
Elective induction
Stop enoxaparin 1 day prior to induction
Elective CS
Stop enoxaparin 1 day prior to CS and resume prophylactic dose (enoxaparin 40 mg
SC QD) at least 3 hours postoperatively if no excessive bleeding
Anaesthetic plan & regional analgesia/anaesthesia
Consult anaesthetist regarding to regional analgesia or anaesthesia during labour and
caesarean section
Regional techniques should be avoided for at least 24 hours after the last therapeutic dose of
enoxaparin
Epidural cannula should not be removed within 12 hours of the last injection
Enoxaparin should not be given for at least 4 hours after the epidural catheter has been
removed (or at least 6 hours if procedure has been traumatic)
Postpartum management
Vaginal delivery
Resume therapeutic enoxaparin after delivery if there is no excessive bleeding
CUHK medic 2010 33
Early mobilisation with graduated elastic compression stockings
CS
Resume prophylactic enoxaparin at least 3 hour post-operation if there is no
excessive bleeding
Resume to full therapeutic enoxaparin by 12 hours later
Start warfarin 2 days after delivery and stop enoxaparin when INR is at the therapeutic range
Duration of anticoagulant:
Below knee DVT: continue till 6 weeks postnatal
Above knee DVT or PE: continue for at least 6 weeks postnatal and until at least 3
months of anticoagulant therapy has been completed
Work up for hereditary thrombophilia after completion of anticoagulant (protein C, protein S
and anti-thrombin III) at least 6 weeks postpartum and when anticoagulant has been
stopped for at least 4 wk
All patients with above knee DVT or PE should be referred to physician for long term follow up
Breast feeding is not contraindicated for either warfarin or LMWH use
Patient should be counseled to avoid COC pills
Reference
RCOG. Thromboembolic disease in pregnancy and the puerperium: acute management.
Guideline No. 28 (2nd ed) 2007.
CUHK medic 2010 34
Fetal medicine
Choroid plexus cyst Updated:11/20/2008
Definition
Cyst in choroid plexus >=5mm in diameter
Clinical significance
Present in 1 – 3 % of normal fetuses
Usually resolve by 24 weeks
Although it is regarded as one of the soft markers for fetal aneuploidies, isolated
choroid plexus cyst does not increase the risk of fetal aneuploidies
Clinical management
If other structural abnormality is not detected and morphology scan is complete and
normal, no need to report
If other structural abnormality is not detected but morphology scan is incomplete,
arrange repeat scan in 1 – 2 weeks to complete morphology scan (USGP or USGM)
If other structural abnormality is detected : refer patient to Fetal Medicine Team for
further management (USG9 appointment in W7EA session)
References
LS Chitty, P Chudleigh, E Wright, S Campbell, M Pembrey. The significance of
choroid plexus cysts in an unselected population: results of a multicenter study.
Ultrasound Obstet Gynaecol 1998; 12: 391-7.
RC Reinsch. Choroid plexus cysts-association with trisomy: Prospective review of
16,059 patients. AJOG 1997; 176: 1381-3.
JK Gupta, M Cave, RJ Lilford, TA Farrell, HC Irving, G Mason, CM Hau. Clinical
significance of fetal choroid plexus cyst. Lancet 1995; 346: 724-9.
CUHK medic 2010 35
Soft marker - provisional
Updated:11/20/2008
Second Trimester Sonographic Soft Markers for Trisomy 21
Strong markers
Nasal hypoplasia
Measure nasal bone in mid sagittal plane of facial profile
=< 2.5 mm
Nuchal edema
Measure nuchal fold in an angled transverse plane including cavum septum
pellucidum, cerebral peduncles and cerbellar hemisphere, from outer skin line to
outer occipital bone line
>= 6 mm
Echogenic bowel
Echogenicity of bowel as echogenic as adjacent iliac crest bone and does not fade
out before the adjacent iliac crest bone upon reducing the gain
Weak markers
Short humerus
Humerus length < 2.5th percentile (-2SD)
Short femur
Femur length < 2.5th percentile (-2SD)
Markers with disputed association with aneuploidies
Echogenic intracardiac focus
Echogenic spot in ventricle as echogenic as adjacent rib bone and does not fade out
before the adjacent rib bone upon reducing the gain
Pyelectasis
Measure anteroposterior width of renal pelvis in transverse plane from inner margin to
inner margin of the pelvis
>= 4 mm
Markers that need to be dealt with in their own right
CUHK medic 2010 36
Nuchal edema
Pyelectasis
Echogenic bowel
Short humerus
Short femur
Management of soft markers on mid trimester scan
Isolated strong marker (Nasal hypoplasia, Nuchal edema, Echogenic bowel)
If any one of the strong markers is detected, refer patient to Fetal Medicine Team for
further management (USG9 appointment in W7EA session)
Isolated weak marker or isolated marker with disputed association with aneuploidy
(Short humerus, Short femur, Echogenic intracardiac focus, Pyelectasis)
If strong marker is not detected and morphology scan is complete and normal, no
need to report the presence of a soft marker. But if the marker needs to be dealt with
in its own right, manage according to the individual marker concerned as stipulated in
3.
If strong marker is not detected but morphology scan is incomplete, arrange repeat
scan in 1 – 2 weeks to complete morphology scan (USGP or USGM)
If any one of the strong markers is detected, refer patient to Fetal Medicine Team for
further management (USG9 appointment in W7EA session)
Markers that need to be dealt with in their own right
Pyelectasis
Mild pyelectasis (AP width 4 – 7 mm)
o Book follow up scan (USGA) at 28 – 34 weeks
o Consult Paediatrician after delivery
Hydronephrosis (AP width >= 8 mm)
o Refer patient to Fetal Medicine Team for further management (USG9)
Short humerus / Short femur
Refer patient to Fetal Medicine Team for further management (USG9 appointment in W7EA
session)
Anti-D Immunoglobulin Updated:10/31/2002
CUHK medic 2010 37
Indications
For prophylaxis for non-sensitized Rhesus D negative mothers.
Timing of administration
See Rhesus D negative
Regimen
For all gestations and all sensitizing events:
250ug (1250iu) imi
should be given as soon as possible after the event and always within 72 hours.
Beyond that, anti-D Ig should still be given within 10 days of the event
no need for routine Kleihauer test after a sensitizing event
no need to repeat anti-D Ig injection if it has been given within prior 4 weeks for
another sensitizing event.
CUHK medic 2010 38
Labour
Third stage of labour
Updated:10/29/2008
Routine management of third stage of labour
Give oxytocic agent prophylaxis on delivery of baby
For low risk cases:
o syntometrine im 1 ampoule im (will not be available by the end of 2008)
o syntocinon when syntometrine is contraindicated or unavailable
5 units iv bolus over 1-2 minutes
May need to give slower injection over at least 5 minutes if
patient has cardiac disease or particularly at risk of
hypotension
10 units im is an alternative to iv, when iv access is not available
For high risk cases such as parity >=4, mulitple pregnancy, co-existing fibroids,
polyhydramnios, placenta praevia, abruptio placentae:
o syntocinon infusion 40 units in 500ml crystalloid Q4H, or
o Carbetoicin 100mcg im
Deliver the placenta:
o Attempt controlled cord traction when there is signs of separation:
lengthening of cord
gush of blood
contracted uterus with rising of its fundus to umbilical level
o Empty urinary bladder if placenta is separated but retained.
o Do not apply fundal pressure and cord traction at the same time as uterine
inversion may occur.
o Examine placenta for completeness and any abnormalities.
Inform Medical Officer if prolonged 3rd stage (retained placenta) or postpartum
haemorrhage.
Take cord blood for blood gas assay (arterial and venous), thyroid function and
G6PD.
Give newborns injection:
CUHK medic 2010 39
o vitamin K 1 to all newborns.
o hyperhep (hepatitis immunoglobulin) to newborns of hepatitis B carrier
mother.
Postnatal discharge
Updated:11/6/2004
Time of discharge
Usual length of stay after term delivery (calculated from the time of birth of the baby):
o Uncomplicated labour and vaginal delivery (included instrumental):
3 days for parity 1 patients,
2 days for patients of parity 2 or above
o Complicated labour and vaginal delivery: 3 days or more
o Caesarean section: 4 days or more
Patient's request for early discharge within 48 hours after birth
Early discharge is allowed only if the following criteria are fulfilled:
o Uncomplicated vaginal delivery
o Patient should have been observed for at least 24 hours after birth
o Midwife has assessed the following:
Patient is mobile with adequate pain control.
Bladder and bowel functions are adequate.
No problem in feeding baby.
Stable emotion.
Advice on perineal care has been given.
Advice on postnatal follow-up and health check for both the mother
and the baby has been given.
Patient is accessible to medical and social support including MCH,
postnatal ward hotline, postnatal clinic at Li Ka Shing Outpatient
Clinic, community nursing service, medical social worker when
needed.
Patient can be contacted for follow-up.
o Doctor or intern has assessed the following:
Perineal wound is normal.
No postpartum haemorrhage or ongoing bleeding.
CUHK medic 2010 40
No fever (> 38 degrees for two or more readings of at least one hour
apart) within 24 hours before discharge.
Rh immunoglobulin has been given if indicated.
No intrapartum or postpartum complications that require inpatient
medical treatment or observation.
Follow up plan has been drawn for any antepartum, intrapartum or
postpartum problems or complications.
Contraceptive advice has been given.
For cases not fulfilling the above criteria: Decision should be made by a medical
officer on individual basis (or agreed by a medical officer after assessment by an
intern). If patient insists early discharge against medical advice, she should sign the
"Discharge with acknowledgement of medical advice" (DAMA).
Consultation
Anaesthetic consultation Updated:7/30/2002
Patients with the following list of disorders require assessment by the obstetric
anaesthetic team.
Schedule admission of these patients at early third trimester(or earlier if indicated) for
consultation or liaise with anaesthetist to see as outpatient.
Cardiac disorders
Cyanotic heart disease or complex heart disease
Valvular heart diseases:
o Moderate to severe mitral regurgitation
o Mitral stenosis
o Pulmonary stenosis / regurgitation
o Aortic stenosis / regurgitation
o Hypertrophic obstructive cardiomyopathy
Cardiomyopathy
Cardiac arrhythmia which either requires treatment or increases peripartum risk
Pulmonary hypertension
Coronary heart disease
Pacemaker in-situ
Respiratory disorders
Severe asthma
Previous tracheostomy or other problem with the major airway
Previous pneumonectomy
CUHK medic 2010 41
Skeletal disorders
Chest deformity e.g. scoliosis, kyphosis
Rheumatoid arthritis with risk of cervical joint subluxation
Miscellaneous
Any other underlying conditions that potentially will affect blood transfusion, general and
regional anaesthesia:
Intracranial space occupying lesions
Increased intracranial pressure
Refusal of blood transfusion e.g. Jehovah's witness
Cross match problems
Bleeding tendency (e.g. thrombocytopenia < 50, Von Willebrand's disease)
Patient currently put on anticoagulant or aspirin
Past history of anaesthetic problems
Any other moderate or severe systemic disturbance due to medical or surgical
disease, or systemic disturbance which poses a constant threat to life and is
incapacitating.
Neonatologist consultation
Updated:11/28/2008
Indications for neonatalogists to standby at delivery in PWH
Multiple gestation
Premature labour (<34 weeks)
Estimated fetal weight < 2 kg
Vaginal breech delivery
Difficult delivery e.g. shoulder dystocia
Suspected fetal distress (non-reassuring fetal heart rate patterns)
Moderate or thick meconium-stained / blood stained amniotic fluid
Oligohydramnios or no liquor
Suspected intrauterine infection / chorioamnionitis
Prolapsed cord
Fetuses with known or suspected malformation that might require immediate medical
attention at birth, e.g. exomphalos, hydrocephalus, diaphragmatic hernia
Abruptio placenta
Placenta previa
Severe hypertension of the mother requiring i.v. sedation / eclampsia
Other conditions in which the obstetrician anticipates adverse neonatal outcome
CUHK medic 2010 42
Conditions required neonatal medical officer"s assessment after delivery
Fetal conditions
o Congenital malformations
o Respiratory depression at birth
Maternal disorders:
o endocrine diseases, e.g. diabetes mellitus, thyrotoxicosis
o autoimmune diseases, e.g. systemic lupus erythematous, myasthenia gravis,
immune thrombocytopenic purpura
o infectious risk e.g. syphilis, Group B streptococcus carrier
o medical diseases on drugs that may affect the baby, e.g. anti-epileptic, anti-
psychotic
o substance abuse
o Unattended delivery
o Other conditions as instructed by obstetricians
Conditions requiring notification of NNU upon admission to labour ward
Gestation of 35 weeks or less
Severe IUGR or severe oligohydramnios
Major congenital disorders which may require special neonatal care or immediate
surgery
Multiple pregnancy
Other conditions as instructed by obstetricians
CUHK medic 2010 43
Drugs
Steroid cover
Updated:5/23/2005
Indications for steroid cover during labour, delivery and surgery
Patients on long-term oral corticosteroids > 10 mg prednisolone daily (or equivalent)
or have received this dose in the last three months.
Dosage of various kinds of steroid that is equivalent to 10mg prednisolone:
Dexamethasone or Betamethasone 1.5mg
Methylprednisolone 8mg
Hydrocortisone 40mg
Cortisone acetate 50mg
Steroid cover is not indicated when:
o oral daily prednisolone intake is 10mg or less or the last dose of steroid is
more than 3 months ago.
o short course of steroids for 1 - 2 week.
Regimen
Labour and intrapartum caesarean section
Give usual dose of steroid before labour
Give 25mg ivi hydrocortisone Q6H at onset of labour till delivery
Resume usual steroid dose post-delivery
In case of complicated instrumental delivery or emergency caesarean section,
continue IV hydrocortisone 25 mg Q6H till 24 hour after delivery or longer till oral
intake is resumed
Minor sugery
For example: cervical cerclage, fetoscopic surgery, first trimester surgical TOP,
operation for ectopic pregnancy.
Give usual dose of steroid pre-operatively
Give stat 25mg ivi hydrocortisone on-call to OT
After uneventful surgery, resume usual steroid dose on resumption of oral intake
CUHK medic 2010 44
Intermediate surgery
For example: elective or pre-labour emergency caesarean section, appendicectomy,
cholecystectomy, ovarian cystectomy complicating pregnancy
Give usual dose of steroid pre-operatively
Give stat 25mg ivi hydrocortisone on-call to OT
then 25mg ivi hydrocortisone Q6H for 24 hours post-operatively or longer till oral
intake is resumed
After uneventful surgery, resume usual steroid dose on resumption of oral intake
Major surgery or complications
For example: internal iliac artery ligation, uterine artery embolization or caesarean
hysterectomy; septicaemia; DIC
Increase to IVI hydrocortisone dose to 50 mg Q6H and gradually wean off at 48-72
hrs post-op/post-delivery
Maintain this regimen until light diet started and usual steroid dose is resumed
Corticosteroid Updated:7/14/2008
For enhancement of fetal lung maturity:
Dexamethasone
Betamethasone
For Maternal indications:
steroid cover during surgery / labour in patients who have received prolonged
steroid treatment
Dexamethasone Updated:7/3/2008
Indication
Give >=24 and <34 week for fetal lung maturation
Regimen
6mg im/iv Q12H for 4 doses
Contraindications
chorioamnionitis
active TB
Special precautions
CUHK medic 2010 45
Poorly controlled diabetes mellitus
Repeat dexamethasone
It should not be routinely given, but can be considered in cases in which the ongoing
risk of preterm delivery remain high
Decision should be made by a specialist
No more than 3 courses in total should be given
The repeat course should not be given in less than 1 week interval
Should not be given in case of PPROM
Nevirapine
Updated:11/6/2002
Nature
A non-nucleoside reverse transcriptase inhibitor of HIV-1.
Indication
To reduce the risk of vertical transmission of HIV from HIV-positive mothers to their
babies.
Not routinely given, but individualized treatment.
Regimen
Intrapartum maternal therapy:
o 200mg po single dose 1 hour prior to Caesarean section or at the onset of
labour
Neonatal therapy:
o To be decided by paediatrician.
Contra-indication
Hypersensitivity
Toxicity
Rash
Deranged liver function (reported with multiple doses in non-pregnant patients)
CUHK medic 2010 46
Discussion / Justification
If the mother has not been treated with antenatal Zidovudine, a two-dose
intrapartum/newborn Nevirapine is superior to Zidovudine alone by 47% and as
effective as Zidovudine + Lamivudine in reducing vertical transmission rate.
Due to the high frequency of nevirapine-resistant mutations of the HIV-1 virus,
Lamivudine + Zidovudine is the preferred regimen to Nevirapine for intrapartum
treatment for HIV +ve mothers who have not received antenatal Zidovudine therapy.
The addition of intrapartum Nevirapine to Zidovudine for patients who have received
full antenatal Zidovudine has not been shown to be of benefit.
References
Dorenbaum A, Cunningham CK , Gelber RD. Two-dose intrapartum/newborn
Nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission. A
randomized trial. PACTG 316. JAMA 2002;288(2):189-198.
Mandelbrot L, Landreau-Mascaro A, Rekacewicz C et al. Lamivudine-
Zidovudine combination for prevention of maternal-infant transmission of
HIV-1. JAMA. 2001;25:285(16):2083-93.
Lamivudine
Updated:11/6/2002
Lamivudine therapy
Nature
A nucleoside reverse transcriptase inhibitor of retrovirus including HIV.
Indication
To reduce the risk of vertical transmission of HIV from HIV-positive mothers who have
not received antenatal Zidovudine therapy.
Not routinely given, but individualized treatment.
Regimen
Intrapartum maternal therapy
o orally 150mg every 12 hours till delivery
o combined with oral Zidovudine
Neonatal therapy by paediatrician
Discussion / Justification
CUHK medic 2010 47
If the mother has not been treated with antenatal Zidovudine,Lamivudine +
Zidovudine is preferred to Nevirapine for the intrapartum treatment for HIV +ve
mothers who had not received antenatal Zidovudine therap, due to the high frequency
of nevirapine-resistant mutations of the HIV-1 virus.
Early observational study suggested Lamivudine might provide additional benefit to
Zidovudine in reducing HIV vertical transmision rate.
However, Lamivudine is associated with high frequency of Lamivudine-resistant
mutations of the virus and there is insufficient data to recommend routine addition of
Lamivudine to Zidovudine for patients who have received full antenatal Zidovudine
therapy.
References
Mandelbrot L, Landreau-Mascaro A, Rekacewicz C et al. Lamivudine-Zidovudine
combination for prevention of maternal-infant transmission of HIV-1. JAMA. 2001 Apr
25;285(16):2083-93.
The Petra Study Team. Efficacy of three short-course regimens of zidovudine and
lamivudine in preventing early and late transmission of HIV-1 from mother to child in
Tanzania, South Africa, and Uganda (Petra study): a randomised, double-blind,
placebo-controlled trial. Lancet 2002;359:1178-86.
Zidovudine
Updated:11/1/2002
Zidovudine therapy
Nature
A nucleoside reverse transcriptase inhibitor of retrovirus including HIV.
Indication
To reduce the risk of vertical transmission of HIV from HIV-positive mothers to their
babies
Regimen
Antenatal maternal therapy:
o 300mg b.d. orally
o Specialist from QEH(SMS)/DH(SPP) may give the dosage differently in order
to improve compliance
Intrapartum maternal therapy
o If patient had antenatal Zidovudine therapy
CUHK medic 2010 48
2mg/kg iv loading dose over 30-60min, then 1mg/kg per hour iv till
clamping of cord
o If patient had not received antenatal Zidovudine therapy
300mg oral therapy for loading following by 300mg q3h till delivery
Combined with Lamivudine
Neonatal therapy
o Give Zidovudine syrup 2mg/kg po 4 doses/day for 6 weeks
o or if not tolerate orally,give iv 1.5mg/kg over 30min Q6H
o start therapy within 8 to 12 hours of birth
o if no intrapartum therapy was given, start therapy immediately after delivery
Monitoring of Zidovudine therapy
To be performed by specialist from QEH(SMS)/DH(SPP)
o baseline CBP, LFT, CPK then
o CBP Q2weeks for 1 month, then Q4 weeks
o LFT, CPK Q4 weeks
o Consider discontinuation if:
Hb<8g/dl
Platelet<100x109/L
WCC<75x109/L
o ALT/AST >5X normal
Discussion / Justification
Zidovudine is the mainstay of treatment for the prevention of perinatal HIV
transmission and should be recommended because it is found to be safe to both the
mother and the baby on the 5-year follow-up studies from the PACTG 076 trial.
If the mother has not been treated with antenatal Zidovudine, a two-dose
intrapartum/newborn Nevirapine is superior to Zidovudine alone by 47% and as
effective as Zidovudine + Lamivudine in reducing vertical transmission rate.
Singel agent nevirapine is associated with high frequency of nevirapine-resistant
mutations of the HIV-1 virus
The addition of Nevirapine to standard Zidovudine therapy has not been shown to be
of benefit
References
Conner EM, Sperling RS, Gelber R et al. AIDS Clinical Trials Group (ACTG) 076.
Reduction of maternal-infant transmission of HIV type 1 with zidovudine treatment. N
Engl J Med 1994; 331: 1173-80
CUHK medic 2010 49
Culnane M, Fowler M, Lee S et al. Lack of long-term effects of in utero exposure to
zidovudine among uninfected children born to HIV-infected women. JAMA 1999;
281(2): 151-157
Hanson IC, Antonelli TA, Sperling RS et al. Lack of tumours in infants with perinatal
HIV-1 exposure and fetal/neonatal exposure to zidovudine. J Acquir Immune Defic
Syndr Hum Retroviraol 1999; 20: 463-467
Dorenbaum A, Cunningham CK , Gelber RD et al. Two-dose intrapartum/newborn
Nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission. A
randomized trial. PACTG 316. JAMA 2002;288(2):189-198.
Mandelbrot L, Landreau-Mascaro A, Rekacewicz C et al. Lamivudine-
Zidovudine combination for prevention of maternal-infant transmission of
HIV-1. JAMA. 2001 Apr 25;285(16):2083-93.
Oxytocic agent
Updated:8/13/2008
Drugs
Oxytocin deviatives
o Syntocinon
o Syntometrine
o Carbetocin
Prostaglandins deviatives
o PGE2
o Hemabate
o Misoprostol
o Cervagem
Indications
Rippening of cervix: PGE2
Induction or augmentation of labour: syntocinon
Prophylaxis and treatment of postpartum haemorrhage: syntocinon, syntometrine,
hemabate
For termination of pregnancy or treatment of abortion: misoprostol, cervagem
Syntocinon
Updated:10/29/200
8
Indications
CUHK medic 2010 50
Induction of labour
Augmentation of labour
Prophylaxis and treatment of postpartum haemorrhage in the third stage of labour
Regimen
For induction and augmentation of labour:
o Start infusion using either infusion drip set or syringe pump (see table 1), and
titrate the infusion rate accordingly.
o Maintain the infusion rate if adequate contractions (3 to 4 contractions per 10
minutes) are achieved, till the next cervical assessment.
o Inform medical officer if more than 20 mu/min of oxytocin is required to
achieve optimal uterine contractions.
For intrapartum managment third stage of labour:
o iv bolus 5 units over 1-2 minutes, or
o im bolus 10 units if no iv access available and in absolute emergency
(unlicensed route)
patients with cardiac disease or those particularly at risk of
hypotension should have the iv bolus 5 units given slower i.e. over 5
minutes
o iv infusion 40 units in 500ml crystalloid solution Q4H once
Table 1. Syntocinon Infusion
Time after
starting
Oxytocin dosage
(milliunits per
minutes)
Infusion rate for 10 units in
500ml of Hartmann
solution (ml/hour)
Infusion rate for 5 units in
50 ml of Hartmann
solution (ml/hour)
0 1 3 0.6
30 2 6 1.2
60 4 12 2.4
90 8 24 4.8
120 12 36 7.2
150 16 48 9.6
180 20 60 12.0
210 24 72 14.4
240 28 84 16.8
270 32 96 19.2
CUHK medic 2010 51
Remark
Midwives can adminster syntocinon bolus injection at third stage of labour according
to departmental standing order.
References: Thomas TA and Cooper GM. Maternal deaths from
anaesthesia. An extract from Why Mothers Die 1997-1999, the
Confidential Enquiries into Maternal Deaths in the United Kingdom.
Br J Anaesth 2002;89:499-508. FDA website:
http://www.drugs.com/pro/syntocinon.html
Carbetocin - provisional
Updated:8/13/2008
Pharmacology
a long-acting synthetic nonapeptide analogue of oxytocin with agonist properties
Indication
first line prophylaxis against postpartum haemorrhage in high risk cases during the
third stage of labour.
Contraindications
allergic to carbetocin, known vascular disease, especially coronary artery disease;
hepatic or renal disease
Regime
100mcg im or iv injection(1 ampoule / 1ml)
Misoprostol
Updated:1/8/2009
Nature of Misoprostol (Cytotec)
A PGE-1 analogue of the prostaglandin group
Indications
First line treatment for first and second trimester miscarriages to evacuate the uterus
First line treatment for second trimester medical induced abortion
CUHK medic 2010 52
First line treatment for cervical ripening prior to mechanical cervical dilatation for first
trimester suction termination of pregnancy
Caution
Patients with high risk for uiterine rupture, hypersensitivity, severe cardiac disease.
Adverse reactions
Uterine rupture
Side effects
GI upset, vomiting, diarrhoea, pyrexia
Route of administration
Oral or vaginal
Regimen
For medical evacuation of the uterus for first trimester miscarriage, single dose of
800micrograms vaginally.
For medical evacuation of the uterus for second trimester abortion (spontaneous or
induced), 400micrograms every 3 hours vaginally for 5 doses. May repeat the course
if necessary. If 2 courses fail, consider change to gemeprost.
For cervical ripening prior to mechanical cervical dilatation for first trimester suction
termination of pregnancy, 200micrograms single dose vaginally 3 hours before the
procedure
Discussion / Justification
Vaginal Misoprostol is more effective than Gemeprost in second trimester TOP.
Vaginal route of Misoprostol is more effective than oral Misoprostol in second
trimester induced abortion
For cervical priming, oral Misoprostol is better than vaginal Gemeprost with greater
baseline cervical dilatation and easier dilatation.
For cervical priming, 200mcg vaginally is as effective as 400mcg vaginally
For cervical priming, vaginal Misoprostol is more effective if given 2-4hrs prior to
surgery than oral Misoprostol given 8-12 hrs prior to surgery.
References: Wong KS, Ngai CSW, Wong AYK et al. Vaginal
Misoprostol compared with vaginal Gemeprost in termination of
CUHK medic 2010 53
second trimester of pregnancy. Contraception 1998;58:207-210. Gilbert A, Reid R. A randomized trial oral versus vaginal administration of Misoprostol for the
purpose of mid-trimester TOP. ANZJOG 2001;41(4):407-410. Ngai SW, Au Yeung KC, Lao T
et al. Oral Misoprostol versus vaginal Gemeprost for cervical dilatation prior to vacuum
aspiration in women in the sixth to twelfth week of gestation. Contraception 1995;51:347-350.
Ngai SW, Chan YM, Tang OS et al. The use of Misoprostol for pre-operative cervical
dilatation prior to vacuum aspiration: a randomized trial. Human Reprod 1999;14:2139-2142.
Lawrie A, Penney G, Templeton A. A randomized comparison of oral and vaginal Misoprostol
for cervicla priming before suction termination of pregnancy. BJOG 1996;103(11):1117-9.
Carbonell JL, Velazco A, Rodriguez Y et al. Oral versus vaginal Misoprostol for cervical
priming in first-trimester abortion: a randomized trial. Eur J Contraception Reprod Health Care
2001;6(3):134-140
Sulprostone
Updated:6/22/2002
Indication
A PGE2-analogue for induction of abortion or induction of labour after intra-uterine
death when other treatment has failed
Decide treatment by FHKAM and senior call
Contraindications
Asthma
Cardiac disease
Hepatic or renal failure
Regimen
Add 500mcg to 250ml of NS for infusion
Infuse at 100mcg per hour
May infuse continuously for 10 hours
Never exceed infusion rate of 500mcg per hour
Maximum totol dosage of 1500mcg
Side effects
Nausea, vomiting, diarrhoea, headache, fever
CUHK medic 2010 54
Warfarin
Updated:10/11/2007
Indication
As prophylaxis and treatment of thromboembolism in postpartum (it is rarely used
antenatally with the exception of metabllic valve replacement)
Regimen
Baseline INR before commencement
Start loading dose 5 mg daily at both Day 1 and day 2
Check INR from Day 3 onwards
Titrate the warfarin dosage to reach the target INR
The sliding scale is a reference for warfarin dose at day 3 and day 4 while further
dosage will be adjusted according to the response to previous dose
Please consult specialist in medical medicine or physician for the management in all
cases on warfarin
It is preferred to start warfarin at evening and blood taking for INR at morning)
INR Warfarin dosage
<=1.5 5 mg
> 1.5 - 2.0 4 mg
> 2.0 - 2.5 3 mg
> 2.5 - 3.0 2 mg
> 3.0 - 3.5 1.5 mg
> 3.5 omit warfarin for 1 day
CUHK medic 2010 55
Misc
CS wound complication Updated:6/22/2002
Management of wound dehescience and wound infection
Initial assessment
Inform medical officer and Midcall-1 in charge of the case and the principal surgeon
for the operation.
Initial wound assessment should be performed by a senior midwife, an intern and the
medical officer in charge.
Record the size and depth of the wound, the presence or absence of
haematoma/pus/necrotic tissue/cavity and surrounding cellulitis.
Take a wound swab for culture and sensitivity.
Care of the wound
Irrigate wound with normal saline and dress the wound one to three times daily.
Frequency of dressing is to be decided by the Medical officer in charge. Usually once
daily dressing would reduce disturbance of the wound and promote healing.
Liaise with midwife for the best type of dressing.
Antibiotic treatment
Empirical treatment of Augmentin 375mgtds should be started while awaiting for
swab culture result.
Patients allergic to penicillin should use erythromycin 500mg qid.
Augmentin has good coverage for Group B strep, most G-negative oragnisms, most
anaerobes and also Staph. aureus (methicillin-sensitive), although sensitivity of these
organisms to Augmentin is not always tested e.g. Staph. aureus
If in doubt of the sensitivity of the cultured organism to Augmentin, please consult
microbiologist before changing the already-started antibiotic regimen.
Antibiotics should continue for at least 7-10 days.
Resuturing of the wound
Time of resuturing is to be decided by the Medical Officer in charge
CUHK medic 2010 56
General anaesthesia is preferred to resuture the wound, unless the patient prefers
local anaesthesia
Re-suturing should be performed either in the main Gynaecological operation theatre
(under GA) or the ward treatment room under aseptic technique (under LA).
Surgeons should be properly gowned up.
Removal of the new sutures should be performed at least 7-10 days after re-suturing.
Patient can be managed as out-patient after re-suturing and followed up in the ward
for the removal of sutures.
In case of a second wound dehiscence, Midcall 1 is to be involved to take personal
care of this complicated patient.
Discussion / Justification
Management of wound dehescience and wound infection
Initial assessment
Inform medical officer and Midcall-1 in charge of the case and the principal surgeon
for the operation.
Initial wound assessment should be performed by a senior midwife, an intern and the
medical officer in charge.
Record the size and depth of the wound, the presence or absence of
haematoma/pus/necrotic tissue/cavity and surrounding cellulitis.
Take a wound swab for culture and sensitivity.
Care of the wound
Irrigate wound with normal saline and dress the wound one to three times daily.
Frequency of dressing is to be decided by the Medical officer in charge. Usually once
daily dressing would reduce disturbance of the wound and promote healing.
Alginate should be used if packing is needed for wounds with lots of discharge.
Antibiotic treatment
Empirical treatment of Augmentin 375mgtds should be started while awaiting for
swab culture result.
Patients allergic to penicillin should use erythromycin 500mg qid.
Augmentin has good coverage for Group B strep, most G-negative oragnisms, most
anaerobes and also Staph. aureus (methicillin-sensitive), although sensitivity of these
organisms to Augmentin is not always tested e.g. Staph. aureus
If in doubt of the sensitivity of the cultured organism to Augmentin, please consult
microbiologist before changing the already-started antibiotic regimen.
CUHK medic 2010 57
Antibiotics should continue for at least 7-10 days.
Resuturing of the wound
Time of resuturing is to be decided by the Medical Officer in charge
General anaesthesia is preferred to resuture the wound, unless the patient prefers
local anaesthesia
Re-suturing should be performed either in the main Gynaecological operation theatre
(under GA) or the ward treatment room under aseptic technique (under LA).
Surgeons should be properly gowned up.
Removal of the new sutures should be performed at least 7-10 days after re-suturing.
Patient can be managed as out-patient after re-suturing and followed up in the ward
for the removal of sutures.
In case of a second wound dehiscence, Midcall 1 is to be involved to take personal
care of this complicated patient.
CUHK medic 2010 58