Soscg 2020 JKNS

CONTENTS
I. Foreword
II. Introduction
III. Guidelines Development Group
IV. Abbreviations and Acronyms
Section 1: Cardiac Diseases in Pregnancy

1.1 Overall Management of Cardiac Diseases in Pregnancy
1.2 Peripartum Cardiomyopathy
Section 2: Connective Tissue Diseases in Pregnancy
2.1 Rheumatoid Arthritis in Pregnancy
2.2 Systemic Lupus Erythematous in Pregnancy
Section 3: Diabetes in Pregnancy
3.1 Gestational Diabetes Mellitus
3.2 Pre-existing Diabetes Mellitus in Pregnancy
Section 4: Haematological Disorders in Pregnancy
4.1 Anaemia in Pregnancy
4.2 Asymptomatic Thrombocytopaenia in Pregnancy
4.3 Rhesus Isoimmunization in Pregnancy
4.4 Thalassaemia Carrier in Pregnancy
Section 5: Hypertensive Disorders in Pregnancy
5.1 Chronic Hypertension in Pregnancy
5.2 Gestational Hypertension and Pre-eclampsia
5.3 Screening for Pre-eclampsia and Antihypertensive Medication
5.3.1 Pre-eclampsia Prophylaxis
5.3.2 Antihypertensive Drugs for Treatment in Pregnancy
5.3.3 Acute Blood Pressure Lowering Agents in Primary Care
5.3.4 Administration of Magnesium Sulphate Injection (Malay Version)
5.3.5 Management Flowchart of Severe Pre-eclampsia/ Eclampsia at Primary
Care (Malay Version)
5.3.6 Eclampsia Kit (Malay Version)
Section 6: Infectious Diseases in Pregnancy
6.1 Retroviral Disease in Pregnancy
6.2 HIV in Serodiscordant Couple
6.3 Syphilis in Pregnancy
6.4 Tuberculosis in Pregnancy
6.5 Viral Hepatitis in Pregnancy
Section 7: Malignancies in Pregnancy
7.1 Breast Cancer in Pregnancy
7.2 Cervical Cancer in Pregnancy
7.3 Ovarian Cancer in Pregnancy
7.4 Thyroid Cancer in Pregnancy
7.5 Haematological Cancer in Pregnancy
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Section 8: Mental Disorders in Pregnancy
8.1 Antenatal and Postnatal Mental Health Screening
8.2 Management of Mental Health Disorders in Pregnancy
Section 9: Neurological Disorder in Pregnancy
9.1 Epilepsy in Pregnancy
Section 10: Obstetric Problems
10.1 Abnormal Fetal Growth
10.1.1 Small for Gestational Age or Fetal Growth Restriction
10.1.2 Large for Gestational Age or Macrosomia
10.2 Bad Obstetric History
10.2.1 History of Stillbirth/ Abnormal Fetus/ Neonatal Death
10.2.2 Traumatic Delivery
10.3 Breech and Malpresentation
10.4 Chickenpox in Pregnancy
10.5 Fetal Movement Assessment
10.6 Group B Streptococcus Carrier in Pregnancy
10.7 Low Lying Placenta
10.8 Multiple Pregnancy
10.9 Previous Uterine Scars
10.10 Recurrent Miscarriages
10.11 Recurrent Preterm Deliveries
Section 11: Pre-Pregnancy & Antenatal Care
11.1 Alcohol Use Disorder in Pregnancy
11.2 Advanced Maternal Age
11.3 Counselling of Prenatal Screening Test in Primary Care
11.4 History of Postpartum Haemorrhage
11.5 Smoking in Pregnancy
11.6 Substance Abuse in Pregnancy
11.7 Weight Gain in Pregnancy
11.7.1 Obesity or Morbid Obesity
11.7.2 Underweight
Section 12: Respiratory Diseases in Pregnancy
12.1 Bronchial Asthma in Pregnancy
12.2 Chronic Lung Disease in Pregnancy
Section 13: Renal Diseases in Pregnancy
13.1 Chronic Kidney Disease in Pregnancy
13.2 Hypokalemia in Pregnancy
13.3 Urinary Tract Infection in Pregnancy
Section 14: Social Problems in Pregnancy
14.1 Domestic Violence
14.2 Teenage Pregnancy or Single Parent
Section 15: Thyroid Disorders in Pregnancy
15.1 Hyperthyroidism in Pregnancy
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15.2 Hypothyroidism in Pregnancy
Section 16: Venous Thromboembolism in Pregnancy
Section 17: Approach to Common Presentations in Pregnancy
17.1 Elevated Liver Enzymes in Pregnancy
17.2 Headache in Pregnancy
17.3 Nausea and Vomiting in Pregnancy
17.4 Palpitation in Pregnancy
17.5 Persistent Proteinuria in Pregnancy
17.6 Pre-syncopal or Syncopal Attack in Pregnancy
17.7 Shortness of Breath in Pregnancy
Section 18: Summary Chart of WHO Medical Eligibility Criteria for Contraceptive
Use
Section 19: Postpartum Intrauterine Contraceptive Device
Section 20: Appendices
20.1 Caesarean Section Summary
20.2 Emergency Obstetric Retrieval
20.2.1 O&G Retrieval in Kota Kinabalu From Public/ Primary Health Care
20.2.2 O&G Retrieval in Kota Kinabalu From District/ Private Hospital (Within KK
Area)
20.2.3 SWACH O&G Medevac Retrieval Flow Chart
20.3 Obstetric Combined Clinic Referral Flow Chart
20.4 Detailed Scan Referral Flow Chart
20.5 Notification for High Risk Discharge (Antenatal or Postnatal Case)
20.6 Pre-pregnancy Clinic Referral Flow Chart
20.7 Pre-pregnancy Clinic Feedback Form
20.8 Refusal of Treatment Form (English & Malay Version)
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FOREWORD
Malaysia has come a long way in keeping the maternal mortality and morbidity rate as low as
possible. The challenges faced in Sabah are unique. The nature of its geographical territory limits
accessibility to healthcare services especially for rural communities. The high turnover of its
healthcare staff also poses a challenge in maintaining a continuous high standard of quality
medical care.
The Sabah Obstetrics Shared Care Guidelines (SOSCG) was first produced in Sabah in 2012
with the collaboration of the Obstetrics & Gynaecology (O&G) Department and the Family Medical
Specialists (FMS) in Sabah. The guideline was designed to help doctors manage antenatal
mothers while at the same time, to tailor clinical practice to local requirement and limitation. It
also aims to strengthen the referral system between health clinics which are run by FMS and the
medical officers in the Hospital Obstetrics team.
SOSCG serves as a tool to guide our doctors in an effort to synchronize and standardize
antenatal care management within the Sabah context. As new knowledge becomes available
and the latest medical advancement at our disposal, it is appropriate and timely to revise this
guideline in order to update our doctors on the latest clinical evidence of antenatal management.
We are often reminded that guidelines are meant to guide towards a course of action and to
streamline processes. Thus, the onus is on our doctors to apply the recommendations in the
guideline in addition to their clinical acumen, patients’ dynamic and available resources.
I wish to record my sincere appreciation and congratulation to the O&G team and all the FMS in
Sabah on their continuous and admirable efforts in revising the SOSCG.
Datuk Dr. Christina Rundi

Director of Health
Sabah State Health Department
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INTRODUCTION
Maternal morbidity and mortality have always been used as a benchmark to reflect a nation’s progress
in their health care system and overall health of a population.
Good antenatal care in return reflects a lower prevalence rate of maternal morbidity and mortality.
In Malaysia, leaps and bounds have been made in the area of maternal health especially with the
introduction of colour coding system to identify risks in pregnancies supported by good referral
systems between interdistrict peripheral hospitals and klinik kesihatan and home-based maternity
cards and books kept by patients that may be presented at any antenatal care clinics/hospital both in
the government and private centres.
In Sabah, achieving good antenatal care, especially among mothers who are deemed as having high
risk pregnancies, has been a challenge. Sabah, with its uniqueness and natural beauty presents many
challenges in the form of its demography, rough inaccessible terrains, poor public transportation and
low economic status among its rural population.
Klinik Kesihatan (KK), Klinik Kesihatan Ibu dan Anak (KKIA), Klinik Desa and Klinik Bergerak are the
primary care centres that are accessible to the mothers in Sabah. Many of these services are placed
strategically in rural areas covering wide areas where the nearest tertiary centres with specialist
maybe a few hundred kilometres away. Many of these clinics have Family Medicine Specialist (FMS)
who are either placed there or are visited regularly by the FMSes.
In order to improve and provide good antenatal care, standardized shared care needs to be provided
uniformly throughout Sabah. And hence Sabah Obstetrics Shared Care Guidelines (known
affectionately as SOSCG guidelines) was introduced. The SOSCG covered various common topics
pertaining to antenatal care and management up to the postpartum period and even pre-pregnancy
care. The guideline was a collaboration between the O&G Dept and FMSes in Sabah.
The 1st edition was released in 2012, although the groundwork was initiated in 2008. Since then the
guideline has become a reference tool to the medical officers managing pre-pregnancy and antenatal
mothers throughout Sabah.
The SOSCG guideline has undergone several updates; the last update was in 2018 (3rd edition).
As medicine is a field of constant change and new developments, the O&G team and the FMSes from
Sabah saw the need to further update the management of current topics and to introduce new topics
that were deemed relevant. The current update saw the O&G team and FMSes throughout Sabah
come together to discuss and contribute to the new updated guideline.
We hope the new updated guideline will continue to improve the care given for the mothers of Sabah
and the care given will be of superior quality and standards and that it will reach all mothers in Sabah.
The Sabah FMSes
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GUIDELINES DEVELOPMENT GROUP
Chairperson Co- chairperson
Dr. Zaiton Yahaya Y. Bhg. Datuk Dr. Soon Ruey
Family Medicine Consultant Senior O&G Consultant
Sandakan Health Clinic Sabah Women’s and Children’s Hospital
Sandakan Kota Kinabalu
Editor
Dr. Hii Ling Yien
Maternal Fetal Medicine Specialist
Sabah Women’s and Children’s Hospital
Kota Kinabalu
Contributors (In Alphabetical Order)

Family Medicine Specialists
Dr. Ahmad Baihaqi bin Azraii Dr. Grace Jikinong
Family Medicine Specialist Family Medicine Specialist
Tandek Health Clinic Luyang Health Clinic
Kota Marudu Kota Kinabalu
Dr. Anita Delilah Salahuddin Dr. Haryati binti Hamzah

Nabawan Health Clinic Tawau Health Clinic
Keningau Tawau
Dr. Eric Henry Dr. Jusnimar binti Khairul Yusri

Sook Health Clinic Lahad Datu Health Clinic
Keningau Lahad Datu
Dr. Farah Waheeda binti Ghulam Khan Dr. Khaw Chwin Khai
Kinarut Health Clinic Menggatal Health Clinic
Papar Kota Kinabalu
Dr. Fazilawati@ Azmira binti Ab. Latif Dr. Lee Wai Khew
Family Medicine Specialist Family Medicine Consultant
Telupid Health Clinic Luyang Health Clinic
Beluran Kota Kinabalu
Dr. George G. Mathew Dr. Mirah binti Papo

Family Medicine Consultant Family Medicine Specialist
Tamparuli Health Clinic Tawau Health Clinic
Tuaran Tawau
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Dr. Mohammad Azmi bin Che Mat Dr. Ng Yoke Lan
Jawi-jawi Health Clinic Inanam Health Clinic
Kota Belud Kota Kinabalu
Dr. Mohd Adam bin Mohd Akil Dr. Norlaily bini Hassan
Tamparuli Health Clinic Lahad Datu Health Clinic
Tuaran Lahad Datu
Dr. Muhamad Faiz bin Mahayidin Dr. Nur Najlaa Bt Ab Aziz

Semporna Health Clinic Inanam Health Clinic
Semporna Kota Kinabalu
Dr. Muhamad Hafiz bin Harun Dr. Nurul Akmanidar bt Zainuddin

Tawau Health Clinic Luyang Health Clinic
Tawau Kota Kinabalu
Dr. Muhammad Akmal bin Mohd Nor Dr. Nurul Idayu bt Mior Azmi
Sindumin Health Clinic Apas Balung Health Clinic
Sipitang Tawau
Dr. Munirah Binti Mohd Basar Dr. Nurul Nadia Mohd Anas
Sandakan Health Clinic Menggatal Health Clinic
Sandakan Kota Kinabalu
Dr. Nasibah Tuan Yaacob Dr. Suraihan bt Sulaiman

Tamparuli Health Clinic Kundasang Health Clinic
Tuaran Ranau
Dr. Tan Yee Jin Dr. Yafizah Yahaya

Telipok Health Clinic Luyang Health Clinic
Kota Kinabalu Kota Kinabalu
Dr. Wong Tze Ling Dr. Zafferina binti Zulghaffar

Penampang Health Clinic Sg Manila Health Clinic
Penampang Sandakan
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Department of Obstetrics & Gynaecology
Dr. Amory S. Chong Dr. Nadia Said
Obstetrics & Gynaecology Specialist Obstetrics & Gynaecology Specialist
Sabah Women’s and Children’s Hospital Tawau Hospital
Kota Kinabalu Tawau
Dr. Dayang Sofiah Ag Ahmad Dr. Nor Azila Mohd Nafiah

Sabah Women’s and Children’s Hospital Lahad Datu Hospital
Kota Kinabalu Lahad Datu
Dr. Fathi Laila Amir Dr. Normaliza Muhamad

Sabah Women’s and Children’s Hospital Sabah Women’s and Children’s Hospital
Dr. Hoong Farn Weng Michael Dr. Norsa'adah Salim

Consultant Obstetrics & Gynaecology Obstetrics & Gynaecology Specialist
Dr. Loh Yoke Ling @ Cecilia Dr. Tan Gi Ni

Dr. Melanie Kuan Lih Jiun Dr. Siti Aishah Tajudin

Sabah Women’s and Children’s Hospital Keningau Hospital
Kota Kinabalu Keningau
Dr. Sofia Annaim Bt Abdussyukur Dr. Yogeeta Gunasagran

Dr. Yew Cheng Boon

Consultant Obstetrics & Gynaecology
Hospital Duchess of Kent
Sandakan
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Abbreviations and Acronyms
ACEi Angiotensin inhibitor CRHD Chronic rheumatic heart
disease
ADHD Attention deficit
hyperactivity disorder CRL Crown-rump length
AED Antiepileptic drug CRP C reactive protein
ALP Alkaline phosphatase CVA Cerebrovascular accident
ANA Antinuclear antibody CVD Cardiovascular disease
APH Antepartum haemorrhage CVS Chorionic villus sampling
APS Antiphospholipid DBP Diastolic blood pressure
syndrome
DFMC Daily fetal movement
ARB Angiotensin receptor chart
blocker
DKA Diabetic ketoacidosis
ART Antiretroviral therapy
DM Diabetes mellitus
AST Aspartate transaminase
dsDNA Double stranded DNA
ALT Alanine transaminase
DIVC Disseminated
ATD Antithyroid drug intravascular
coagulopathy
AZA Azathioprine
DR Detection rate
BP Blood pressure
DR-TB Drug resistant
BFMP Blood film for malaria tuberculosis
parasite
D&C Dilatation & curettage
BSP Blood sugar profile
DVP Deepest vertical pool
CAH Congenital adrenal
hyperplasia EBL Estimated blood loss
CCP Cyclic citrullinated peptide EBV Epstein Barr Virus
CFU Colony-forming units ECV External cephalic version
CHF Congestive heart failure ECG Electrocardiography
CKD Chronic kidney disease ECHO Echocardiogram
CMV Cytomegalovirus EEG Electroencephalogram
CPG Clinical practice EF Ejection fraction
guidelines
EFW Estimated fetal weight
CS Caesarean section
eGFR Estimated glomerular
C&S Culture and sensitivity filtration rate
CNS Central nervous system EP Emergency physician
9
EPDS Edinburgh postnatal HIV Human immunodeficiency
depression scale virus
ESR Erythrocyte sedimentation HOD Head of department
rate
HPT Hypertension
ESRF End stage renal failure
HPV Human Papillomavirus
EULAR European League Against
Rheumatism HVS High vaginal swab
FASD Fetal alcohol spectrum IAP Intrapartum antibiotic

disorder prophylaxis
FAS Fetal alcohol syndrome ICS Inhaled corticosteroids
FBC Full blood count ICSI Intracytoplasmic sperm

injection
FBS Fasting blood sugar
ICU Intensive care unit
FGR Fetal growth restriction
IDA Iron deficiency anaemia
FMS Family medicine specialist
IM Intramuscular
FNAC Fine needle aspiration for
cytology ITP Immune
thrombocytopenia purpura
FPR False positive rate
IUCD Intrauterine contraceptive
GA General anaesthesia device
GBS Group B streptococcus IUS Intrauterine system
GDM Gestational diabetes IV Intravascular
mellitus
IVF In vitro fertilization
GGT Gamma glutamyl
transferase JKM Jabatan Kebajikan
Masyarakat (Department
GI Gastrointestinal of Social Welfare)
GINA Global initiative for JVP Jugular venous pressure
asthma
KUB Kidney, ureter and
GTT Gestational transient bladder
thyrotoxicosis
LDH Lactate dehydrogenase
Hb Haemoglobin
LEF Leflunomide
HBGM Home blood glucose
monitoring LFT Liver function test
HBV Hepatitis B virus LGA Large for gestational age
HCQ Hydroxychloroquine LMW Low molecular weight
HCV Hepatitis C virus LSCS Lower segment

caesarean section
HELLP Haemolysis, elevated liver
enzymes, low platelets
10
LVEF Left ventricular ejection PO per os (medication taken
fraction by mouth)
MCH Mean cell haemoglobin POA Period of amenorrhea
MCV Mean cell volume PBF Peripheral blood film
MEC Medical eligibility criteria PCOS Polycystic ovarian
syndrome
MFM Maternal fetal medicine
PH Pulmonary hypertension
MMRC Modified Medical
Research Council PHC Pre hospital care
MOGTT Modified oral glucose POP Progestogen only pills
tolerance test
PPCM Peripartum
MOH Ministry of Health cardiomyopathy
MOPD Medical outpatient PPH Postpartum haemorrhage
department
PPIUCD Postpartum intrauterine
MSU Midstream urine contraceptive device
MSW Medical social worker PPROM Preterm prelabour rupture
of membrane
MTB Mycobacterium
tuberculosis PPT Postpartum thyroiditis
MTAC Medical therapy PrEP Pre-exposure prophylaxis
adherence clinic
PTB Pulmonary tuberculosis
MTX Methotrexate
PTSD Post traumatic stress
NPH Isophane insulin disorder
NRT Nicotine replacement PTU Propylthiouracil
therapy
RF Rheumatoid factor
NSAIDs Non-steroidal anti-
inflammatory drugs Rh Rhesus
NT Nuchal translucency POA Period of amenorrhea
NVP Nausea and vomiting in RP Renal profile

pregnancy RPG Random plasma glucose
NYHA New York Heart RVD Retroviral disease
Association
SBP Systolic blood pressure
OAD Oral antidiabetic drugs
SCAN Suspected Child Abuse
OSA Obstructive sleep apnoea and Neglected Team
OSCC One Stop Crisis Centre SGA Small for gestational age
PCP Pneumocystis pneumonia SIDS Sudden infant death
PDA Patent ductus arteriosus syndrome
11
SLE Systemic lupus
erythematosus
SMBG Self-monitoring blood
glucose
SOPD Surgical outpatient
department
SSZ Sulfasalazine
STD Sexually transmitted
disease
SUA Serum uric acid
TIA Transient ischaemic
attack
T1DM Type 1 diabetes mellitus
T2DM Type 2 diabetes mellitus
TDI Total dose infusion
TNF Tumour necrosis factor
TOP Termination of pregnancy
TRAb TSH receptor
autoantibodies
TSH Thyroid stimulating
hormone
TTP Thrombotic
thrombocytopenia purpura
UFEME Urine full examination and
microscopic examination
USS Ultrasound scan
UTI Urinary tract infection
VBG Venous blood gas
VDRL Venereal disease of
research laboratory
VVC Verbal confidentiality
contract
VMA Vanillylmandelic acid
VTE Venous thromboembolism
WHO World Health
Organisation
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SECTION 1 CARDIAC DISEASES IN PREGNANCY
1.1 Overall Management of Cardiac Disease in Pregnancy
Phase Plan of Action
1 Pre-pregnancy • All women in the reproductive age group and plan to conceive
should be referred to the Pre-pregnancy Clinic upon
diagnosis.
• Women with condition in which pregnancy risk is WHO class
IV should have family counselling sessions with strong
advice for effective contraception.
• Sterilization should be offered if family completed.
• Women with valvular lesions requiring surgery should be
advised to conceive after moderate to severe valvular lesions
treated.
• Women should put on long acting reversible contraception
until the treatment completed.
• Women on lifelong warfarin should be counselled on high risk
of miscarriage and fetal demise.
• Ensure compliance to follow-up in cardiac clinic.
2 Booking • Investigations in health clinic: Refer for urgent ECHO/ O&G
Clinic appointment within 1 to 2 weeks.
• If patient is symptomatic or clinically unwell, refer for
admission.
• For women with pre pregnancy care plan - refer to Combined
clinic
• Urge husbands/partners to attend visits.
• Preliminary investigation by health clinic: BP, FBS, RP, ECG.
3 Subsequent • Shared care between FMS, cardiologist and Combined clinic
antenatal follow- team.
up • Detailed scan in MFM Clinic at 22-24 weeks for patients with
congenital heart disease.
• Further follow-up plan will be made on case-to case basis:
➢ WHO/NYHA I & II: at least 2 visits at week 22-28 & weekly
visit from 36 weeks onwards.
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➢ WHO/NYHA III&IV: once in 2 weeks visit at week 22-28,
followed by weekly visit afterwards & consider admission
at 36 weeks (with anaesthetic review).
• Anticoagulant as per guideline.
• Antimicrobial prophylaxis as planned by cardiology team
(daily oral penicillin V or monthly IM Benzathine Penicillin).
• Correct anaemia if any.
• Correct factors that may contribute to cardiac decompression,
e.g. infection, arrhythmia, hypertension.
4 Delivery • Outline by O&G department by 34 - 36 weeks.
• Intrapartum antimicrobial prophylaxis as per type of cardiac
lesion.
5 Postpartum • Individualised care plan.
• Postnatal in-patient monitoring usually 48 hours to 1 week,
depending of type of cardiac disease.
• Avoidance of aggravating factors.
• VTE prophylaxis based on the severity of cardiac lesion.
• Importance of contraception and planned pregnancy
reinforced.
6 Upon discharge • Notification of high-risk cases discharge as per guideline.
• Review by medical officer at health clinic within 1 week.
• Assessment of cardiac status to look for symptoms of heart
failure.
• FMS appointment within 1 month.
• Cardiac clinic appointment before discharge.
• Pre pregnancy clinic under O&G team 2 – 3 months.
7 Lactation • Breastfeeding is generally encouraged.
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REMARKS:
1. Cardiovascular disease affects approximately 0.2- 4% of pregnant women.
2. Pregnancy increases the cardiac workload by 30% with a further 20% increase
intrapartum.
3. Risk of fetal congenital heart disease in an affected mother stands at 4%, well above
the background severe general malformation rate of 2 – 3%.
4. Characteristics symptoms of heart failure:
a. Shortness of breath (dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea)
b. Reduced effort tolerance
c. Ankle swelling (may be absent)
5. Signs of heart failure:
a. Elevated jugular-venous pressure (JVP)
b. Third heart sound
c. Laterally displaced apical impulse in the presence of cardiac murmur
d. Peripheral oedema
e. Tachycardia
f. Narrow pulse pressure
6. Therapeutics
a. Anti-arrhythmic agents and anti-coagulation agents in pregnancy should be
thoroughly discussed during consultations.
b. Anti-failure medications such as digoxin and diuretics can be continued in
pregnancy.
c. ACE inhibitors are contraindicated in pregnancy but safe during breastfeeding.
d. Statins are generally contraindicated.
e. Beta blockers are the mainstay of fixed output lesions such as MS and AS and
in coronary artery disease.
7. Modified WHO Classification of Maternal Cardiovascular Risk(s):
Condition in which pregnancy risk is WHO I
a. Uncomplicated, small or mild
• pulmonary stenosis
• patent ductus arteriosus
• mitral valve prolapsed
b. Successfully repaired simple lesions (atrial or ventricular septal defect, patent
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ductus arteriosus, anomalous pulmonary venous drainage)
c. Atrial or ventricular ectopic beats, isolated
Conditions in which pregnancy risk is WHO II or III
WHO II (if otherwise well and uncomplicated)
a. Unoperated atrial or ventricular septal defect
b. Repaired tetralogy of Fallot
c. Most arrythmias
WHO II-III (depending on individual)
a. Mild left ventricular impairment
b. Hypertrophic cardiomyopathy
c. Native or tissue valvular heart disease not considered WHO I or IV
d. Marfan syndrome without aortic dilatation
e. Aorta<45mm in aortic disease associated with bicuspid aortic valve
f. Repaired coarctation
WHO III
a. Mechanical valve
b. Systemic right ventricle
c. Fontan circulation
d. Cyanotic heart disease (unrepaired)
e. Other complex congenital heart disease
f. Aortic dilatation 40-45mm in Marfan syndrome
g. Aortic dilatation 45-50mm in aortic disease associated with bicuspid aortic
valve
Condition in which pregnancy risk is WHO IV
(pregnancy is not recommended or contraindicated, termination of pregnancy
should be discussed)
a. Pulmonary arterial hypertension of any cause
b. Severe systemic ventricular dysfunction (LVEF<30%, NYHA III–IV)
c. Previous peripartum cardiomyopathy with any residual impairment of left
ventricular function
d. Severe mitral stenosis, severe symptomatic aortic stenosis
e. Systemic right ventricle with moderate or severely decreased ventricular
function
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f. Marfan syndrome with aorta dilated > 45mm
g. Aortic dilatation > 50mm in aortic disease associated with bicuspid aortic
valve
h. Uncorrected severe coarctation
i. Vascular Ehlers-Danlos
j. Fontan with any complication
5. New York Heart Association (NYHA) Functional Classification
CLASS I No limitation.
Ordinary physical activity does not cause undue fatigue, dyspnea or
palpitation.
CLASS II Slight limitation of physical activity.
Such patients are comfortable at rest.
Ordinary physical activity results in fatigue, palpitation, dyspnea or angina.
CLASS III Marked limitation of physical activity.
Although patients are comfortable at rest, less than ordinary activity will
lead to fatigue, palpitation, dyspnea or angina.
CLASS IV Inability to carry on any physical activity without discomfort.
Symptoms of congestive heart failure are present at rest.
With any physical activity, increased discomfort is experienced.
Reference(s):
1. ESC Guidelines on the management of cardiovascular disease in pregnancy, 2018.
2. Clinical practice guideline: Heart Disease in Pregnancy, 2nd edition, 2016
3. Perinatal Care Manual 3rd Edition, Ministry of Health Malaysia, 2013.
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(Taken from Clinical practice guideline: Heart Disease in Pregnancy, 2nd edition, 2016)
18
(Taken from Clinical practice guideline: Heart Disease in Pregnancy, 2nd edition, 2016)
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1.2 Peripartum Cardiomyopathy (PPCM)
1 Pre-pregnancy • All women in the reproductive age group with history of
PPCM should have effective contraception until cardiac
function improves.
• Emphasize the importance of follow up under cardiologist.
2 Diagnosis and • Identify women at risk for PPCM and monitor presence
subsequent signs and
antenatal care • symptoms of heart failure during pregnancy or postnatal
period.
• Women with previous history of PPCM or suspected
cardiomyopathy need to be referred to cardiologist for
cardiac assessment and revise cardiac medication if
necessary.
• Shared care among FMS, cardiologist and Combined clinic
team.
• If presence of symptoms and signs of heart failure, refer
hospital immediately.
• Anticoagulant therapy in all patients with PPCM as per
cardiology plan.
• Antenatal management at the level of tertiary hospital.
3 Delivery • Delivery in hospital with specialist and ICU backup.
• Timing and mode of delivery as outlined by O&G.
from hospital • Contraception before discharge (preferably long acting
contraception e.g. Implanon).
• Patient to inform health clinic upon discharge and review
by medical officer at 1 week after discharge.
• Ensure contraception (e.g. Implanon) and
thromboprophylaxis in place.
5 Postnatal care • FMS appointment within 1 month.
• Pre pregnancy clinic under O&G in 6 to 8 weeks.
• Cardiologist/ECHO appointment as planned (if not given
need to take appointment within 3 to 6 months).
6 Risk of • Refer Pre pregnancy Care Clinic in Specialist Clinic -
subsequent hospital/ FMS
pregnancy • If LV function fully recovered: subsequent pregnancy not
contraindicated.
• If LV function not recovered: subsequent pregnancy is
contraindicated.
7 Future pregnancy • Require Cardiologist assessment prior next pregnancy.
plan
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• To ensure patient follow up with cardiologist.
8 Lactation • Breastfeeding is discouraged in NYHA III/ IV (to reduce

high metabolic demand)
REMARKS:
1. Peripartum cardiomyopathy
a. Heart failure develops in the last month of pregnancy or within 5 months of
delivery with EF less than 45% and not attributed by other causes.
b. Prevalence of PPCM in Malaysia is at 34 per 100,000 live births.
c. Incidence is low (<0.1%) but high morbidity and mortality (5%-32%)
2. Risk factors: Multi-parity, obesity, family history, smoking, diabetes,
hypertension, Pre-eclampsia, malnutrition, advanced age of mothers or teenage
pregnancy.
3. Nursing care/postnatal visit:
a. Assessment of important symptoms and signs of heart failure: Immediate
referral if presence.
b. Ensure compliance to medications.
c. Non-pharmacological therapies (individualized) – low sodium diet (limit 2g
sodium per day, fluid restriction and light daily activity (walking).
4. Prognosis:
a. About 28-50% of patients recover baseline LV function within 6 months.
b. Prognosis is positively related to recovery of LV function.
c. LVEF is the strongest predictor of outcome.
d. Failure of LV size to return to normal is associated with increased morbidity
and mortality.
e. The 5-year survival rate is 94% and mortality varies from 0.9%-15%.
f. A subsequent pregnancy caries a recurrence risk of 30-50%.
5. The recurrence risk is higher in the 30% of women who have symptomatic
residual disease. Women whose cardiac functions have returned to near
normal have good prognosis. Their recurrence is at 2 – 5%
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Reference(s):
1. American Heart Association: Peripartum Cardiomyopathy 2013
2. Peripartum Cardiomyopathy: Review and Clinical practice, American journal of
critical care, March 2012
3. Clinical practice guideline: Heart Disease in Pregnancy, 2ndEdition ,2016.
4. ESC Guidelines on the management of cardiovascular disease in pregnancy, 2018.
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SECTION 2 CONNECTIVE TISSUE DISEASES IN PREGNANCY
2.1 Rheumatoid Arthritis in Pregnancy
1 Pre-pregnancy • Refer to pre – pregnancy clinic (FMS/ O&G).
• Avoid unplanned pregnancy.
• Should defer pregnancy until disease is under good control
and on medications compatible with pregnancy, whenever
possible.
• If planning to conceive
➢ Refer rheumatologist for assessment
➢ Folic acid 5mg daily
• NSAIDS should be discontinued during a conception cycle
and used sparingly during the first trimester.
• Medications that can generally be used throughout
pregnancy are hydroxychloroquine (HCQ), sulfasalazine
(SSZ), azathioprine (AZA).
• Prednisolone may be used in low dose during pregnancy
• Pregnancy is contraindicated for patients on Methotrexate
(MTX), Leflunomide (LEF), JAK -2 inhibitors and
biological agents (teratogenic)
• Note:
➢ MTX need to be withhold 3-6 months prior to conception
➢ Leflunomide need to be withhold 2 years prior to
conception
2 Booking/ At • If clinical features suggestive of RA in pregnancy (EULAR
diagnosis Criteria 2010) – refer FMS, then refer medical /rheumatology
AND Combined Clinic.
• For RA patients already on medical/ rheumatology follow-up,
to inform FMS and refer Combined Clinic early.
• If patient on MTX/ LEF – refer to medical/ rheumatology team
for early clinic appointment, may need to discontinue.
• Investigations:
23
➢ FBC, RP, LFT, ESR/CRP
➢ UFEME
➢ RF, anti-CCP (if suspecting RA)
• Calcium supplementation continued during pregnancy.
• MOGTT for patients on prednisolone.
• Detailed scan at 22 – 24 weeks.
3 Subsequent • Monitor for disease flares
antenatal follow- ➢ NSAIDs- use sparingly in 1st and 2nd trimester but avoid
in 3rd trimester.
up
➢ Prednisolone may be used sparingly in low dose.
• Refer Occupational therapist if indicated for splinting etc.
4 Delivery • As per obstetric indications
5 Postpartum • Monitor for flares.
• Refer Rheumatologist for follow-up at Rheumatology Clinic.
6 Lactation • Safe to continue: NSAIDs (but aspirin should be avoided),
Corticosteroids, HCQ, SSZ, TNF inhibitors, AZA
• Inadequate data: JAK inhibitors (tofacitinib)
• Contraindicated: Methotrexate, Leflunomide, cyclosporine,
cyclophosphamide, chlorambucil and other biologics
REMARKS:
1. Hydroxychloroquine (HCQ), Sulfasalazine (SSZ), Azathioprine (AZA) and
Corticosteroids in doses up to 15 mg/day (prednisolone equivalent) are
compatible with pregnancy.
2. Clinical evaluation based on 2010 ACR/EULAR classification criteria.
3. Majority will achieve disease control in pregnancy.
4. A flare is associated with functional disability, intense fatigue, more swelling, more
pain, more stiffness, flu like symptoms.
5. SSZ: use with caution in setting of prematurity, hyperbilirubinaemia, G6PD
deficiency.
Reference(s):
1. EULAR textbook on Rheumatic Diseases 2012.
2. Up to date: Patient information: Rheumatoid arthritis and pregnancy (Beyond the Basics).
3. CPG Management of Rheu Arthritis, MOH MaHTAS, 2019.
24
4. Aletaha D, Neogi T et al, ARTHRITIS & RHEUMATISM Vol. 62, No. 9, September 2010, pp
2569–2581 DOI 10.1002/art.27584.
5. Krause ML, Makol A; Management of rheumatoid arthritis during pregnancy: challenges and
solutions, Open Access Rheumatology 23 Mar 2016: 23-36.
6. Wasserman AM; Diagnosis and Management of Rheumatoid Arthritis, American Family
Physician Volume 84, Number 11 December 1, 2011:1245-1252.
7. Fernández-Ávila DG, Rincón-Rian˜ o DN, Gutiérrez JM. Onset of Rheumatoid Arthritis during
pregnancy. Rev Colomb Reumatol. 2018; 25:141–145.
Target population:
Patients who (i) have at least one joint with clinical
Score
synovitis, and (ii) the synovitis not better explained
by another disease
Add score of categories A-D, score of ≥ 6/10 needed to
classify patient as having definite RA
A. Joint involvement (tender/ swollen)
1 large joint 0
1 – 10 large joints 1
1 – 3 small joints (with or without involvement of 2
large joints)
1 – 10 small joints (with or without involvement of 3
large joints)
>10 joints (at least 1 small joint) 5
B. Serology
Negative RF/ ACPA 0
Low-positive RF/ low-positive ACPA 2
High positive RF/ high-positive ACPA 3
C. Acute phase reactants
Normal CRP & ESR 0
Abnormal CRP/ ESR 1
D. Duration of symptooms
< 6 weeks 0
≥ 6 weeks 1
2010 ACR/ EULAR Classification criteria for Rheumatoid Arthritis
25
2.2 Systemic Lupus Erythematosus in Pregnancy
1 Pre-pregnancy • Refer to pre – pregnancy clinic (FMS/O+G) for counselling
and detailed risk discussion.
• Avoid unplanned pregnancy
➢ Contraception
▪ Oestrogen based contraindicated
▪ Progestogen based seem safe
▪ Risk of thrombosis need to be considered
• Should defer pregnancy until disease is under good control
and on medications compatible with pregnancy, whenever
possible.
• If planning to conceive
➢ Refer rheumatologist for assessment and counselling
➢ Folic acid 5mg daily
• Assess disease activity, major organ involvement,
hypercoagulability and concurrent medical conditions.
• Pregnancy is allowed if:
➢ Disease in remission for ≥ 6 months or stable low disease
activity on treatment
➢ BP well-controlled
➢ eGFR > 60ml/min
➢ Proteinuria < 1g/day (proteinuria 2+)
• Advise for contraception if early disease/currently active
disease.
• High risk of worsening complications if severe impairment of
organ function +/- pre-existing organ damage.
2 Booking • Woman who is not diagnosed with SLE but with signs and
symptoms suggestive of SLE (use EULAR/ACR SLE Criteria)
➢ Assess severity – if severe manifestation, refer urgently
to MOPD
26
➢ If non severe – early referral to FMS / MOPD/
rheumatology clinic assessment with baseline
investigations.
• Woman who is known case of SLE
➢ Refer FMS
➢ Early referral to Combined Clinic appointment
➢ Assessment to detect disease flare
• VTE risk scoring – weightage of 3 in active disease
(thrombophilic state).
• Refer CPG of Prevention and Treatment of VTE/ VTE Risk
Assessment in Pregnancy and Puerperium (MOH 2017).
• Investigations:
➢ ANA/ dsDNA (if not diagnosed SLE)
➢ FBC, RP, LFT, ESR/CRP, uric acid
➢ Red cell cast in urine (UFEME)
➢ Urine 24hr protein (if proteinuria present)
• Complement levels (C3, C4)
3 Subsequent • Calcium supplementation continued during pregnancy.
antenatal follow- • T. Aspirin 150mg or Cardiprin 100mg daily from 12 weeks
up until delivery.
• Monitor for flare, anaemia, pre-eclampsia and fetal growth
restriction.
• Blood pressure - monitor closely as risk of pre-eclampsia.
• FBC, RP, LFT, Uric acid, UFEME every trimester.
• MOGTT at 16 weeks and/or 26-28 week.
• Detailed scan at 22 – 24 weeks.
• Serial fetal growth monitoring monthly – risk of FGR/ SGA.
4 Delivery • As per obstetric indications- hospital delivery.
5 Postpartum • Monitor for flares.
• If antiphospholipid syndrome present, continue medical
thromboprophylaxis for 6 weeks after delivery.
• Ensure effective contraception (Refer MEC chart)
27
6 Lactation • Generally safe
REMARKS:
1. Diagnosis of SLE: EULAR/ACR criteria
2. Drugs safe in pregnancy:
a. Azathioprine
b. Hydroxychloroquine
c. Prednisolone
d. Aspirin
e. Paracetamol
3. Drugs contraindicated in pregnancy
a. Methotrexate
b. Cyclophosphamide
c. NSAIDs
4. SLE Flare
a. Symptoms: Fatigue, fever, weight loss, joint pain, rash
b. Serositis
c. Renal involvement
d. Cardiac involvement
e. Pulmonary involvement
f. GI involvement
Reference(s):
1. EULAR textbook on Rheumatic Disease 2012.
2. Up to date: Pregnancy in women with systemic lupus erythematosus. Last updated
10/1/2018.
3. CPG Management of Hypertension Malaysia 2013.
4. CPG Prevention and Treatment of Venous Thromboembolism 2013.
5. Fanouriakis A, Kostopoulou M, Alunno A, et al. Ann Rheum Dis 2019;78:736–745.
6. Aringer M, Costenbader K, Daikh D, et al. Ann Rheum Dis 2019;78:1151–1159.
7. Gordon C, Amissah-Arthur M, et al. Rheumatology 2018;57: e1-e45doi:10.1093/
rheumatology/ kex286.
8. Knight C.L, Nelson-Piercy C. Management of systemic lupus erythematosus during
pregnancy: challenges and solutions. Open Access Rheum Mar 2017;37-52.
9. Nguyet -C V L; Ghetu MV, MD; and Bieniek ML. Systemic Lupus Erythematosus:
Primary Care Approach to Diagnosis and Management. American Family Physician
August 15, 2016. Volume 94, Number 4: 284-294.
28
2019 European League Against Rheumatism/ American College of Rheumatology
classification criteria for systemic lupus erythematosus
Entry criterion
Antinuclear antibodies (ANA) at a titer of ≥1:80 on Hep-2 cells or an equivalent positive test (ever)
If absent, do not classify as SLE

If present, apply additive criteria
Additive criteria
Do not count a criterion if there is a more likely explanation than SLE
Occurrence of a criterion on at least one occasion is sufficient.
SLE classification requires at least one clinical criterion and ≥10 points.
Criteria need not occur simultaneously.
Within each domain, only the highest weighted criterion is counted toward the total score.
Clinical domains and criteria Weight Immunology domains and criteria Weight
Constitutional Antiphospholipid antibodies
Fever 2 Anti-cardiolipin antibodies OR
Haematologic Anti-ß2GP1 antibodies OR
Leukopenia 3 Lupus anticoagulant 2
Thrombocytopenia 4 Complement proteins
Autoimmune haemolysis 4 Low C3 OR low C4 3
Neuropsychiatric Low C3 AND low C4 4
Delirium 2 SLE-specific antibodies
Psychosis 3 Anti-dsDNA antibody* OR
Seizure 5 Anti-Smith antibody 6
Mucocutaneous
Non-scarring alopecia 2
Oral ulcers 2
Subacute cutaneous OR discoid 4
lupus
Acute cutaneous lupus 6
Serosal
Pleural or pericardial effusion 5
Acute pericarditis 6
Musculoskeletal
Joint involvement 6
Renal
Proteinuria > 0.5g/24h 4
Renal biopsy Class II or V lupus 8
nephritis
Renal biopsy Class III or IV lupus 10
nephritis
Total score:
Classify as Systemic Lupus Erythematosus with a score of 10 or more if entry criterion

fulfilled
29
SECTION 3 DIABETES IN PREGNANCY
3.1 Gestational Diabetes Mellitus
1 Booking • Screen every pregnant woman for GDM according to risk
factors#.
• Screening and diagnosis diabetes in pregnancy – Refer
Algorithm A.
➢ Women with history of GDM or presence of 2 or more
risk factors to do MOGTT as soon as possible.
➢ Presence of 1 risk factor (except history of GDM), to do
MOGTT at 12-14 weeks, if normal repeat at 24- 28
weeks.
▪ MOGTT should not be performed in women with
hyperemesis gravidarum.
➢ Pregnant women ≥ 25 years old without other risk
factors should have screening for GDM at 24- 28 weeks.
• Subsequent management depends on MOGTT result¥
• Once GDM diagnosed, do the following:
➢ Counsel patient regarding maternal and fetal
complications.
➢ Advise dietary changes and exercise.
➢ Dietician appointment.
➢ Dating scan to date and confirm viability of pregnancy.
➢ Detailed scan is generally not necessary for GDM on
diet control.
➢ Overt diabetes€ in pregnancy should be managed as
pre-existing diabetes (refer for detailed scan if HbA1c ≥
8%).
➢ HbA1c (baseline).
➢ BSP.
2 Subsequent • Blood sugar profile (BSP)*
antenatal follow- ➢ Generally, every 4 weeks, more frequently if not well
up controlled.
30
➢ To start treatment (metformin and/or insulin) if BSP out
of range after dietary advice (treatment can be started
inpatient or outpatient depending on patient’s
preference).
➢ To consult FMS/ O&G for treatment initiation.
➢ Refer to district hospital or O&G team if admission is
required.
• Monthly growth scan from 28 weeks (to plot on growth
chart) – refer O&G if indicated (LGA, polyhydramnios, fetal
anomaly, etc.).
• For uncomplicated and well-controlled GDM, continue
management at health clinic.
3 Delivery • To be seen by FMS or O&G specialist at 34- 36weeks
gestation for plan of delivery:
➢ GDM on diet control – FMS (do not allow postdate).
➢ GDM on oral antidiabetic – refer O&G specialist at 36
weeks.
➢ GDM on insulin – review in O&G clinic at 34- 36 weeks.
• Patients who develop maternal or fetal complications -
Refer O&G.
• Hospital delivery.
4 Postpartum • Offer lifestyle advice (weight control, diet and exercise).
• Discuss options of contraception with patient / couple∞
• Respective health clinic will continue with follow up care.
• Do MOGTT 6 weeks postpartum to detect diabetes and pre-
diabetes. If normal, annual diabetic screening should be
performed.
• For newly diagnosed DM during postnatal test, to be
followed up in health clinic/ medical and advice for pre-
pregnancy clinic.
• For those with normal postnatal test, to do MOGTT as soon
as possible in next pregnancy.
5 Lactation • Breastfeeding is encouraged.
31
6 Pre-pregnancy • To enroll in pre- pregnancy clinic for patient who have risk
(e.g. obesity, any medical illness).
REMARKS:
1. # Risk Factors for GDM
a. Age > 25 years old
b. Glycosuria ≥ 2+ on two occasions
c. Booking BMI > 27kg/m2
d. First degree relative with diabetes
e. Previous macrosomic baby (≥ 4kg)
f. Previous unexplained intrauterine death, recurrent miscarriages, congenital
anomalies, previous history of shoulder dystocia
g. Previous history of Gestational Diabetes Mellitus
h. Current obstetric problems (suspicious macrosomia, polyhydramnios,
essential hypertension, pregnancy- induced hypertension, current use of
steroids)
2. Screening test
a. Initial screening of high-risk women (multiple risk factors/ previous GDM)
should be done at booking using any of the following:
b. 75 gm MOGTT at 0-minute (fasting) and 120 minutes (2hrs post) plasma
glucose measurement.
3. ¥ Definition of GDM using 75 gm MOGTT:
a. GDM is diagnosed in the presence of any one of these results:

o FPG: ≥ 5.1 mmol/L
o 2-hour postprandial (2-HPP): ≥ 7.8 mmol/L
b. It is important to complete the MOGTT test with fasting and 2HPP reading, so
that overt DM is not missed.
4. € Definition of Overt DM
a. Overt DM is suspected in the presence of at least one of the following:
o FPG ≥7.0 mmol/L
o RPG ≥11.1 mmol/L with symptoms
32
b. However, the diagnosis of overt DM needs to be confirmed with a second test
(FPG/ RPG/ MOGTT) if MOGTT is not done in the first test.
c. If MOGTT has performed as first test and result reveals overt DM, no need to
repeat MOGTT or proceed with second test.
d. Offer immediate treatment with insulin with or without Metformin:
o If FBS >7.0mmol/L at diagnosis OR
o If FBS 6.0-6.9 mmol/L with complications such as macrosomia or
polyhydramnios
5. *BSP targets (mmol/L):
a. The blood glucose targets should be as the following:
o Fasting or pre-prandial / pre bed: ≤ 5.3 mmol/L
o 1-hour postprandial: ≤ 7.8 mmol/L
o 2-hours postprandial: ≤ 6.7 mmol/L
b. The frequency of SMBG in diabetes in pregnancy should be individualised
based on glycaemic control.
c. Post-prandial glucose level monitoring should be encouraged, especially for
patients practising Home Blood Glucose Monitoring (HBGM).
6. Timing for BSP Monitoring
7. ∞Contraception based on “Medical Eligibility Criteria for Contraceptive Use –

refer to MEC chart
Reference(s):
1. CPG on Management of Diabetes in Pregnancy 1st Edition, Ministry of Health Malaysia,
2017.
2. National Institute for Health and Care Excellence (NICE) guideline, Diabetes in
Pregnancy: management from preconception to the postnatal period, 25 February 2015.
3. Malaysian Ministry of Health Clinical Practice Guidelines on Management of Type 2
Diabetes Mellitus (5th edition), December 2015.
33
(taken from CPG on Management of Diabetes in Pregnancy)
34
3.2 Pre-existing Diabetes in Pregnancy
1 Pre-pregnancy • Refer to FMS/ O&G for preconception care (Pre-pregnancy
clinic).
• Assessment:
➢ Disease severity – Aim HbA1c < 6.5%
➢ Diabetes complications.
➢ Other co-morbidities.
➢ Glycaemic control & optimization.
➢ Review medications
▪ Women with T2DM who are planning a pregnancy
should switch medication from oral antidiabetic drugs
(OAD) to insulin for good glycaemic control.
▪ Acceptable antidiabetic medication: Metformin,
Insulin (Human/ Analog).
▪ The following medications should be discontinued:
angiotensin-converting enzyme inhibitors,
angiotensin II receptor blockers and statins.
• Counselling to mother:
➢ Maternal and fetal complications.
➢ Symptoms and signs of hypoglycaemia.
➢ Importance of blood glucose optimization prior to
pregnancy
➢ Planned pregnancy for contraception advice according to
Medical Eligibility Criteria.
➢ Weight reduction if overweight or obese.
• Folic acid 5 mg per day should be given at least three months
prior to conception and continue until 12 weeks of gestation.
2 Booking • Consult FMS (Outpatient)/ O&G Specialist (inpatient) for
initiation/ adjustment of insulin.
• Dating scan.
• Get Combined Clinic appointment.
• Detailed scan at 22-24 weeks.
35
• Perform the following:
➢ RP
➢ HbA1c (baseline to determine risk of pregnancy, if not
done in the last 3 months).
➢ Retinal assessment.
➢ Dietary counseling by dietician.
➢ Women with T1DM/ T2DM are at high risk of developing
Pre-eclampsia/ eclampsia
▪ Baseline LFT and Serum Uric Acid
▪ To commence T. Calcium Carbonate 1g BD
▪ Start T. Aspirin 150mg ON or T. Cardiprin 100mg ON
from 12 weeks (before 20 weeks) until delivery, unless
contraindicated.
3 Subsequent • Shared care among FMS, MFM, physician/ endocrinologist.
antenatal follow- • 2 weekly BSP, more frequently if not controlled. ^
up ➢ Basal bolus insulin regime is preferred during pregnancy.
• Monthly growth scan (to plot on growth chart) and AFI from
28 weeks.
• Refer Diabetes Educator/ Medication Therapy Adherence
Clinic (MTAC) for poorly controlled DM if available.
• Retinal assessment
➢ Retinal assessment at booking and repeat at least once
throughout the pregnancy.
➢ If retinopathy is present, refer ophthalmology.
• Renal assessment
➢ RP
➢ Urine dipstick- if protein present to proceed with 24-hour
urine protein or urinary albumin-to-creatinine ratio.
➢ If creatinine > 125 mmol/l or 24-hour urine protein >0.5
g/day, to refer Medical/ Nephrologist.
➢ Consider thromboprophylaxis if 24-hour urine protein > 5
g/ day.
4 Delivery • Outlined by O&G
36
• In pregnant women with pre-existing diabetes:
➢ With no complications, delivery at 38 weeks.
➢ Who develop maternal or fetal complications - refer O&G,
may require early delivery with coverage by antenatal
corticosteroids.
• Hospital delivery
5 Postpartum • Pre-existing T1DM
➢ Lower insulin dosage
• Pre-existing T2DM (for breastfeeding)
➢ Continue insulin at lower dosage or resume pre-
pregnancy metformin.
➢ Avoid other types of oral antidiabetic drugs.
• Discuss options of contraception with couple.
6 Lactation • Encourage breastfeeding.
7 Upon discharge • Notification of high-risk case discharge to Health clinic as per
from hospital guideline.
• Health clinic/ Medical to continue with follow up care:
➢ For pre-existing T1DM and T2DM, to refer back to their
routine diabetes care arrangements (Health clinic/
Medical clinic)
➢ Newly diagnosed T2DM should be referred and be
followed up in health clinic/ medical clinic
• Pre-pregnancy clinic for pre-existing DM at 4- 8 weeks
postpartum.
REMARKS:
1. ^ Antenatal target blood glucose control:
a. Blood Sugar Profile

o Pre-breakfast / fasting (following an 8-hour of overnight fast): ≤ 5.3 mmol/L
o Pre-prandial/pre-bed: ≤ 5.3 mmol/L
o 1-hour post-prandial: ≤ 7.8 mmol/L
o 2-hours post-prandial: ≤ 6.7mmol/L
37
b. HbA1c: may not accurate if patient has underlying anaemia.
c. Post-prandial glucose level monitoring is encouraged, especially for patients
practising Home Blood Glucose Monitoring (HBGM).
2. Drug Treatment During Pregnancy:
a. The best insulin regime is multiple daily injections (basal-bolus regime) for better
glycaemic control during pregnancy.
b. Women with diabetes may be advised to use metformin as an adjunct or
alternative to insulin during pregnancy.
c. Women with diabetes who are on treatment with metformin and/ or insulin prior
to conception are advised to continue the treatment during pregnancy.
d. All other oral blood-lowering agents should be discontinued when pregnancy is
confirmed.
e. Use isophane insulin (also known as NPH insulin) as the first choice for long-
acting insulin during pregnancy.
f. Long-acting insulin analogues may be used in cases of repeated nocturnal
hypoglycaemia.
3. Effect of DM to mother and fetus:
Pregnancy related Diabetes related Fetal risk
• Miscarriage • Increase need for • Neural tube defects:

• Preterm birth antidiabetic anencephaly, Arnold-Chiari
• Induction of labour medication malformation, spina bifida,
• Operative delivery • Worsening of end ventriculomegaly
organ damage if • Cardiovascular malformation:
presence prior to AV septal defects, transposition
pregnancy of great vessels
• Caudal regression syndrome
• Macrosomia with resultant
hypoglycaemia,
hypomagnesaemia,
hyperbilirubinaemia
• Risk of IUD is up to 50% in
untreated DM, even with
38
control, the risk still remains
higher at 3 – 5 fold.
4. ∞ Contraception based on “Medical Eligibility Criteria for Contraceptive Use”
Reference(s):
1. CPG on Management of Diabetes in Pregnancy, Ministry of Health Malaysia 2017.
2. Malaysian Ministry of Health Clinical Practice Guidelines on Management of Type 2
Diabetes Mellitus (5th edition), December 2015.
3. National Institute for Health and Care Excellence (NICE) guideline, Diabetes in
Pregnancy: management from preconception to the postnatal period, 25 February
2015.
39
SECTION 4 HAEMATOLOGICAL DISORDERS IN PREGNANCY
4.1 Anaemia in Pregnancy
1 Booking • Asymptomatic anaemia
➢ Hb 8 - ≤ 11 g/dl, irrespective of gestational age
▪ Follow-up at health clinic
➢ Hb < 8 g/dl, POA < 36 weeks
▪ Continue follow-up at health clinic
➢ Hb < 8 g/dl, POA > 36 weeks
▪ Refer O&G team for management plan
• Symptomatic anaemia, irrespective of gestational age &
Hb level
➢ Refer to O&G for hospital admission
➢ Do relevant investigations:
▪ FBC
▪ Serum Ferritin
▪ Hb analysis (discuss with FMS)
▪ Hb DNA analysis (discuss with FMS)
▪ PBF
▪ BFMP
▪ Urine FEME
▪ Stool for ova & cyst
➢ Start therapeutic dose of oral haematinics
▪ Repeat Hb after 2 weeks
➢ Consider parenteral iron in confirmed iron deficiency
anaemia if:
▪ Unable to tolerate oral iron therapy
▪ Poor response to oral iron therapy
▪ Rapid iron replenishment is required
➢ After completed parenteral iron, repeat Hb at 1-2
weeks and resume oral iron therapy after 1 week.
➢ To discuss with FMS for intravenous iron supplement
if presence of logistic issue
40
2 Subsequent • Monitor Hb level at health clinic
antenatal follow up • Monthly fetal growth monitoring at health clinic
3 Delivery plan • Keep Hb > 11.0 g/dl
• May allow postdate, unless specified otherwise
4 Delivery • Hospital delivery
• PPH prophylaxis
5 Postpartum • Discuss options of contraception with patient / couple
• Continue haematinics for 3 months postpartum
REMARKS:
1. Definition of anaemia:
a. Hb < 11.0 g/dl in the first and third trimester
b. Hb < 10.5 g/dl in the second trimester
Classification Hb level (g/dl)
Mild 9.0 – 11.0
Moderate 7.1 – 8.9
Severe ≤ 7.0
2. In confirmed thalassaemia carrier:

a. To screen husband as well
b. Refer “Thalassaemia Carrier in Pregnancy” chapter for management
3. Recommended prophylaxis oral iron dose:
a. T. Ferrous Fumarate 200mg OD
b. Elemental iron requirement: 30-60 mg daily
Recommended therapeutic oral iron dose:
a. T. Ferrous Fumarate 400 mg OD
b. Elemental iron requirement: 100 – 200mg daily
4. Various iron combinations are widely available with various dosages:
Iron preparation Dose per tablet Elemental iron
Ferrous fumarate (Obimin) 90mg 30 mg
Ferrous fumarate (Zincofer) 350mg 115 mg
Ferrous sulphate (Iberet) 525 mg 105 mg
Ferrous gluconate (Sangobion) 250mg 30mg
41
Iron polymaltose (Maltofer) 370mg 100mg
5. Recommendation of diet while taking iron supplement

Improve iron absorption Reduce iron absorption
• Taken with an empty stomach, • Take other medications at the same
1 hour before meals with a time
source of vitamin C (ascorbic • Antacids
acid) such as orange juice to • Calcium supplement
maximise absorption • Dairy products
6. Repeat Hb testing is required 2 weeks after commencing treatment to assess

compliance, correct administration and response to treatment. Expected Hb rise is
approximately 2 g/dl over 3-4 weeks.
7. Preparation of parenteral iron

Iron preparation Dose per vial Route
LWM iron dextran (Cosmofer®) 100mg/ 2ml IV/ IM/ TDI
Iron sucrose (Venofer) 100mg/ 5ml IV/ TDI
*IV – intravascular, IM – intramuscular, TDI – total dose infusion
a. Iron dextran has higher risk of hypersensitivity.
b. High molecular weight iron dextra (e.g. imferon) no longer available due to its
related adverse effects.
c. Iron sucrose has fewer side effects.
d. All parenteral iron should be given in hospital or outpatient setting with
emergency and resuscitation facilities by trained staff.
e. Expected Hb increment after parenteral iron: 1-2 g/dl in 2 weeks
f. Repeat Hb after reassessment in 2 weeks.
8. Contraindications for parenteral iron:

a. Non-iron deficiency anaemia
b. Thalassemia (relative contraindication)
c. 1st trimester
d. Known allergy to iron
42
Reference(s):
1. National Thalassaemia Screening Programme, Malaysian Ministry of Health, 2007.
2. Perinatal Care Manual (Third Edition) 2013.
3. WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of
severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health
Organization, 2011 (WHO/NMH/NHD/MNM/11.1).
4. UK guidelines on the management of iron deficiency in pregnancy. British Journal of
Haematology, 2012, 156, 588–600. doi:10.1111/j.1365- 2141.2011.09012.
5. Blood Transfusion in Obstetrics: Green-top Guideline No. 47, May 2015.
43
Usage of Parenteral Iron for IDA in Pregnancy
Calculation of total iron dose (IM or IV)
Total dose Body weight during booking visit (kg) x (Target- Actual Hb) (g/dl) x
(mg): 10 x 0.24) + 500mg (iron for iron stores for weight >35kg)
*Target Hb level for treatment: 11.0 g/dl
Number of 100mg Ampoules to be administered (mg)

Weight Actual Haemoglobin (g/dL)
(kg) 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5
35 10 9 9 8 8 8 7 7
40 10 10 9 9 8 8 7 7
45 11 10 10 9 9 8 8 7
50 12 11 10 10 9 9 8 7
55 12 12 11 10 10 9 8 8
60 13 12 11 11 10 9 9 8
65 14 13 12 11 10 10 9 8
70 14 13 13 12 11 10 9 8
75 15 14 13 12 11 10 10 9
80 16 15 14 13 12 11 10 9
85 16 15 14 13 12 11 10 9
90 17 16 15 14 13 11 10 9
95 18 16 15 14 13 12 10 9
100 18 17 16 15 13 12 11 10
IM Iron Dextran 100mg/ 2ml IV Iron Sucrose 100mg/ 5ml

Maximum dose/ day: 1 ampoule (100mg) Maximum dose/ day: 2 ampoules (200mg)
Regime: 2 ampoules (200mg) 3 times/ week
Intramuscular (Z-track technique):
1 ampoule (100mg) daily on alternate Intravenous infusion:
buttocks • 2 ampoules in 200ml Normal Saline,
Test dose: 25mg (0.5ml) – Monitor patient for infuse in at least 30 minutes, OR
1 hour for adverse reaction • 2 ampoules in 100ml NS, infuse at 12
drops/ min for first 15-30 mins, then 36
drops/ min until completed
44
FLOWCHART: MANAGEMENT OF ANAEMIA IN PREGNANCY
ASYMPTOMATIC SYMPTOMATIC (irrespective of

FBC at booking visit gestational age and Hb level)
Hb ≥ 11.0 g/dL Hb 9.0 – 10.9 g/dL Hb < 9.0 g/dL Refer O&G for
(mild anaemia) (Moderate / severe admission
anaemia)
If MCH ≤ 27 or family Start trial of IDA

history of thalassemia: treatment 1. Investigate: Serum ferritin, PBF,
Send Hb electrophoresis Stool ova & cyst, BFMP
2. Start trial of IDA treatment
3. While waiting for the results,
Prophylaxis of IDA: Treatment of IDA: stepwise increment of oral iron
Ferrous fumarate 200mg Ferrous fumarate 400mg OD therapy every 2 weeks based on
OD Ascorbic Acid 100mg OD compliance & FBC
Ascorbic Acid 100mg OD Vit B-Complex 1 tab OD
Vit B-Complex 1 tab OD Folic Acid 5mg OD
Folic Acid 5mg OD
If not tolerating, consider 2nd line Stool ova & cyst positive
If not tolerating, consider 2nd oral iron therapy* →Albendazole 400mg single
line oral iron therapy* dose (use in 2nd & 3rd trimester)
Serum ferritin
Repeat Hb every month Repeat FBC & review by
doctor in 2weeks
<30 Diagnosis ≥30 & MCH
of IDA ≤27 Send Hb
Hb ≥ 11.0 Hb < 11.0
Rise in Hb No rise in Hb electrophoresis
g/dL g/dL
1. Investigate: Serum BFMP positive: Admit

Continue Follow as per ferritin, PBF, Stool for treatment
iron mild/ moderate/ ova & cyst, BFMP
prophylaxis severe anaemia
2. Stepwise
flowchart
increment of oral
iron therapy every
2 weeks based on
compliance & FBC
Consider parenteral iron if:

• Unable to tolerate oral 1. Continue IDA treatment
iron therapy 2. If Hb drops, assess compliance, *According to availability
• Poor response to oral investigate, & if necessary stepwise in respective districts
iron therapy increment of oral iron therapy
• Rapid iron replenishment 3. Repeat FBC every 2 weeks
45
4.2 Asymptomatic Thrombocytopenia in Pregnancy
1 At booking/ • Screen for thrombocytopenia at booking by performing
diagnosis FBC.
• Repeat FBC required.
• Referral to medical / O&G if repeat FBC remain
thrombocytopenic.
• Look for bleeding tendencies, if present clinically
immediate referral is required.
• Tests to be done:
➢ PBF
➢ LFT
➢ RP
➢ Viral screening (HIV, HCV, HBV)
➢ ANA
• Refer patient with asymptomatic thrombocytopenia in
pregnancy with platelet <100 x109/L to O&G clinic.
• Patient with mild asymptomatic thrombocytopenia (100-
150 x109/L) can be monitored at health clinic.
• Known thrombocytopenia in pregnancy need to be under
specialist care.
2 Subsequent • Follow plan laid out by O&G / Haematology clinic.

antenatal follow-
up
3 Delivery plan • Hospital delivery.

• PPH prophylaxis.
4 Postpartum • Discuss options of contraception with patient / couple.

(Medical Eligibility Criteria for Contraceptive)
5 Upon discharge • Routine discharge procedure.

from hospital • Repeat FBC at 6 weeks postpartum for gestational
46
thrombocytopenia.
• For other causes of thrombocytopenia, follow medical
plan.
REMARKS:
1. Definition of thrombocytopenia in pregnancy: platelet <150 x109/L

a. Mild: 100-150 x109/L
b. Moderate: 50-100 x109/L
c. Severe: <50 x109/L
2. Thrombocytopenia occurs in 7-8% of all pregnancy:

a. 70-80% are gestational thrombocytopenia
b. 15-20% are severe pre-eclampsia
c. <1% are HELLP syndrome and APS
3. Differential diagnosis:
a. Hereditary
b. Autoimmune (SLE, APS)
c. ITP/ TTP
d. Pre-eclampsia
e. HELLP
f. DIVC
g. Drug-induced
h. Viral Infection (HIV, Dengue, HCV)
i. Hypersplenism due to chronic liver disease
j. Haematological malignancy
k. Gestational thrombocytopenia
l. Spurious-platelet clumping
4. Gestational thrombocytopenia should have platelet normalised by 6 weeks

postpartum.
Reference(s):
1. Myers B. Thrombocytopenia in pregnancy, Royal College of Obstetrics and Gynaecology
guidelines, 2009.
2. Malaysian CPG on Immune Thrombocytopenic Purpura, 2006:16-20.
47
4.3 Rhesus Isoimmunisation In Pregnancy
1 Booking • Check blood group & Rh type in all antenatal cases at first
visit.
• Check husband's blood group & Rh type if woman is rhesus
negative.
• Indirect Coomb’s test required to detect sensitization.
➢ at first antenatal visit for known case
➢ diagnosis of new cases
2 Subsequent • If Coomb's test positive, refer to MFM or O&G.
antenatal follow- • If initial Coomb’s test negative, repeat test is required at 24-
up 26 weeks.
• Refer O&G for Anti-D immunoglobulin (with negative
indirect Coomb’s test):
➢ For routine antenatal prophylaxis at 28 weeks.
➢ For potential antenatal sensitizing event.
3 Delivery plan • As outlined by O&G.
4 Delivery • Hospital delivery.
• PPH prophylaxis.
5 Postpartum • Administer IM anti-D immunoglobulin 500 lU within 72
hours if negative indirect Coomb's test.
• Discuss options of contraception with patient couple.
REMARKS:
1. Anti-D antibodies may cause severe haemolytic disease of fetus and newborn as a
result of feto-maternal haemorrhage in Rh negative women with Rh positive fetus.
2. Indirect Coomb's test detects anti-D antibodies.
3. Paternal antigen status.

a. if father is Rh negative, the pregnancy is not at risk for severe fetal haemolytic
disease
b. if father is Rh positive, pregnancy is at risk
4. Potentially sensitizing events
48
Before 12 weeks of gestation:
a. Miscarriages requiring surgical intervention
b. Threatened miscarriage
c. Termination of pregnancy (TOP)
d. Chorionic villus sampling
e. Molar pregnancy
f. Ectopic pregnancy
Between 12 to 20 weeks of gestation:

a. Miscarriages requiring surgical intervention
b. Threatened miscarriage
c. Termination of pregnancy (TOP)
d. Chorionic villus sampling
e. Molar pregnancy
f. Intrauterine death, in-utero therapeutic intervention/ surgery (e.g. intrauterine
transfusion, shunting)
g. Antepartum haemorrhage (APH)
h. Fall/ abdominal trauma
Reference(s):
1. Qureshi, H., et al. "BCSH guideline for the use of anti-D immunoglobulin for the
prevention of haemolytic disease of the fetus and newborn." Transfusion Medicine 24.1
(2014). 8-20
2. The Management of Women with Red Cell Antibodies during Pregnancy, Green-top
Guideline No.65, May 2014
3. The Use of Anti-D Immunoglobulin for Rhesus D Prophylaxis, Green-top Guideline No.
22, March 2011
49
4.4 Thalassaemia Carrier in Pregnancy
1 Pre-pregnancy • If couple is thalassaemia carrier, refer to FMS/ O&G (Pre-
pregnancy clinic) for counselling, including information
regarding prenatal diagnosis.
• Advice for contraception.

• Advice for early booking before 12 weeks gestation.
2 Booking • All antenatal women should be offered screening if they fall
into these categories:
➢ Past history of unexplained anaemia.
➢ Family history of anaemia (unknown cause) or

haemoglobinopathy.
➢ Belonging to an ‘at risk’ ethnic background for

haemoglobinopathies.
• Request for diagnosis confirmation (Hb analysis) if:
➢ Women who have no risk factors for

haemoglobinopathies but blood results show MCV ≤ 80fL
and MCH ≤ 27pg and a normal ferritin level (e.g. >
30ug/L).
• Pregnancy confirmed
➢ For known case of thalassaemia carrier, verify diagnosis
with previous document or formal report to avoid
thalassaemia intermedia being treated as thalassaemia
carrier.
➢ Arrange for dating scan.
➢ Screen partner for thalassaemia status (if not done yet).
➢ Refer to O&G / MFM Clinic immediately for couple

requesting prenatal diagnosis or agreeable for prenatal
diagnosis**
50
▪ To be seen at 11 weeks gestation
▪ CVS preferably before 13 weeks 6 days gestation

and amniocentesis at 15 weeks gestation
▪ If opting for termination of pregnancy, invasive test

needs to be done before 20 weeks gestation.
• Detailed scan appointment at 24 weeks POG if couple are α-
thalassaemia carrier.
3 Subsequent • Monitor Hb level.
antenatal follow-
• Check serum ferritin before giving iron supplement
up
➢ Serum ferritin <30 ug/dL signify iron depletion
➢ Management of iron deficiency anaemia as in “Anaemia

in Pregnancy” topic
• Folic acid 5mg should be given throughout pregnancy.
• Referral to medical/ O&G when Hb <7g/dL or

symptomatic of anaemia***
• Enquire regarding history of transfusion reaction if ever

receive blood transfusion or multiple blood transfusion.
4 Delivery • Generally, may allow post-date, unless specified otherwise.
• PPH prophylaxis
5 Postpartum • Babies (at risk of being thalassaemia major or carrier) to be

seen at 6 months in health clinic and decide on cascade
screening.
• Discuss contraception with woman/ couple.
• Breastfeeding is safe and should be encouraged.
6 Upon discharge • Routine discharge procedure.
from hospital • Pre-Pregnancy Clinic appointment at 3/12 postnatal (if future
51
pregnancy possible) if parents are thalassaemia carriers.
• Register in Pre-Pregnancy Care at health clinic.
REMARKS:
1. Prenatal diagnosis for thalassaemia status is performed by DNA molecular
analysis by CVS or amniocentesis.
2. Low ferritin & high TIBC suggests coexisting IDA
3. ** Special charges apply for prenatal diagnosis tests as the test is done in private
lab.
4. Requirement before MFM clinic appointment for prenatal diagnosis tests in

specialist hospital:
a. Formal report of Hb analysis or Hb DNA analysis of the couple
b. Advise to bring spouse during counselling for prenatal diagnosis
c. Dated pregnancy and early referral to arrange appropriate timing for prenatal
diagnosis
5. *** Routine blood transfusion for Hb < 7g/dL in thalassemia carrier is

discouraged as risk of alloimmunization. Discussion with haematologist is
required before transfusion.
Reference(s):
1. Management of Beta-thalassaemia in pregnancy, Green Top Guidelines No. 66,
March 2014.
2. Ryan K, Bain BJ, Worthington D, James J, Plews D, Mason A, et al.; British Committee
for Standards in Haemotology. Significant haemoglobinopathies: guidelines for
screening and diagnosis. Br J Haematol 2010; 149:35–49.
3. Nice Institute for Health and Clinical Excellence. Screening for haematological
problems. Antenatal Care: routine care of the healthy pregnant woman. London Royal
College of Obstetrician and Gynaecologists; March 2008.
4. Clinical Practice Guidelines, Pregnancy Care, 2018 edition, Australian Government,
Department of Health, Page 181-184.
5. Management of Transfusion Dependent Thalassaemia, Ministry of Health Malaysia,
2009.
52
SECTION 5 HYPERTENSIVE DISORDERS IN PREGNANCY
5.1 CHRONIC HYPERTENSION IN PREGNANCY
1 Pre-pregnancy • Can be done in health clinic, however if required further
evaluation refer to O&G clinic.
• Safe medication in pregnancy include methyldopa, labetalol
or nifedipine.
2 Booking/ • Change ACEI, ARB, Thiazides to antihypertensive
Diagnosis medication which are safe in pregnancy.
• Dating Scan – to date and confirm viability / number of fetus.
• Start Aspirin and Calcium (refer to Section 5.3)
• Use only the following anti-HPT in pregnancy:
➢ Less than 20 weeks: T. Methyldopa preferred
➢ 20 weeks and above: Either T. Methyldopa or Labetalol.
Nifedipine can be used if still not controlled.
• Target BP control while started on antihypertensive agent:
➢ SBP 120 – 135 mmHg, DBP 80 – 85 mmHg
• Do the following:
➢ BP, weight, urine protein
➢ Baseline PE profile (FBC, RP, SUA, LFT)
➢ Educate and advise mother to return immediately if
symptoms of pre-eclampsia
➢ Refer to Combined Clinic for shared care if difficult to
control HPT or secondary cause for HPT identified
▪ Refer O&G if exposure to ACEI, ARB or thiazides in
first trimester for detailed scan at 22 - 24 weeks of
gestation.
3 Subsequent • Ask for symptoms of pre-eclampsia at every visit.
antenatal follow- • Maternal surveillance with BP, weight, urine protein
up (frequency depends on severity).
• Refer O&G team if:
➢ Severe hypertension, SBP≥ 160 mmHg and/ or DBP ≥
110 mmHg – for hospital admission.
53
➢ Moderate HPT on 1st diagnosis, BP: 150-159 mmHg /
100-109 mmHg.
• Reason for admission is to assess maternal & fetal
complications:
➢ District health clinic case to be admitted at nearest
district hospital
➢ Health clinics in Kota Kinabalu to refer O&G and if
need admission, to be admitted at HWKKS, Tuaran or
Papar Hospital.
• Pre-eclampsia profile:
➢ Monitor FBC, RFT, SUA, LFT at every
trimester.
➢ 24-hour urinary protein, urine albumin: creatinine ratio
or urine protein: creatinine ratio if proteinuria.
➢ Refer O&G if abnormal value.
• Fetal surveillance with SFH, FKC, fetal growth and
amniotic fluid monitoring by serial ultrasound, starting at 24
weeks, at 4-weekly interval.
• Educate and advise mother to return immediately if
symptoms of pre-eclampsia.
• Refer at 34-36 weeks gestation for plan of delivery.
• If pre-eclampsia or fetal compromise is detected at any
time:
➢ Refer to hospital
4 Delivery • Outlined by O&G Specialist at 36 weeks.
5 Postpartum • Continue antenatal anti-HPT after delivery if necessary.

• Aim for BP <140/90 mmHg.
• Continue to monitor BP after delivery (frequency
individualised).
• Discuss options of contraception with patient/ couple.
• Importance of contraception and planned pregnancy
reinforced.
54
• Breastfeeding is encouraged (refer to Remarks for suitable
anti-HPT).
6 Upon discharge • Notification of high - risk cases discharge as per guideline.
from hospital • Respective health clinic will continue with follow-up care
(unless specified otherwise on high risk discharge summary).
• Pre-pregnancy clinic appointment at 3/12 postnatal (if future
pregnancy possible).
REMARKS:
1. Essential hypertension itself is a predisposition for superimposed pre-eclampsia,
the risk being 15 – 20%. This risk maybe higher in secondary hypertension
especially renal hypertension.
2. Blood pressure in pregnancy will follow the normal pregnancy pattern unless pre-
eclampsia intervenes mid-trimester. Blood pressure dips in pregnancy reaching a
nadir at 20 – 24 weeks and then gradually rising to equal pre-pregnancy level 36
weeks onwards, to peak day 3 – 4 day postpartum.
3. Pre-pregnancy
a. Be aware of anti-HPTs contraindicated in pregnancy e.g. ACEI, ARB,
thiazides, certain β- blockers or direct renin inhibitors
b. Ascertain the cause if not sought:
▪ Serum creatinine
▪ Nephritis screen (proteinuria/ haematuria): VDRL, HIV, Hep B & C, C3&4
and renal ultrasound
▪ Low potassium
▪ Adrenal imaging if suggestive
▪ ECG indicated if long standing chronic hypertension or uncontrolled
hypertension
▪ ECHO if CVS findings suggestive or abnormal ECG
c. Important secondary causes of chronic HPT in pregnancy:
▪ CKD e.g. Glomerulonephritis, reflux nephropathy
▪ Adult PCOS
55
▪ Renal artery stenosis
▪ Systemic disease with renal involvement e.g. DM, SLE
▪ Endocrine disorder e.g. Pheochromocytoma, Cushing’s Syndrome
▪ Coarctation of aorta
It is not possible to investigate these disorders fully during pregnancy, may
need to be deferred after delivery.
4. At booking or during antenatal follow up

a. Minimise number of drugs
b. Drug doses may need to be tapered mid-trimester, even ceased.
c. Symptoms of pre-eclampsia:
▪ severe headache
▪ visual disturbance (blurring, flashing)
▪ vomiting
▪ severe epigastric pain
▪ sudden swelling of face, hands or feet
d. Fetal anomaly screening depending on availability of service: Women with
chronic hypertension is at 20-30% increased risk for fetal congenital cardiac
anomaly.
5. Refer Appendix “Medical Eligibility Criteria for Contraceptive Use

6. Drugs:
a. Methyldopa is the safest and most tested drug in pregnancy.
b. Prolonged beta blocker is associated with SGA.
c. Diuretics are not recommended in pregnancy and breastfeeding as they
reduce uteroplacental flow causing FGR and also increase maternal blood
viscosity, further predisposing to VTEs.
d. ACE inhibitors are contraindicated in pregnancy.
e. Angiotensin receptor blockers (ARBs are contraindicated in breastfeeding and
during breastfeeding.
f. Anti-HPT acceptable in breastfeeding: Nifedipine, Labetalol, Captopril,
Enalapril, Atenolol or Metoprolol (avoid diuretic or angiotensin receptor
blockers).
56
7. Investigations for causes secondary hypertension that have little value in
pregnancy include:
a. Urinary/ serum cortisol estimates
b. Urinary VMA
Reference(s):
1. Training Manual for Hypertensive Disorders in Pregnancy, 3rd edition 2018.

2. NICE guideline (NG133) “Hypertension in Pregnancy: Diagnosis & Management”,
published 25 June 2019.
3. WHO Recommendations for Prevention and Treatment of Pre-eclampsia and
Eclampsia, 2011.
4. Malaysian Clinical Practice Guideline on Management of Hypertension, 5th edition
2018.
5. 2017 ACC/ AHA/ AAPA/ ABC/ ACPM/ AGS/ APhA/ ASH/ ASPC/ NMA/ PCNA -
Guideline for the Prevention, Detection, Evaluation, and Management of High Blood
Pressure in Adults: A Report of the American College of Cardiology / American Heart
Association Task Force on Clinical Practice Guidelines.
6. International Society for the Study of Hypertension in Pregnancy (ISSHP), 2018.
7. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol.
2019;133(1): e26.
57
5.2 Gestational Hypertension & Pre-eclampsia
1 Pre-pregnancy • Refer to O&G clinic if previous history of pre-eclampsia
requiring delivery less than 34 weeks
➢ Consider screening for APS or secondary causes of
hypertension if clinically suggestive.
• Advise on effective contraception until the results available
➢ The COC may not be appropriate for women with
hypertension especially with possibility of background
APS unascertained.
2 Booking • Identify patient at risk of pre-eclampsia
• Offer women with high risk of pre-eclampsia for pre-
eclampsia screening (Refer to Section 5.3)
• Aspirin and Calcium supplementation if 1 major criterion
and 2 minor criteria from the pre-eclampsia screening
➢ T. Aspirin 150mg or T. Cardiprin 100mg ON
➢ T. Calcium Carbonate 1g BD
3 At diagnosis for • Ensure correct BP measurement in pregnancy.
Gestational • Baseline FBC, RFT, SUA, LFT, UFEME
Hypertension • Mild gestational hypertension - manage at health clinic
• Moderate and severe gestational hypertension - refer for
admission
4 At diagnosis of • Hypertension with new onset of proteinuria or significant
pre-eclampsia growth discrepancy from serial growth scan.
• Refer O&G for specialist clinic assessment or hospital
admission.
5 At diagnosis of • Stabilization
Severe Pre- ➢ Hospital admission after informing O&G Specialist on-
eclampsia/ call
Eclampsia ➢ Give loading dose IM MgSO4 before transfer (after
58
discussing with O&G specialist on-call/ FMS, to
document time and mode of administration in referral
letter).
➢ Ensure CBD in situ after given loading dose MgSO 4
before transfer.
➢ Give IM Dexamethasone if instructed by O&G specialist
on-call / FMS (to defer if BP still hypertensive crisis
despite acute management)
• Request for Obstetrics Emergency Retrieval Team (OERT)
if not able to transfer patient promptly or resuscitate
adequately.
6 Treatment • When to start anti-HPT?
➢ To differentiate whether the women in crisis or not
▪ HPT crisis (SBP ≥ 160 and/or DBP ≥ 110):
o Repeat BP in 15 minutes after resting, if
persistent HPT crisis, consider treating.
o Treatment choice: Nifedipine 10-20mg or
Labetalol 200mg stat. Reassess after 30min, if
BP still uncontrolled, to inform O&G again.
▪ Not in crisis:
o Start treatment when SBP ≥ 140mmHg and / or
DBP ≥ 90mmHg
• Choice of anti-HPT:
➢ Less than 20 weeks: T. Methyldopa preferred.
➢ 20 weeks and above: Either T. Methyldopa, Labetalol,
Nifedipine can be used^.
• Treatment target:
➢ SBP 110 - 140mmHg, DBP 80 - 85mmHg
• Discuss with FMS/O&G if SBP < 110 or DBP < 80
regarding the need to reduce medication.
• Criteria of admission:
➢ Severe hypertension, SBP≥ 160mmHg and/or DBP ≥
110mmHg.
59
➢ Moderate HPT on 1st diagnosis, BP: 150-159mmHg /
100-109mmHg.
➢ Mild HPT in those with treatment and persistent BP
>140/90mmHg with proteinuria.
Reason for admission is to assess maternal & fetal
complications.
District health clinic case to be admitted at nearest district
hospital after discussed with FMS/ O&G specialist.
• Health clinics in Kota Kinabalu – If need admission after
referred to O&G specialist, to be admitted at SWACH,
Tuaran or Papar Hospital.
7 Subsequent • Ask for symptoms of pre-eclampsia at every visit.
antenatal follow- • Maternal surveillance with BP, weight, urine protein
up (frequency depends on severity)
• Pre-eclampsia profile
➢ Monitor FBC, RFT, SUA, LFT every trimester (To do
clotting studies if PLT <100x103/mL)
➢ 24-hour urinary protein if proteinuria
➢ Spot urine protein such as urine protein: creatinine
ratio (UPCR) or urine albumin: creatinine ratio
(UACR) or if suspected PE. However, UPCR is
preferred than UACR.
➢ Refer O&G if abnormal value*
• BP monitoring:
➢ Mild: weekly
➢ Moderate: at least 2x/ week
➢ Severe or symptomatic: hospital admission
• Fetal surveillance with SFH, FKC, fetal growth and amniotic
fluid monitoring by serial ultrasound, starting at 28 weeks,
at 4-weekly interval.
• Frequency of visits depends on severity.
60
• Refer at 34-36 weeks gestation for plan of delivery.
• If pre-eclampsia/ Eclampsia / fetal compromise is detected
at any time, refer to hospital for further management.
8 Delivery plan • Outlined by O&G Specialist at about 36 weeks.
9 Postpartum • Continue to monitor BP after delivery until 3 months
postpartum (frequency of monitoring is individualized).
• For those on treatment, dose of anti-HPT should be
continued and tailed down gradually.
• Consider reducing anti-HPT if BP < 120/80 mmHg, it
should not be stopped abruptly.
• If patient was on methyldopa, stop after delivery and
change to an alternative treatment if necessary (e.g.:
nifedipine, amlodipine, labetalol or atenolol).
• For those without treatment, consider anti-HPT after
delivery if BP ≥ 140/90mmHg.
• Consider chronic HPT if BP ≥ 140/90 mmHg after 3 months
postpartum.
• Discuss options of contraception with patient/couple.
• Breastfeeding is encouraged (refer to Remarks).
from hospital • Respective health clinic will continue with follow-up care
(unless specified otherwise on high risk discharge
summary).
• Home visit: EOD monitoring of BP, urine protein, signs &
• At 2 weeks: review at health clinic or earlier if any problem
by medical officer.
• Pre-pregnancy clinic appointment at 3/12 postnatal if:
➢ Eclampsia
➢ Early onset severe pre-eclampsia (< 34 weeks)
61
REMARKS:
At diagnosis
1. BP measurement in pregnancy
a. Ambulatory – sitting
Blood pressure measured with the woman rested and seated at 45degree angle
with the arm at the level of the heart. (If the mid-arm circumference is > 33 cm,
use a large cuff).
b. Hospitalization - woman rest on a coach or bed on her right side with 15-30°
tilt and the right arm well supported at same level as the heart.
2. Measurement of blood pressure:
a. Aneroid sphygmomanometer
b. Automated: shown to be reliable in pregnancy.
c. Mercury sphygmomanometer
d. Correct cuff
*BP fall in normal pregnancy & will rise again in 3rd trimester.
3. Definition
a. Hypertension is defined as BP ≥ 140 and/or 90 mmHg after a period of rest
on 2 occasions, 4-6 hours apart
b. ↑ SBP ≥ 30 mmHg and/or ↑DBP ≥ 15 mmHg above pre-pregnancy or first
trimester BP is no longer recognized as HPT in pregnancy but close observation
is warranted.
4. HPT in pregnancy can be due to:
a. Chronic HPT: HPT before pregnancy or diagnosed < 20 weeks gestation
b. Gestational hypertension: HPT during pregnancy in a previously normotensive
woman, usually occurs > 20 weeks gestation
5. Gestational hypertension:
a. BP ≥140/90 mmHg
b. No proteinuria
6. Grading for gestational hypertension:
a. Mild: 140-149/90-99
b. Mod: 150-159/100-109
c. Severe: SBP≥ 160 and/or DBP ≥ 110
7. Pre-eclampsia:
a. New onset of HPT ≥ 20 weeks gestation:
62
o SBP ≥ 140 mmHg
o DBP ≥ 90 mmHg
AND coexistence of 1 or more of the following new-onset conditions:
b. Proteinuria (24-hour urine protein ≥ 300mg/day or urine protein creatinine ratio
30mg/mmol or urine albumin creatinine ratio ≥ 8mg/mmol)
c. Urine dipstick testing:
o 1+ = 0.3g/L
o 2+ = 1g/L
o 3+ = 3g/L
o 4+ > 20g/L
*if urine protein >1+ form dipstick, should proceed for 24-hour urine protein
quantification or spot urine protein: creatinine ratio, depending on availability of
service. Urine protein: creatinine ratio is preferred than urine albumin: creatinine
ratio.
d. Other Maternal Organ Dysfunction:
o Creatinine ≥ 90 micromol/litre
o ALT/AST > 40 IU/litre (+/- Epigastric pain)
o Neurological complications (e.g.: eclampsia, altered mental status, blindness,
stroke, clonus, severe headaches or persistent visual scotomata)
o Hematological complications (e.g.: PLT < 150, DIVC, hemolysis)
o Uteroplacental dysfunction (e.g.: fetal growth restriction, abnormal umbilical
artery doppler waveform analysis, or stillbirth)
8. Severe Pre-eclampsia:
BP ≥ 160/110 with proteinuria ≥ 2+ or end-organ involvement
9. Eclampsia:
HPT + seizure
Subsequent antenatal follow-up
1. Symptoms of pre-eclampsia:
a. severe headache
b. visual disturbance (blurring, flashing)
c. vomiting
d. severe epigastric pain
e. sudden swelling of face, hands or feet.
2. PE profile:
63
a. Creatinine level: ≥ 90 (abnormal for pregnancy)
b. Uric acid level (according to gestational weeks)
Gestation (weeks) 24 32 36 38
Uric Acid (mmol/L) 280 320 340 380
c. To do clotting studies if PLT < 100
d. AST/ALT > 40 (abnormal)
e. 24-hour urinary protein ≥ 300mg / 24 hours (abnormal)
f. Spot urine protein: creatinine ratio ≥ 30mg/mmol (0.3mg/mg) (abnormal)
3. PE profile should be documented.
4. There is role of VTE prophylaxis in significant proteinuria (e.g. nephrotic range) from
quantification of urine protein – to refer MFM or O&G specialist before
commencement.
Postpartum
1. Anti-HPT acceptable in breastfeeding: Nifedipine, Labetalol, Captopril,

Enalapril, Atenolol or Metoprolol (avoid diuretic or angiotensin receptor
blockers)
2. Refer Appendix “Medical Eligibility Criteria for Contraceptive Use”.

Upon discharge from hospital
1. Refer Appendix “Notification of High-Risk Cases Discharge”.
Reference(s):
1. Training Manual for Hypertensive Disorders in Pregnancy, 3rd edition 2018.
3. WHO Recommendations for Prevention and Treatment of Pre-eclampsia and Eclampsia,
2011.
4. The SOMANZ Guideline for the Management of Hypertensive Disorders of Pregnancy,
2014.
5. International Society for the Study of Hypertension in Pregnancy (ISSHP), 2018.
6. Malaysian Clinical Practice Guideline on Management of Hypertension, 5th edition 2018.
64
5.3 Screening for Pre-eclampsia And Antihypertensive Medication
5.3.1 Pre-eclampsia Prophylaxis
Pre-Eclampsia Prophylaxis
(Aspirin and Calcium supplementation)
Risk Factors for developing Pre-Eclampsia1:
(Patient is categorized as HIGH RISK if she has ONE MAJOR or MORE THAN ONE
MODERATE risk factors)
Major risk factor: Moderate risk factor:
1. Hypertensive disease during a previous 1. Primiparity

pregnancy 2. Age ≥ 40 years old
2. Chronic kidney disease 3. Pregnancy interval > 10 years
3. Auto-immune disease (SLE/APS) 4. BMI ≥ 35 kg/m2 at booking
4. T1DM, T2DM 5. Family history of Pre-Eclampsia
5. Chronic HPT 6. Multi-fetal pregnancy
• If patient is high risk for developing PE:
➢ Start Calcium Carbonate 1g BD at booking (start latest by 20 weeks) 2,3

➢ Start Cardiprin 100mg ON if available or Aspirin 150mg ON between 12 weeks
– 20 weeks and continue until delivery 2,4,5
➢ If patient is > 20 weeks, to consult O&G specialist if patient requires aspirin
initiation.

1 Pre-pregnancy • Risk stratification to be performed at booking to identify
patients at risk of developing pre-eclampsia (PE)
• If patient is at high risk for developing PE:
➢ Start Aspirin and Calcium as prophylaxis (as stated above)
2 Subsequent • High risk patients – shared care between O&G / FMS
antenatal follow- ➢ Follow up plan will be outlined by O&G after initial
up assessment (Generally, O&G follow up for patients with
major risk factors, and FMS follow up for patients with
moderate risk factors)
➢ Require increased surveillance (e.g. earlier and more
frequent assessment of fetal growth and maternal
65
clinical condition)
➢ O&G follow up if patient develops PE
3 Delivery • Women taking Aspirin should be advised that once she is in
labour, she should not take the next dose of Aspirin6
• Where delivery is planned, Aspirin should be discontinued
24 hours before planned delivery
• Delivery plan (mode, timing) as per obstetric indication
Reference(s):
2. Malaysian Clinical Practice Guideline on Management of Hypertension (5th edition),

2018.
3. WHO Recommendation Calcium Supplementation during Pregnancy for the

Prevention of Pre-Eclampsia and its complications, 2018.
4. International Society for the study of Hypertension in Pregnancy (ISSHP), 2018.
5. WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and

Eclampsia. Geneva, World Health Organization; 2011.
6. Low-dose Aspirin and Calcium Supplementation for the Prevention of Pre-Eclampsia.

The Obstetrician & Gynaecologist (TOG) 2014.
66
5.3.2 Anti-Hypertensive Drugs for Treatment in Pregnancy
Drugs Action Contraindication Adverse effect
PO Methyldopa Central Pheochromocytoma Hepatic necrosis
250mg - 1g TDS Hepatitis Haemolytic
Liver cirrhosis anaemia
History of Increase risk of
depression postnatal
Depression depression
Current use of
monoamide oxidase
inhibitors
PO Labetalol Beta adrenergic Obstructive airway Hepatic injury
Initial: 100mg BD blocker with mild disease Bronchospasm
Maintenance: 200 - alpha vasodilation Bronchial asthma Bradycardia
400mg TDS effect Heart block Tingling of scalp
Severe bradycardia (resolve within 24
hours)
PO Nifedipine Peak blood level Cardiogenic shock Peripheral
10 – 20mg TDS occurs in Unstable angina oedema
approximately 30 Myocardial Mood changes
mins infarction event in Increase risk of
past 1 month heart failure in
patient with aortic
stenosis
67
5.3.3 Acute Blood Pressure Lowering Agents in Primary Care
Drugs Contraindication Adverse Effect

Inj. Labetalol 5mg/ml Obstructive airway Hepatic injury
disease
(TRANDATE 5mI ampoule) Bronchospasm
Bronchial asthma
Route: IV Bradycardia
Heart block
Dose: 10mg over 1 min, repeat at 5 min Urination
interval Severe difficulty
bradycardia
(total maximum dose: 200mg) Tingling of scalp
(resolve within
Action: Maximum effect occurs within 5 24 hour)
minutes, duration of action about 6
hours, may last up to 18 hours
Inj. Hydralazine Hydrochloride Severe Angina
tachycardia
Route: IV Tachycardia
Idiopathic
Dose: systemic lupus Palpitation
1. 1mI of Inj. Hydralazine 20mg/ml erythematous Systemic lupus
reconstitute with 1 ml of Water for Heart failure with erythematous
Injection high cardiac like symptoms
2. 5-10mg slow IV within 1 minute, output
repeat 5-10mg slow IV in intervals of Dissecting aortic
20-30 minutes as indicated aneurysm
Hydralazine should be given in slow IV Myocardial
injection, to avoid critical reduction in insufficiency due
cerebral or uteroplacental perfusion) to mechanical
obstruction
T. Nifedipine 10mg Cardiogenic Peripheral
oedema
Route: PO shock
Mood changes
Dose: 10mg stat, repeat with 10 Unstable angina
Increase risk of
mg in 30 minutes interval if indicated Myocardial heart failure in
(total maximum dose: 60mg per day) infarction event in patient with
past 1 month aortic stenosis
Action: Peak blood level occurs in
approximately 30 mins
68
5.3.4 Administration of Magnesium Sulphate Injection (Malay Version)
Panduan Pemberian Suntikan MgSO4
CARA PEMBERIANMgSO4 INTRAMUSKULAR
LOADING DOSE
5gm MgS04+ 1ml 2% Lignocaine untuk sebelah

buttock
- sediakan untuk 2 belah buttock
(dengan Lignocaine)
MAINTENANCE
5gm MgSO4, setiap 4 jam (alternate

buttocks)
(tanpa Lignocaine)
RECURRENT SEIZURE
(bagi ibu yang mengalami sawan selepas

1 jam pemberian loading atau maintenance
dos)
5gm MgSO4 (tanpa Lignocaine)
* Sekiranya ibu mengalami ‘cardiorespiratory collapse’ selepas pemberian MgSO4:
• Beri suntikan IV Calcium Gluconate 10%, 10mls.

• Suntikan ini mesti diberi dengan perlahan dalam masa 10 minit sebagai antidote.
• Suntikan ini diberi oleh Pegawai Perubatan.
69
5.3.5 Management Flowchart of Severe Pre-eclampsia/ Eclampsia at Primary Care
(Malay Version)
CARTA ALIR PEMBERIAN IM MgSO4 BAGI PENGENDALIAN KES SEVERE PRE-
ECLAMPSIA / ECLAMPSIA DI PERINGKAT PENJAGAAN KESIHATAN PRIMER
Terima kes Severe Pre-eclampsia / Eclampsia
Dapatkan bantuan dari anggota kesihatan lain
Baringkan pesakit ke posisi left lateral dan pastikan saluran pernafasan tidak
tersekat (bagi kes eclampsia, beri bantuan oksigen)
Periksa dan rekod vital signs: BP, PR dan RR dan denyutan jantung janin
Berikan suntikan IM MgSO4 5gm pada kedua-dua belah punggung ibu (rujuk cara
penyediaan dan pemberian suntikan IM MgSO4
Pasang IV infusi normal saline
Teruskan mengambil dan merekod BP, PR, RR, patella reflex dan urine output untuk mengesan toksisiti
Sawan berulang? Tekanan darah systolic ≥ 150mmHg atau

diastolic ≥ 100mmHg?
Ya Tidak Tidak Ya
Ulang pemberian IM MgSO4 5gm Beri T. Labetalol 200mg stat atau T.

(10mls) pada sebelah punggung ibu Nifedipine 10mg stat (atas arahan Pakar
Perubatan Keluarga / Pegawai Perubatan)
Uruskan ibu untuk rujukan ke hospital
Dokumentasi
70
5.3.6 Eclampsia Kit (Malay Version)
Senarai Peralatan Di Dalam ‘Eclampsia Kit’
Bil. Peralatan Jumlah

1. Injection Magnesium Sulphate 2.47gm in 5 mls 4 - 8 ampul
2. Injection Calcium gluconate 10%, 10gm, 10mIs 1 ampul

3. Injection Liqnocaine 2% 1 vial / ampul
4. Tab. Nifedipine 10 mg 4 biji
5. Tab. Labetolol 100 mg 4 biji
6. IVD Normal saline 2 botol
7. IVD set 2 set
8. Venofix branula:
Saiz 16G 2 unit
Saiz 18G 2 unit
9. Needle:
Saiz 21G 5 unit
10. Syrinqe:
5 ml 4 unit
10 ml 4 unit
11. Swab Alcohol 10 pcs
12. Swab kering 5 pcs
13. Plaster 1 roll
PERALATAN LAIN
Bil. Peralatan Jumlah

1. Foley’s Catheter:
Saiz 16F 1 unit
Saiz 18F 1 unit
2. Urine Bag 1 unit

3. Guedel Airway
Saiz 3 Small adult, 80mm Hijau 1 unit
Saiz 4 Medium adult, 90mm Kuning 1 unit
Saiz 5 Large adult, 100mm Merah 1 unit
71
SECTION 6 INFECTIOUS DISEASES IN PREGNANCY
6.1 Retroviral Disease in Pregnancy
1 Pre-pregnancy • Refer HIV positive woman to pre-pregnancy clinic for
counselling.
• Advise to get pregnant only when the viral load is
suppressed.
• Harm reduction counselling.
2 Booking (known • Ensure mother’s compliance to ART.
case) • Check baseline investigation FBC, LFT, RP, RBS, UFEME,
screen for co-infections (Hep B, Hep C, RPR).
• Check CD4 and viral load if no recent result past 1 year.
• Refer ID physician if suspect virological failure.
• Shared care management between FMS and O&G team or
Combined Clinic.
• Screen spouse/partner.
• Harm reduction counselling.
• For newly diagnosed RVD, refer to FMS immediately for ART
commencement
➢ Notify new case
➢ Screen spouse/partner
➢ Harm reduction counselling
➢ Look for opportunistic infections
• If mother is diagnosed after 28 weeks, to discuss with ID
physician for choice of ART regimen
• Ensure compliance to ART
3 Subsequent • Monitor FBC, RP and LFT during each specialist clinic.
antenatal follow- • To do baseline viral load 2-4 weeks after ART
up commencement if diagnosed during pregnancy and repeat
32 weeks
• MOGTT at 24-28 weeks if ART regime contains protease
inhibitor
• Trace viral load taken at 32 weeks around 36 weeks
gestation in ID Combined Clinic or FMS clinic to decide mode
of delivery.
• Time of delivery as per obstetric indication.
4 Delivery • Delivery in the hospital with specialist.

• Refer to O&G for mode of delivery depends on viral load
result
• Refer infant to paediatric team
72
5 Postpartum • Discuss options of contraception with patient/ couple (refer to
MEC)
• Suggest BTL if patient/couple agreeable
• Advise patient on importance of early booking in next
pregnancy
• To supply contraception and dual protection with condom
• Arrange FMS / ID Clinic appointment to continue ART
• ART in pregnant women should be continued life-long after
delivery
6 Lactation • Breastfeeding is contraindicated
• Suppression of lactation (Cabergoline 1mg stat dose)
• Refer Lactation Unit staff for counselling and preparation of
infant formula milk.
• Arrange for supply of formula milk up to 2 years
REMARKS:
1. Risk of vertical transmission is 25 - 35% without any intervention.
2. ART can reduce vertical transmission to 2% whole management bundle.
3. Preferred choice of ART is Tenofovir + Emtricitabine + Efavirenz
4. If late diagnosis of HIV (> 28 weeks) or viral load not suppressed, should consult ID
Physician as patient must be commenced on ART without delay and regimen may
include Raltegravir or Dolutegravir to achieve more rapid viral load suppression
5. Strict adherence to ART must be stressed throughout the pregnancy.
6. PCP prophylaxis can be initiated regardless of stage of pregnancy and continue
throughout the pregnancy
7. Refer to breastfeeding guideline in Mother with HIV
8. Contraception choice - refer to MEC in view of interaction with ART
Reference(s):
1. Management of HIV Infection in pregnant women, February 2008
2. Malaysian Consensus Guidelines on Antiretroviral Therapy 2017
3. Circular on breastfeeding 2017 (by KKM)
4. British HIV Association guidelines for the management of HIV in pregnancy and
postpartum 2018
73
6.2 HIV in Serodiscordant Couple (HIV - positive Male, HIV -negative
Female)
1 Pre-pregnancy • Pre-conception counselling.
• Pregnancy must be well planned.
• Couples should go for STD screening prior planning for
conception (refer Remarks).
• HIV-positive partner is strongly recommended to be on ART
and is virologically suppressed before attempting conception
• Stress on compliance to ART and condom use (if not
virologically suppressed).
• Recommend PrEP for HIV-negative female if:
➢ Husband not on treatment/non-compliance/VL not known
➢ Husband’s VL not suppressed
• If husband VL suppressed,
➢ PrEP is not required but mother must be well counseled
and closely monitored
• Plan for timed unprotected intercourse during fertile period
[sexual intercourse limited to the 2-3 days before and the day
of ovulation (peak fertility)]
➢ If conception does not occur within 6 months, workup for
infertility.
2 Booking • To be reviewed by FMS.
• Early booking if UPT positive.
• Emphasize on safe sex or abstinence.
➢ Condom use should be encouraged in pregnancy
because of increased risk of HIV acquisition during
pregnancy.
3 Subsequent • Mother must be closely monitored – to repeat HIV screening
antenatal follow- each trimester.
up • Antenatal follow up under FMS.
• Advise permanent sterilization if completed family.
74
4 Delivery • Vaginal delivery unless otherwise indicated.
5 Postpartum • Referral to pre-pregnancy care clinic.

• To be advised on dual protection contraception.
• PrEP to be continued for the duration of breastfeeding if
husband not on treatment/non-compliance/VL not known/VL
not suppressed.
6 Lactation • No contraindication in breastfeeding.
REMARKS:
1. ‘Virologically suppressed’ - undetectable viral load in 2 consecutive viral load
readings at least 3 months apart.
2. STD screening is important because genital tract inflammation is associated with
increase genital tract shedding of HIV.
Reference(s):
1. Malaysian Consensus Guidelines on Antiretroviral Therapy, 2017.
2. Preconception Counselling and Care for Women of Childbearing Age Living with
HIV, CDC 2019
75
6.3 Syphilis in Pregnancy
1 Pre-pregnancy • Woman with multiple partners or high - risk behaviour need
to do STD screening.
• Woman with history of previous infection, need to treat if
there is increase in titre.
➢ Refer O&G clinic if previous child complicated by
congenital syphilis.
2 Booking • Routine screening of RPR/TPPA for all mothers at booking.
• For known cases trace previous RPR titre.
• Screen partner and to treat empirically if mother given
treatment.
• Screen for other STIs (i.e. Hep B, Hep C) if there is risk.
• Notification for new cases.
• Advice for harm reduction.
Indications for treatment:
• Newly diagnosed syphilis at any stage.

• Unclear history of syphilis treated prior to this pregnancy.
• Titre during current pregnancy is ≥ 1:8.
• Serological cure (a four-fold drop in RPR titre, e.g. from
16 to 4) did not occur
• Increased titre from titre before pregnancy.
3 Subsequent • Referral to FMS for assessment and counselling
antenatal follow- • Look up for signs of fetal infection i.e. polyhydramnios,
up hydrops, IUGR, hepatosplenomegaly
• At a minimum, serologic titres should be repeated at 28-32
weeks gestation and at delivery
• To repeat serological titres one month after completion of
treatment
• To repeat treatment if there is an increase of titre/ new
infection
76
• To consult GUM/Dermatology specialist if resistance
suspected (no fourfold RPR reduction)
• Refer O&G at 34-36 weeks gestation for further assessment
4 Delivery • Time of delivery as per obstetric indication
• Advise hospital delivery
• Refer baby to Paediatrics team
5 Postpartum • Contraception (refer to MEC)

• Advise patient on importance of early booking in next
pregnancy
• Refer mother and partner to continue follow up titre
as outpatient in health clinic
• Refer to pre-pregnancy clinic
6 Lactation • No contraindication for breastfeeding
REMARKS:
1. Threshold to start treatment based on titre (with or without previous history of
treatment for syphilis):
2. Treatment with IM Benzathine Penicillin 2.4 MU weekly x3 doses
3. Doxycycline and Tetracycline are contraindicated in pregnancy
4. Erythromycin should not be used as first line unless patient is allergic to penicillin
5. Need to do test dose for penicillin allergy
6. Look for Jarisch-Herxheimer reaction within 24 hours after penicillin especially in
2nd half of pregnancy
7. Refer Appendix: Medical Eligibility Criteria for Contraceptive Use
Reference(s):
1. Malaysian Guidelines in the treatment of Sexually Transmitted Infection Fourth Edition
2015
2. UK National Guidelines on the Management of Syphilis 2015, December 31, 2015
3. WHO Guideline on syphilis screening and treatment for pregnant women, 2020
77
6.4 Tuberculosis in Pregnancy
1 Pre- • All women of child bearing age suspected of TB should be
pregnancy asked about current or planned pregnancy.
• Women with TB on treatment should be advised for
contraception until completed treatment
2 Booking • To screen all pregnant mothers according to checklist
• Patient suspected for tuberculosis based on history and
physical examination, do investigations such as:
➢ Sputum AFB direct smear X 3
(Induced sputum if unable to produce sputum)
➢ CXR with abdominal shield
➢ Biopsy if indicated (extrapulmonary tuberculosis)

• If diagnosed tuberculosis:
➢ Refer Pusat Rawatan 1 (PR 1) and FMS once diagnosed for
follow up
➢ Notify and contact tracing
➢ Baseline investigations (FBC, RBS, BUSE, creatinine, LFT,
sputum MTB C&S, HIV rapid test)
➢ Refer O&G specialist if presence of any maternal or fetal
complication.
➢ VTE risk scoring (refer to topic VTE) for active TB
• For relapsed PTB:
➢ Need GenXpert test (discuss with respective team
according to local policy)
• Treatment regime:
➢ For pulmonary tuberculosis - 2 EHRZ / 4HR
(Pyridoxine 30 mg OD to be given with Isoniazid to prevent
fetal neurotoxicity)
➢ For extrapulmonary tuberculosis – refer to ID team (may

need to refer to respective sub to get the tissue diagnosis)
➢ For Pulmonary DR-TB – refer to respiratory physician
78
➢ For extra Pulmonary DR-TB – refer to ID team
3 Subsequent • Check on DOTS
antenatal • Consider inpatient if poor compliance
follow-up • Continue anti-TB treatment
• Monitor patient as per guidelines
• Closely monitor FBC, RP and LFT
• Ultrasound monthly after 28 weeks to look for FGR
5 Postpartum • Refer baby to Paediatric team to initiate isoniazid prophylaxis

if indicated
• Defer giving BCG if mother is diagnosed < 2 months before
delivery, mother is sputum positive just before delivery or the
newborn baby is symptomatic
• Defer BCG in newborns at risk of perinatal TB until INH
prophylaxis is completed
• Inform health clinic upon discharge to ensure continuity of TB
treatment
6 Lactation • Breastfeeding is not contraindicated
REMARKS:
1. TB in pregnancy has been associated with increased risk of maternal and perinatal
morbidity namely premature delivery, SGA and LBW.
2. Clinical diagnosis of tuberculosis in pregnant women can be difficult due to non-
specific symptoms related to the physiological response to pregnancy.
3. Mantoux test is considered safe and valid for use in pregnancy.
4. Pregnant women are more likely to postpone having chest x ray. Chest X-ray must
not be delayed in diagnosis of PTB even before 12 weeks because the risk of ionizing
radiation is so low for one with an abdominal shield.
5. First-line anti-TB drugs are safe in pregnancy and breastfeeding.
6. Streptomycin cause fetal ototoxicity and should not be used during pregnancy.
7. Breastfeeding should be continued – used 3 ply surgical mask if the mother is still
infectious.
79
8. Infant-mother separation is considered if the mother has MDR-TB or is non- compliant
to treatment.
9. Children below 5 years may need Isoniazid prophylaxis.
10. Screening questions for tuberculosis in pregnancy:
Criteria Yes No Remark
Chronic cough?
If Yes, duration of chronic cough
Less than 2 weeks
More than 2 weeks
Haemotypsis
Prolonged fever
Loss of appetite
Loss of weight
Night sweat
Co morbid (DM, ESRF, RVD, COPD)
TB contact
Stay in TB hot spot area
Reference(s):
1. Malaysia CPG Management of Tuberculosis 2012
2. South Australia Guideline 2014
3. Obstetrics, Gynaecology and Reproductive Medicine Journal
4. CPG Management of Drug Resistant Tuberculosis, Malaysia 2017
5. Centres for Disease Control and Prevention
6. KKM, Garis panduan Kawalan Tb di kalangan kanak-kanak, Malaysia 2017
7. JKNS, Garis panduan pengujudan triaging untuk saringan TB di klinik, 2014.
80
6.5 Viral Hepatitis in Pregnancy
1 Pre-pregnancy • Screen for Hep C co-infections if not done previously.
• Screen husband and family.
• Counsel on risk-taking behaviours.
2 Booking • To do HBe antigen, HBe antibody, LFT, RP.
• To do viral load (HBV DNA load) with local arrangement for
specimen transfer after discuss with Medical/
Gastroenterologist from tertiary hospital.
• Review 2 weeks - 1 month to review result.
3 Subsequent • Trace result LFT, HBe Antigen and HBe antibody.
antenatal follow- • Refer to FMS for Hepatitis B in pregnancy.
up • Referral to Gastroenterology clinic urgently to initiate
treatment if HBe antigen reactive or deranged liver enzymes
(as chart below).
• For Combined clinic care with O&G specialist/ MFM if HBe
antigen reactive or deranged LFT.
• To do LFT monitoring (every trimester) at health clinic and
monitor closely for hepatic flares/deranged liver enzyme.
4 Delivery • Timing & mode of delivery as per obstetric indication.
• Standard precaution.
• Refer infant to Paediatric team:
➢ Hep B vaccine given as per national policy
➢ Hep B immunoglobulin given at birth within 12 hours post-
delivery
5 Postpartum • Offer contraception (refer MEC)
• Refer mother with HBe antigen reactive to follow up in
Gastroenterology clinic
• Advice patient on importance of early booking in next
pregnancy
• Pre-pregnancy care at FMS clinic appointment within 3/12 with
LFT
6 Lactation • Allow breastfeeding
81
REMARKS:
1. HBV DNA viral load is only done in QEH. Fresh specimen needs to arrive to the lab within
24 hours collected. There is designated form to fill up for the test and need to refer to
Gastroenterologist before sending to prevent rejection of sample.
Algorithm for hepatitis B virus during pregnancy

Pregnant woman
First trimester: Check HBsAg
HBsAg negative* HBs Ag positive
HepB vaccination of infant at Check baseline: ¥

birth • Liver panel
• HBV DNA
• HBeAg and anti-HBe
Repeat HBV DNA and liver panel at end of

second trimester (26 to 28 weeks)
HBV DNA >200,000 int. units/mL HBV DNA ≤200,000 int. units/mL
(>106 copies/mL) (≤106 copies/mL)
Offer antiviral therapy to the mother Within 12 hours of birth infant should initiate
HepB vaccine series + receive HBIG
Within 12 hours of birth infant should

initiate HepB vaccine series + receive
HBIG
Anti-HBc: hepatitis B core antibody; anti-HBe: hepatitis B e antibody; anti-HBs: hepatitis B surface antibody;
HBeAg: hepatitis B e antigen; HBIC: hepatitis B immune globulin; HBsAg: hepatitis B surface antigen; HBV:
hepatitis B virus.
* Check anti-HBs and anti-HBc if mother is at high risk for HBV infection (e.g. injection drug user, sexual partner
or household contact has chronic HBV). Mothers with no evidence of prior HBV infection (ie, negative for HBsAg,
anti-HBs, and anti-HBc) should be vaccinated. In addition, such women should have HBsAg repeated late in
pregnancy (approximately 28 weeks).
¥ Women who have a high HBV DNA (>200,000 int. units/mL), elevated aminotransferase levels, and/or a
positive HBeAg should be referred to a hepatologist to see if early initiation of antiviral medications is needed.
Source: UpToDate 2020 - hepatitis B and pregnancy
Reference(s):
1. UpToDate 2020 - hepatitis B and pregnancy, last update May 28, 2019.
2. Asian-Pacific clinical practice guidelines on the management of hepatitis B: a 2015 update.
3. Management of Hepatitis B in Pregnancy: The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists July 2016.
4. South Australian Perinatal Practice Guidelines: Hepatitis B in pregnancy.
5. Chronic Hepatitis B in Pregnancy A Workshop Consensus Statement on Screening,
Evaluation, and Management.
6. Sabah Obstetric Shared Care Guideline 2012.
82
SECTION 7 MALIGNANCIES IN PREGNANCY
7.1 Breast Cancer in Pregnancy
1 Pre-pregnancy • Contraception
➢ Current breast cancer: Copper IUCD, as hormonal
contraception is contraindicated. Pregnancy should be
deferred till 2 years after completion of treatment.
➢ Family history of breast cancer: Any contraception
methods
➢ Decision to conceive based on MDT discussion
2 Booking • History:
➢ If known case, stage of cancer and therapy
▪ Tamoxifen is contraindicated in pregnancy
➢ If past history: symptoms of recurrence breast cancer
• Physical examination: Breast inspection and palpation for
painless lump, axillary lymph nodes
• Investigation: Breast ultrasound, bilateral mammography,
core biopsy
• Detailed scan for fetal anomaly
• Refer to O&G/ MFM team if newly diagnosed breast cancer
for multidisciplinary discussion with breast endocrine surgeon,
oncologist, neonatologist and MFM team
3 Subsequent • Shared care with FMS, obstetrician/MFM, oncologist, breast
antenatal follow- endocrine surgeon
up • Consider surgical treatment during pregnancy as planned by
breast endocrine surgeon
• For patient who are undergoing chemotherapy:
➢ Monitor for fetal wellbeing, development and IUGR
➢ Monitor for preterm contraction
➢ Baseline echocardiography for woman who receive
chemotherapy
• Radiotherapy is contraindicated (most cases)
83
• VTE risk scoring
4 Delivery • Mode of delivery as per obstetric indication
• Timing of delivery – as near term as possible, at least 3

weeks after last cycle of chemotherapy
• Examine placenta for metastatic disease
5 Postpartum • Medical thromboprophylaxis

• Oncological treatment may begin immediately after vaginal
delivery, or a week after uncomplicated caesarean section.
• Ensure effective long-term reversible contraception until
completion of treatment.
• Ensure compliance to follow up until completion of treatment.
6 Lactation • Breastfeeding is contraindicated if receive chemotherapy
Reference(s):
1. Breast cancer in pregnancy, Lancet 2012. doi: 10.1016/S0140-6736(11)61092-1.

2. WHO Medical Eligibility Criteria 2018
84
7.2 Cervical Cancer in Pregnancy

1 Pre-pregnancy • Woman who is known pre-malignant lesion before
pregnancy should practise effective contraception until
completion of management.
• Woman at reproductive age who is newly diagnosed high
grade pre-malignant lesion or cervical malignancy should be
referred immediately for further counselling by
gynaeoncologist including feasibility of fertility sparing
treatment.
• Women who have not completed treatment for cervical
malignant should have effective contraception, intrauterine
device is contraindicated.
2 Booking • History:
➢ If newly diagnosed or known case incomplete treatment–
refer to O&G specialist immediately
➢ If past history: assess for symptoms of recurrence
• Physical examination: Abdominal, pelvic examination and
speculum examination.
• Investigation to be decided by gynaeoncologist: Colposcopy
with biopsy if presence of cervical lesion, MRI scan for
staging if newly diagnosed cervical cancer.
• Multidisciplinary discussion between gynaeoncologist,
oncologist, maternal fetal medicine specialist and
neonatologist are mandatory for newly diagnosed cervical
cancer in pregnancy.
3 Subsequent • Shared care between FMS, MFM/ O&G specialist and
antenatal follow- Gynae-oncologist.
up • Ensure compliance under specialist clinic review
• VTE risk score – for thromboprophylaxis if active disease (to
discuss with O&G specialist/ MFM)
• If chemotherapy is required during pregnancy:
85
➢ To commence after first trimester
➢ Monitor fetal growth
➢ Fetal anomaly scan
➢ Risk of premature delivery
4 Delivery • Outlined by Gynaeoncologist and MFM team.
• High possibility of iatrogenic premature delivery.
5 Postpartum • Medical thromboprophylaxis.

• Clinic review under O&G specialist.
• Ensure compliance to gynaeoncologist follow up.
6 Lactation • Breastfeeding is contraindicated if on chemotherapy
Reference(s):
1. FIGO Cancer Report 2018: Cancer in Pregnancy, DOI: 10.1002/ijgo.12621

2. WHO Medical Eligibility Criteria 2018
86
7.3 Ovarian Cancer in Pregnancy
1 Pre-pregnancy • Contraception – any contraception allowed
2 Booking • History: Abdominal, pelvic pain or back pain, constipation,
abdominal distension, and urinary symptoms.
• Physical examination: acute abdomen, adnexal mass
• Investigation: Abdominal or transvaginal ultrasound,
consider non contrast MRI if feature of ovarian mass
suggestive of malignancy (to discuss with O&G team).
• CA-125, beta HCG and alpha fetoprotein are not useful in
pregnancy, making the diagnosis during pregnancy is
challenging.
• If known case of ovarian malignancy pre pregnancy, to refer
O&G team immediately for multidisciplinary discussion with
gynaeoncologist, MFM/O&G specialist and neonatologist.
3 Subsequent • Shared care with FMS, gynaeoncologist, MFM/ O&G
antenatal follow- specialist
up • VTE risk scoring
• To commence chemotherapy after first trimester if indicated
• Surgery can be performed after 16 weeks.
• Fetal anomaly scan
• Fetal growth assessment
4 Delivery • Time and mode of delivery is outlined by O&G team
• Delivery when fetal maturity acceptable.
5 Postpartum • Contraception
• Ensure compliance to gynaeoncology clinic
6 Lactation • Breastfeeding is contraindicated if receive chemotherapy
Reference(s):
1. FIGO Cancer Report 2018, DOI:10.1002/ijgo.12621
87
7.4 Thyroid Cancer in Pregnancy
➢ Any methods can be used, long term reversible
contraception is preferred untill completion of treatment
for thyroid cancer.
➢ Efffective contraception to delay pregnancy at least 6
months after radio-iodine therapy
• Aim for normal TSH level
• Ensure compliance to thyroid hormone replacement
2 Booking • History: symptoms of hyperthyroidism or hypothyroidism
• Physical examination: inspection and palpation of thyroid,
retrosternal percussion, lymph nodes
• Investigation:
➢ Neck ultrasound
▪ FNAC if size of the solitary nodule siza >1 cm, solid
and hypoechoic, or TIRADS ≥4
3 Subsequent • Shared care with FMS, Obstetrician and Endocrine
antenatal follow- Surgeon
up • Thyroid ultrasound each trimester
• Monitor Thyroid Function Test every trimester
• Thyroid hormone supressive therapy aiming TSH 0.3 to 2
mU/L.
• Thyroidectomy in second trimester for patients with larger,
more aggressive or rapidly growing cancers, or in the
presence of extensive nodal or distant metastasis.
• Ensure compliance to follow up
4 Delivery • Time and mode of delivery as per obstetric indication.
5 Postpartum • Refer back to primary team for surgical intervention if not

done during pregnancy and continuation of follow up until
completion of the treatment.
88
• Effective contraception until completion of therapy, at least
12 months after completion of radioactive iodine (RAI)
therapy.
6 Lactation • Breastfeeding is contraindicated if receive RAI.
• Breastfeeding must be stopped 6 weeks prior to the RAI.
REMARKS:
1. Thyroid image reporting and data system
TIRADS 1 Normal thyroid gland

TIRADS 2 Benign lesions
TIRADS 3 Probably benign lesions
TIRADS 4 Suspicious lesions (4a, 4b and 4c with increasing risk of malignancy)
TIRADS 5 Probably malignant lesions (>80% risk of malignancy)
TIRADS 6 Biopsy proven malignancy
Reference(s):
1. American thyroid association guidelines.
89
7.4 Haematological Cancer in Pregnancy
➢ Active disease: POP, Implanon, IUCD
➢ Avoid pregnancy unless in remission for 2-3 years
2 Booking • History: fatigue, shortness of breath, fever, night sweats, or
weight loss exceeding 10 percent of body weight
• Physical examination: lymph nodes, hepatosplenomegaly
• Refer to physician if suspected haematological cancer
• Investigation:
➢ FBC (unexplained anemia, thrombosis,
thrombocytopenia)
➢ Baseline renal and liver function
➢ Following investigation should discussed with
haematologist:
▪ CXR with pelvic shield
▪ Lymph node biopsy
▪ Bone marrow biopsy
▪ Staging by imaging study
3 Subsequent • Shared care with FMS, obstetrician/ MFM and Clinical
antenatal follow- Hematologist
up • Chemotherapy is contraindicated in the first trimester,
classic cytotoxic drugs and anti-metabolites are teratogenic
• If maternal’s condition require immediate therapy,
termination of pregnancy is recommended
• Anti-emetics: metoclopromide, ondansentron
• Monitor fetal growth as risk of FGR
• VTE risk scoring for active disease
4 Delivery • Decided by multidisciplinary team and patient
5 Postpartum • As per primary team management

• Ensure compliance to follow up
• Medical thromboprophylaxis if indicated
6 Lactation • Breastfeeding is contraindicated when treatment with
chemotherapy or staging with PET scan
Reference(s):
1. Haematological cancers in pregnancy Lancet 2012; 379: 580–87 Guideline.
90
SECTION 8 MENTAL DISORDERS IN PREGNANCY
8.1 Antenatal and Postnatal Mental Health Screening
1 Booking • Screen for depression/ anxiety/stress using DASS-21
questions at booking:
➢ If abnormal score for depression, to proceed with
Edinburgh Postnatal Depression Scale (EPDS).
➢ If EPDS score ≥ 12, refer to MO/ FMS for further
assessment.
➢ Use DSM V/ ICD-10 criteria to diagnose depression and
categorize to mild, moderate or severe.
➢ Refer to FMS or psychiatrist for treatment and follow up.
➢ If severe depression i.e. suicidality or psychosis to refer
to psychiatry team urgently.
➢ If abnormal score for anxiety, to proceed with GAD-7

scale.
➢ Refer psychiatrist for all anxiety cases.
➢ If abnormal score for stress, refer MO for further

assessment.
➢ Refer FMS/ counsellor for further management if needed.
• Ask all pregnant mothers any history of severe mental illness

e.g. severe and incapacitating depression, psychosis,
schizophrenia, bipolar disorder, schizoaffective disorder,
postpartum psychosis and severe perinatal mental illness in
a first-degree relative
➢ If present refer to MO for further assessment
2 Subsequent • Repeat screening at least once in 3rd trimester of pregnancy
antenatal follow- or at any time in pregnancy if clinically indicated.
up • Refer for psychiatrist assessment if new onset of mental
disorder.
91
3 Delivery • Delivery as per obstetric indication.
4 Postpartum Screen for mental illness at 6-12 weeks postnatal:
• Repeat at least once in the first postnatal year or at any time
in the first postnatal year if clinically indicated.
• Sudden onset of symptoms suggesting postpartum
psychosis needs urgent referral for immediate assessment
within 4 hours of referral.
REMARKS:
List of hospitals with in-house psychiatrist and psychiatry ward for admission
a. HMBP *(Hospital Pitas/ Tuaran/Kudat/ Kota Belud)

b. HQE1 *(Hospital Ranau/ Sipitang/ Beaufort/ Kuala Penyu/ Papar/ Kota Marudu/
HQE2/ HWKKS)
c. Hospital Keningau *(Hospital Tambunan/ Tenom)
d. Hospital Tawau *(Hospital Kunak/ Semporna/ Lahad Datu)
e. Hospital Sandakan *(Hospital Kinabatangan/ Beluran)
* list of hospitals covered by the psychiatrist in-charge in respective hospital
** any problem/ consultation can be made with the psychiatrist in-charge in each
locality
*** Admission to HQE 1 is reserved for patient requiring ECT
Reference(s):
1. Antenatal and postnatal mental health: clinical management and service guideline. NICE
guidelines [CG 192]. Published date: December 2014 Last updated: February 2020.
2. Malaysia CPG on Management of Major Depressive Disorder (2nd edition) 2019.
3. Sidik SM, Arroll B, Goodyear-Smith F. Validation of the GAD-7 (Malay version) among women
attending primary care clinic in Malaysia. J Prim Heath Care. 2012 Mar 1;4(1):5-11, A1.
4. Ramli M, Roszaman R, Kartini A, Rosnani S. Concurrent Validity of The Depression and
Anxiety Components in The Bahasa Malaysia Version Of The Depression Anxiety And Stress
Scales (DASS). ASEAN Journal of Psychiatry, Vol. 12 (1) Jan–June 2011.
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A. DASS-21 Score (Soal Selidik DASS)
SOAL SELIDIK DASS
Langkah 1: Sila baca dan jawab soal selidik DASS.
Langkah 2: Masukkan skala markah jawapan ke dalam ruangan kosong di bahagian 2, mengikut soalan (S) bagi setiap kategori (Stres,
Anzieti dan kemurungan).
Langkah 3: Jumlahkan skala markah bagi setiap kategori bagi mengetahui tahap status kesihatan mental ada.
Langkah 4: Sila isikan keputusan dalam Bahagian 3 dan isikan dalam keratan di muka hadapan.
BAHAGIAN 1
Sila baca setiap kenyataan di bawah dan bulatkan jawapan anda pada kertas jawapan berdasrkan jawapan 0, 1, 2 atau 3
bagi menggambarkan keadaan anda sepanjang minggu yang lalu. Tiada jawapan yang betul atau salah. Jangan mengambil
masa yang terlalu lama untuk menjawab mana-mana kenyataan.
Please read each statement and circle number 0,1,2 or 3 which indicates how much the statement applied to you over the
past week. There are no right or wrong answers. Do not spend too much time on any statement
0 = Tidak langsung menggambarkan keadaan saya 2 = Banyak atau kerapkali menggambarkan keadaan saya
Did not apply to me at all Applied to me to some degree, or some of the time
1 = Sedikit atau jarang-jarang menggambarkan keadaan saya 3 = Sangat banyak atau sangat kerap menggambarkan
Applied to me to a considerable degree, or a good part of time keadaan saya
Applied to me very much, or most of the time
1. Saya dapati diri saya sukar ditenteramkan 0 1 2 3
I found it hard to wind down
2. Saya sedar mulut saya terasa kering 0 1 2 3
I was aware of dryness of my mouth
3. Saya tidak dapat mengalami perasaan positif sama sekali 0 1 2 3
I couldn’t seem to experience any positive feeling at all
4. Saya mengalami kesukaran bernafas (contohnya pernafasan yang laju, tercungap-cungap walaupun tidak 0 1 2 3
melakukan senaman fizikal)
I experienced breathing difficulty (eg. Excessively rapid breathing, breathlessness in the absence of physical
exertion)
5. Saya sukar untuk mendapatkansemangat bagi melakukan sesuatu perkara 0 1 2 3
I found it difficult to work up the initiative to do things
6. Saya cenderung untuk bertindak keterlaluan dalam sesuatu keadaan 0 1 2 3
I tended to over-react to situations
7. Saya rasa menggeletar (contohnya pada tangan) 0 1 2 3
I experienced trembling (eg. In the hands)
8. Saya rasa saya menggunakan banyak tenaga dalam keadaan cemas 0 1 2 3
I felt that I was using a lot of nervous energy
9. Saya bimbang keadaan di mana saya mungkin menjadi panik dan melakukan perkara yang membodohkan diri 0 1 2 3
sendiri
I was worried about situations in which I might panic and make a fool of myself
10. Saya rasa saya tidak mempunyai apa-apa untuk diharapkan 0 1 2 3
I felt that I had nothing to look forward to
11. Saya dapati diri saya semakin gelisah 0 1 2 3
I found myself getting agitated
12. Saya rasa sukar untuk relaks 0 1 2 3
I found it difficult to relax
13. Saya rasa sedih dan murung 0 1 2 3
I felt down-hearted and blue
14. Saya tidak dapat menahan sabardengan perkara yang menghalang saya meneruskan apa yang saya lakukan 0 1 2 3
I was intolerant of anything that kept me from getting on with what I was doing
15. Saya rasa hampir-hampir menjadi panik/ cemas 0 1 2 3
I felt I was close to panic
16. Saya tidak bersemangat dengan apa jua yang saya lakukan 0 1 2 3
I was unable to become enthusiastic about anything
17. Saya rasa tidak begitu berharga sebagai seorang individu 0 1 2 3
I felt I wasn’t worth much as a person
18. Saya rasa mudah tersentuh 0 1 2 3
I felt I was rather touchy
19. Saya sedar tindakbalas jantungsaya walaupun tidak melakukan aktiviti fizikal (contohnya kadar denyutan 0 1 2 3
jantung bertambah, atau denyutan jantung berkurangan)
I was aware of the action of my heart in the absence of physical exertion (eg sense of heart rate increase, heart
missing a beat)
20. Saya berasa takut tanpa sebab yang munasabah 0 1 2 3
I felt scared without any good reason
21. Saya rasa hidup ini tidak bermakna 0 1 2 3
I felt that life was meaningless
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BAHAGIAN 2
Panduan Mengira Skor:
Masukkan skala markah jawapan bagi soalan (S) bagi setiap kategori.
STRES
Soalan S1 S6 S8 S11 S12 S14 S18 Jumlah
Markah
ANZIETI
Markah
KEMURUNGAN (DEPRESSION)
Markah
Selepas dijumlahkan, sila rujuk kepada petak skor saringan dan terjemahkan jumlah
skor untuk mengetahui tahap status kesihatan mental anda
SKOR SARINGAN
Kemurungan Anzieti Stres
Normal 0-5 0-4 0-7
Ringan 6-7 5-6 8-9
Sederhana 8-10 7-8 10-13
Teruk 11-14 9-10 14-17
Sangat teruk 15+ 11+ 18+
BAHAGIAN 3
Isikan keputusan (normal, ringan, sederhana, teruk atau sangat teruk) dalam jadual
di bawah.
KEPUTUSAN UJIAN DASS
Ujian Tahap
Stress
Anzieti
Kemurungan
SKOR DASS
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A. Edinburgh Postnatal depression scale (EPDS)
Sila tandakan jawapan yang paling hampir bagi menggambarkan apa yang telah anda rasa anda rasakan
DALAM MASA TUJUH HARI yang lalu dan bukan sekadar hari ini sahaja.
Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you
feel today
No Soalan/ Questions Skor
1. Saya dapat ketawa dan melihat kelucuan  Sebanyak mana biasa/As much as I always could
pada sesuatu perkara  Kurang daripada biasa/Not quite so much now
I have been able to laugh and see the  Sangat kurang daripada biasa/Definitely not so much now
funny sides of things  Tiada langsung/Not at all
2. Saya menanti dengan penuh harapan  Sebanyak mana biasa/As much as I ever did
bagi mendapat kenikmatan apabila  Kurang daripada biasa/Rather less than what I used to do
melakukan sesuatu perkara  Sangat kurang daripada biasa/Definitely less than I used
I have look forward with enjoyments to to do
things  Tiada langsung/Hardly at all
3.* Saya menyalahkan diri sendiri secara  Ya, sepanjang masa/Yes, most of the time
tidak sepatutnya apabila sesuatu yang  Ya, kadangkala/Yes, some of the time
tidak kena terjadi  Jarang sekali/Not very often
I have blamed myself unnecessarily  Tiada pernah/No, never
when things went wrong
4. Saya berasa risau atau bimbang tanpa  Tidak langsung/No, no at all
sebab  Amat jarang sekali/Hardly ever
I have been anxious or worried for no  Ya, kadangkala/Yes, sometimes
good reason  Ya, sangat kerap/Yes, very often
5.* Saya berasa takut atau panik tanpa  Ya, sangat kerap/Yes, quite a lot
sebab  Ya, kadangkala/Yes, sometimes
I have felt scared or panicky for no good  Jarang sekali/No, not so much
reason  Tidak pernah/No, not at all
6.* Saya dibebani oleh terlalu banyak  Ya, kebanyakan masa saya tidak berupaya
masalah menanganinya langsung/ Yes, most of the time I haven’t
Things have been getting on top of me been able to cope at all
 Ya, kadangkala saya tidak berupaya menanganinya
seperti biasa/ Yes, somestimes I haven’t been coping as
well as usual
 Tidak, kebanyakan masa saya berupaya menanganinya
dengan baik/No, most of the time I have coped quite well
 Tiada, saya berupaya menangani semua masalah dengan
baik pada setiap masa/No, I have been coping as well as
ever
7.* Saya berasa sungguh sedih sehingga  Kebanyakan masa/ Yes, most of the time
saya mengalami kesukaran untuk tidur  Kadang-kadang/ Yes, sometimes
I have been so unhappy that I have had  Jarang-jarang sekali/ Not very often
difficulty sleeping  Tidak pernah/ No, not at all
8.* Saya berasa sedih atau serabut  Ya, kebanyakan masa/ Yes, most of the time
I have felt sad or miserable  Ya, agak kerap/ Yes, quite often
 Jarang-jarang sekali/Not very often
 Tidak pernah/ No, never
9.* Saya berasa sangat sedih sehingga saya  Ya, kebanyakan masa/ Yes, most of the time
menangis  Ya, agak kerap/ Yes, quite often
I have been so unhappy that I have been  Hanya sekali sekala/ Only occasionally
crying  Tidak pernah/ No, never
10.* Pernah terlintas di fikiran saya keinginan  Ya, kebanyakan masa/ Yes, quite often
untuk mencederakan diri sendiri  Ya, agak kerap/ Sometimes
The thought of harming myself has  Amat jarang sekali/ Hardly ever
occured to me  Tidak pernah/ Never
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PEMARKAHAN
SCORING
SOALAN 1, 2 & 4 (tanpa *) diberi skor 0, 1, 2 atau 3 di mana kotak paling atas adalah 0 dan kotak paling bawah
adalah 3.
QUESTIONS 1, 2, & 4 (without an *) Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as
3.
SOALAN 3, 5-10 (dengan *) diberi skor terbalik di mana kotak paling atas adalah 3 dan kotak paling bawah adalah
0. QUESTIONS 3, 5-10 (marked with an *) Are reverse scored, with the top box scored as a 3 and the bottom box
scored as 0.
Markah tertinggi: 30
Maximum score: 30
Cut-off EPDS versi Bahasa Melayu: ≥ 12

Cut-off for Malay version of EPDS: ≥ 12
Sila buat penilaian risiko bunuh diri jika soalan 10 > 0

Please assess suicidal risks if question 10 > 0
B. GAD-7 Scale Scoring

GENERALISED ANXIETY DISORDER (GAD) -7 (Malay version)
Dalam tempoh 2 minggu lepas, berapa kerapkali anda terganggu oleh masalah berikut? /
Over the last 2 weeks, how often have you been bothered by any of the following problems?
No. Questions Coding
Q1 Berasa resah, gelisah atau tegang. Tidak pernah sama sekali/ Not at all 0
Beberapa hari/ Several days 1
Feeling nervous, anxious or on edge. Lebih dari seminggu/ More than half the days 2
Hampir setiap hari/ Nearly every day 3
Q2 Tidak dapat menghentikan atau mengawal Tidak pernah sama sekali/ Not at all 0
kebimbangan. Beberapa hari/ Several days 1
Lebih dari seminggu/ More than half the days 2
Not being able to stop or control worrying.
Hampir setiap hari/ Nearly every day 3
Q3 Terlalu bimbang mengenai pelbagai perkara Tidak pernah sama sekali/ Not at all 0
yang berlainan. Beberapa hari/ Several days 1
Worrying too much about different things.
Hampir setiap hari/ Nearly everyday 3
Q4 Mempunyai masalh untuk tenang. Tidak pernah sama sekali/ Not at all 0
Having trouble relaxing. Lebih dari seminggu/ More than half the days 2
Q5 Terlalu resah sehingga susah untuk berdiam Tidak pernah sama sekali/ Not at all 0
diri. Beberapa hari/ Several days 1
Being so restless it is hard to sit still.
Q6 Mudah menjadi rimas dan menjengkelkan. Tidak pernah sama sekali/ Not at all 0
Being easily annoyed or irritable. Lebih dari seminggu/ More than half the days 2
Q7 Berasa takaut bahawa sesuatu yang buruk akan Tidak pernah sama sekali/ Not at all 0
terjadi. Beberapa hari/ Several days 1
Feeling afraid as if something awful might
happen.
Scoring: GAD-7 positive ≥ 8 GAD-7 negative < 8
96
8.2 Management of Mental Health Disorders in Pregnancy
1 Pre-pregnancy • Refer FMS /psychiatrist for assessment.
• Effective contraception if women are taking FDA category C
and D medication.
2 Booking • Refer psychiatrist for assessment.
• Assess:
➢ Symptoms related to mental disorder, duration and
severity of symptoms.
➢ Current or past treatment of mental disorder and
response to treatment/ previous hospitalisations.
➢ Adherence to treatment.
➢ Assessment of family and social support (family, housing,
employment, economic).
➢ Preparedness towards the pregnancy and acceptance of
pregnancy (planned / unplanned pregnancy).
➢ Mental disorder during previous pregnancy.
➢ Risk of self-harm and suicide.
➢ Possibility of domestic violence and sexual abuse.
• Screen for substance abuse, e.g. alcohol, smoking, drugs.
3 Subsequent • Shared care between FMS / psychiatrist / O&G.
antenatal follow- • Detailed scan at 24 weeks depends on type of medication
up taken.
• MOGTT for patient on antipsychotic medication.
• Monitor regularly for symptoms of relapse throughout
pregnancy.
4 Delivery • Generally, may allow postdate unless specified otherwise.
• Routine discharge procedure.
5 Postpartum • Look for symptoms of postpartum psychosis / depression –
EPDS during home visit.
• Assess risk of infanticide and mother-infant interaction.
97
• Contraception counselling for patient (refer to MEC).
• Review family support.
• Follow up in psychiatry clinic.
• Pre-pregnancy clinic appointment at 3/12.
6 Lactation • Encourage breast feeding.
• Advise to take psychotropic medication just after
breastfeeding.
• Monitor the baby for adverse effects such as drowsiness,
hypotonia, rigidity, tremor and withdrawal symptoms
REMARKS:
1. Pre-pregnancy
Discuss with all women of childbearing potential who have a new, existing or past
mental disorder: The use of contraception and any plans for a pregnancy
a. How pregnancy and childbirth might affect a mental health problem, including the
risk of relapse.
b. How a mental health problem and its treatment might affect the woman, the fetus
and baby.
c. How a mental health problem and its treatment might affect parenting.
2. Advice on treatment for women with mental disorder in pregnancy:
a. benefits and potential risks of treatment to mother and fetus/ breastfed baby in
both short- and long-term.
b. possible consequences of no treatment or if treatment is changed or stopped
abruptly.
c. uncertainty of benefits and risks of treatments in perinatal period.
3. High risk group:
a. Those with physical health problem causing disability.
b. Past history of mental disorder.
c. Family History of depression/mental disorder.
d. Substance abuse.
4. Risk factors for perinatal depression:
a. Socioeconomic disadvantage
b. Unintended pregnancy
98
c. Younger age
d. Unmarried
e. Lack of intimate partner empathy and support
f. Hostile in-laws
g. Intimate partner violence
h. Insufficient emotional and practical support
i. History of mental health problems
5. Use of depot preparation e.g. fluphenazine decanoate during pregnancy should be
avoided in order to limit the duration of any possible toxic effect to the fetus.
6. Do not offer valproate/ carbamazepine/lithium for acute or long-term treatment of a
mental health problem in women of childbearing potential.
7. FDA category of drug used for mental health disorder in pregnancy:
Group Drugs Category Side effects
Antipsychotic Haloperidol C A very low association
Chlorpromazine C non-structural
Olanzepine C teratogenicity has been
Clozapine B associated with
Risperidone C haloperidol.
Quetiapine C No report on major
Aripiprazole C teratogenic potential
Amisulpride C with other drugs.
Asenapine C
Anxiolytics Diazepam D Some studies suggest
(Benzodiazepines) Alprazolam D oral cleft palate defects.
Clonazepam C
Lorazepam D
Antiepileptics and Valproic acid D Lithium usage in 1st
mood stabilizers Lamotrigine C trimester has been
Lithium D associated with
Carbamazepine D increased risk of
cardiovascular
malformation,
99
specifically Ebstein
anomaly.
Valproic acid &
Carbamazepine usage
in 1st trimester 10-fold
increase in neural tube
defects. Oral clefts
have also been
reported.
SSRI Escitalopram C No serious side effects
Sertraline C of SSRIS have been
Fluoxetine C reported.
Fluvoxamine C
Tricyclic Amitriptyline C No report of
antidepressants Clomipramine C teratogenicity
Some cardiac disorders
and persistent
pulmonary artery
hypertension have
been reported.
Other Agomelatine B Agomelatine were
antidepressants Mirtazapine C reported to cause
Duloxetine C elevated liver enzymes.
Venlafaxine C No confirmed risk of
birth defects.
Reference(s):
1. Antenatal and postnatal mental health: clinical management and service guidance. NICE
guidelines [CG192]. Published date: 17 December 2014. Last updated Feb 2020.
2. Malaysia CPG on Management of schizophrenia in adults, May 2009.
3. Malaysia CPG on Management of major depressive disorder.2nd edition, 2019.
4. Review Article: Psychiatric Disorders During Pregnancy and Postpartum, Sharma et al,
Journal of Pregnancy and Child Health 2017, 4:2.
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SECTION 9 NEUROLOGICAL DISORDER IN PREGNANCY
9.1 Epilepsy in Pregnancy
1 Pre-pregnancy • All women with epilepsy in the reproductive age should be
referred to the pre-pregnancy clinic.
• Review medication by neuromedical team if plan to conceive.
• Advise to take folic acid 5mg daily.
• Aim for seizure control at least 1 year before conception.
• Use the lowest effective dose of a single anticonvulsant
whenever possible.
2 Booking • Do not stop antiepileptic drug.
• Refer to neuromedical team if women previously under
neuromedical team follow up, to review medication.
• Combined Clinic appointment.
• Folic acid 5mg daily till delivery.
• Maintain the pre-existing therapy if seizure is well controlled.
3 Subsequent • Shared care between FMS and Combined Clinic.
antenatal follow- • Detailed scan at 24 weeks.
up • Perform serial growth scans monthly from 28 weeks of
gestation.
• Watch for sign of depression, anxiety and neuropsychiatric
symptoms in mothers on AED.
• Advise compliance to AED.
• Advise to avoid triggering factor such as sleep deprivation
and stress.
• Routine monitoring of serum AED level is not recommended
during pregnancy.
4 Delivery • Generally, may allow postdate unless specified otherwise.
5 Postpartum • Reinforce the importance of contraception and planned
pregnancy (refer MEC)
• AED dose adjustment (if required) need further discussion
101
with physician/ neurologist
• Monitor neonates for side effects of AEDs e.g. drowsiness,
jitteriness and hypotonia.
• Screen mothers for depression.
• Advise on safety issues and strategies to prevent accidental
injury with involvement of family members.
• Neurology/ medical clinic appointment.
• FMS pre-pregnancy clinic appointment at 3/12 postnatal (if
future pregnancy is possible).
REMARKS:
1. Seizure frequency in pregnancy: 60% no change, 30% increase, 10% decrease.
2. Risk of seizures greatest during delivery period (due to pain, emotional stress and
hyperventilation).
3. Give woman a clear understanding of the risks of uncontrolled seizures and the
possible teratogenicity of AED. Where possible, avoid Sodium valproate and AED
poly-therapy. Phenytoin, Carbamazepine, Sodium Valproate, Lamotrigine and
Levetiracetam cross the placenta.
4. In utero exposure to carbamazepine, lamotrigine, levetiracetam and phenytoin
does not appear to adversely affect neurodevelopment of the child.
5. Effects of AED on pregnancy:
a. Mother – increased risk of pre-eclampsia, premature delivery, hemorrhage,
caesarean delivery, IUGR, stillbirth
b. Fetus - Major congenital malformation (50% increased risk with sodium
valproate, carbamazepine, phenytoin)
1. AEDs FDA category Side effects
Phenytoin D Cleft lip and palate, cardiac defects,
craniofacial defects, digital
hypoplasia
Sodium Valproate X Neural tube defects, cardiac defects,
urogenital malformations
Carbamazepine D Neural tube defects
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Ethosuximide C Cleft palate
Vigabatrin C Cleft palate
Lamotrigine C Oro-facial cleft
Topiramate D Cleft lip and palate, hyposoadias
Levetiracetam C No increased risk
6. Safety strategies:
i. Nurse the baby on the floor
ii. Use very shallow baby baths and do not bathe the baby unaccompanied
iii. Lay the baby down if there is a warning aura
iv. No co-sleeping with baby in parent’s bed
v. Avoid sleep deprivation and alcohol
Reference(s):
1. Green-top Guideline No.68, June 2016
2. SIGN- Scottish Intercollegiate Guidelines Network, May 2015
3. Consensus guidelines on the management of epilepsy 2010 (Malaysia Guideline)
4. Women and epilepsy. Edmonton Epilepsy Association, 2011
5. Clinical Guideline Epilepsy and pregnancy management, SA Maternal and neonatal clinical
network 19 December 2014
103
SECTION 10 OBSTETRIC PROBLEMS
10.1 Abnormal Fetal Growth
10.1.1 Small for Gestational Age (SGA) or Fetal Growth Restriction
(FGR)
1 Pre-pregnancy • Identify women with risk factors**
• Optimize modifiable preconception risk factors:
➢ Aim for good control of hypertension, DM.
➢ Stop smoking/ substance abuse.
2 Booking • Dating scan in first trimester via CRL.
• Assess for risk factors for SGA**
• Consider aspirin and calcium prophylaxis (refer to Section
5.3).
3 Subsequent • Optimize pre-existing medical comorbid (HPT, DM,
antenatal follow- anaemia).
up • Refer O&G if growth fetal growth parameters < 10 centiles
or suspected FGR before 24 weeks.
• Measure SFH at each antenatal clinic visit from 24 weeks
onwards and plot on customized chart.
• For 2-3 weekly fetal growth scan from 28 weeks onwards.
• Delivery as near term as possible.
• Timing and mode of delivery to be outlined by O&G team.
5 Postpartum • Refer newborn to Paediatric team if indicated.
• Contraception.
• Advise early booking for next pregnancy.
6 Lactation Encourage breastfeeding
104
REMARKS:
1. Definition:
a. SGA is defined as fetal abdominal circumference (AC) or estimated fetal
weight (EFW) <10th centile.
b. FGR is defined as pathological restriction of the genetic growth potential.
2. **Risk factors for SGA or FGR during booking assessment in first trimester:
Minor risk factors Major risk factors

a. Maternal age 35 years a. Maternal age >40
b. IVF singleton pregnancy b. Smoker >11 cigarettes/day
c. Nulliparity c. Paternal SGA
d. BMI<20 d. Cocaine
e. BMI 25-34.9 e. Daily vigorous exercise
f. Smoker 1-10 cigarettes/day f. Previous SGA baby
g. Low fruit intake pre-pregnancy g. Previous stillbirth
h. Previous pre-eclampsia h. Maternal SGA
i. Pregnancy interval <6 months i. Chronic hypertension
j. Pregnancy interval  60 j. Diabetes with vascular disease
months k. Renal impairment
l. Antiphospholipid syndrome
m. Heavy bleeding similar to menses
n. PAPP-A <0.4 MoM
Reference(s):
1. Sabah Obstetrics Shared Care Guideline (3rd edition) (2018)
2. RCOG, Green-top Guidelines No. 31 (2014)
105
10.1.2 Large for Gestational Age or Macrosomia
1 Pre-pregnancy • Identify women with risk factors:
➢ Pre-existing DM
➢ Dyslipidaemia
➢ Previous history of macrosomic baby
➢ Obesity
➢ Constitutional factors (familial predisposition)
• Optimize modifiable preconception medical conditions:
➢ Aim for good control of DM, dyslipidaemia
➢ Advise for weight loss
• Discuss regarding possible pregnancy outcome with LGA /
Macrosomia:
➢ Preterm delivery
➢ Prolonged labor / obstructed labor
➢ Shoulder dystocia in vaginal delivery
➢ Caesarean section
2 Booking • Assess at booking for risk factors for LGA.
• MOGTT if previous history of macrosomic baby.
3 Subsequent • Monthly fetal growth scan from 24 weeks.
antenatal follow- • If growth parameters >90th centile or suspected macrosomia
up (EFW>4kg).
➢ For MOGTT (Omit if already perform at 26-28 weeks).
➢ Refer O&G by 34-36 weeks for assessment and plan of
delivery.
• If pre-existing DM/GDM, to optimize blood sugar control to
reduce risk of macrosomia.
• Advise for exercise suitable for pregnancy (aerobic and
strength conditioning exercises).
• Timing and mode of delivery to be outlined by O&G team.
5 Postpartum • Refer newborn to Paediatric team if birth weight >4kg
106
• MOGTT at 6 weeks postpartum
• Contraception
6 Lactation • Encourage breastfeeding
REMARKS:
1. Decision on mode of delivery for suspected macrosomia / at risk for shoulder
dystocia in index pregnancy would be made after assessment at 34-36 weeks,
including:
a. Previous shoulder dystocia
b. Previous pregnancy outcome
c. Presence / absence of DM/GDM in index pregnancy
d. Clinical estimation of estimated birth weight
e. Ultrasound parameters (AC, EFW)
Reference(s):
2. RCOG, Green-top Guidelines No. 42 (2012)
3. ACOG, Practice Bulletin No. 216 – Macrosomia (2020)
107
10.2 Bad Obstetric History
10.2.1 History of Stillbirth/ Abnormal Fetus/ Neonatal Death
1 Pre-pregnancy • Refer FMS or O&G for assessment & counselling.
• Assess mental health.
• Obtain a thorough history of abnormal fetus/ ENND, and/ or
assess for predisposing factors**
• Optimize pre-existing medical conditions and change to a
pregnancy-safe medication regime.
• Perform screening tests:
➢ OGTT, TSH, HBs Ag, VDRL, HIV screening
• Advice on immunization^
• Prescribe Folic acid 5mg daily at least 3 months before.
conception until 12 weeks of gestation (for those at high risk
of neural tube defects).
• Advise for smoking cessation and weight loss if applicable.
• Refer to O&G clinic if had history of syndromic baby or
congenital abnormality for genetic counselling if service
available.
• Best to conceive when mentally and physically ready with
contraception plan in place.
2 Booking • First trimester dating scan.
• To remind patient to bring record of previous pregnancy or
record about syndromic child if still follow up under paediatric
team.
• Refer FMS for shared care – counselling should include
offering prenatal screening test, if indicated.
• Refer O&G/ MFM if patient agree for prenatal screening test
(refer to Section 18).
• MOGTT/ Infectious screening# / Optimize pre-existing
medical condition.
108
• If patient appears to have symptoms of psychological stress
or PTSD from previous abnormal fetus/ ENND, refer to
Section 10.2.2 and manage accordingly.
3 Subsequent • Refer O&G/ MFM for detail scan (once confirmed viability
antenatal follow- and gestation).
up • Monthly fetal growth scan from 24 weeks of gestation to look
for abnormal fetal growth.
• Timing and mode of delivery as per obstetric indications.
5 Postpartum • Refer newborn to Paediatric team if indicated.
• Contraception.
6 Lactation Encourage breastfeeding
REMARKS:
1. Definition
a. Stillbirth – intrauterine death ≥ 22 weeks gestation or birth weight ≥ 500g if
uncertain of gestation
b. Early Neonatal Death (ENND) - death of a newborn between 0 – 6 days of life.
c. Late Neonatal Death – death of a newborn between 7 – 27 days of life
More than 80% of ENND are caused by premature birth, complications during labor
and delivery, and infections.
2. **Predisposing factors to stillbirth, abnormal fetus or neonatal death
a. Past history of abnormal fetus / ENND/ perinatal death
b. Pre-existing medical conditions – DM, HPT, obesity, underweight, thyroid,
chronic renal disease, DM, thrombophilia, SLE
c. Sexually-transmitted infections – Chlamydia, Gonorrhoea, Syphillis, HIV
d. Urogenital infections – Group B Strep, Urinary tract infections
e. Advanced maternal age
f. Fetal aneuploidy – Trisomy 21, 18 and 13
3. #Recommended Preconception Infectious Disease Screening:
a. Syphillis
b. HIV
c. HBs Ag
109
d. TORCHES – to be taken in O&G clinic if indicated
4. ^Recommended Preconception Immunization:
a. Hepatitis B
b. Influenza
c. MMR – avoid pregnancy for three months after vaccination
d. DTaP – Diphtheria, Tetanus, Pertussis
e. Varicella – avoid pregnancy for one month after vaccination
Reference(s):
1. Malaysian Health at A Glance 2018. Ministry of Health Malaysia, 2019.
2. Farahi N, Zolotor A. Recommendations for preconception counselling and care. Am Fam
Physician. 2013;88(8):499-506
110
10.2.2 Traumatic Delivery
1 Pre-pregnancy • Identify women with consequences of a past traumatic
delivery such as anxiety, stress and avoidance of future
pregnancy:
• Assess for symptoms of psychological stress and post-
traumatic stress disorder (PTSD) (refer to REMARKS)
• Refer FMS for risk stratification and to decide on referral
pathway.
➢ Refer Counsellor / Psychologist / Psychiatrist for
counselling as needed.
➢ Refer O&G if past obstetric-related trauma needs to be
rectified.
• Best to conceive when mentally and physically ready with
contraception plan in place.
2 Booking • Obtain a thorough history of past traumatic delivery, and/or
look for predisposing factors to trauma (refer to REMARKS)
• Assess for symptoms of psychological stress and PTSD.
• Refer FMS for risk stratification and to decide on referral
pathway as needed (refer to REMARKS)
3 Subsequent • Interval assessment for symptoms of psychological stress /
antenatal follow- PTSD as they may escalate during 3rd trimester
up • For those with symptoms related to past traumatic delivery,
O&G to:
➢ Revisit previous labour and delivery to explore issues and
feelings concerning disappointment or fear
➢ Discuss mode of delivery, pain relief and maternal
request for this delivery
➢ Encourage patient to join antenatal classes
• For those with traumatic caesarean delivery – refer to O&G
team for assessment for the suitability of trial of vaginal
delivery.
111
4 Delivery • Hospital with specialist
5 Lactation • Encourage breastfeeding to promote mother-infant bonding

(if not medically contraindicated)
REMARKS:
1. Past traumatic delivery may involve but not limited to the following:
a. Fear of maternal or fetal death
b. Long and difficult labour
c. Unrelieved pain during labour and/or childbirth
d. Medical interventions (Pitocin, forceps, vacuum extraction, caesarean delivery)
e. Perceived loss of control during delivery experience
f. Unexpected bad outcome of delivery: ill infant or intrauterine death
g. Labour complications (e.g., severe perineal injuries, massive postpartum
haemorrhage, severe surgical site infection, etc)
2. Other predisposing factors to trauma:
a. Childhood sexual abuse
b. Lack of social support
c. Lack of information
d. Poor coping strategies
e. Perception of hostile or uncaring staff
3. Symptoms of psychological stress:
a. Anxiety symptoms
b. Withdrawn
c. Agitated
d. Appearing dazed
e. Disorientated
f. Depressed
g. Amnesia
4. Symptoms of post-traumatic stress disorder (PTSD):
a. Flashbacks
b. Nightmares
c. Emotionally numbed
112
d. Depression
e. Anxiety
f. Bonding difficulties
g. Fear of sexual intimacies
h. Avoidance of normal vaginal delivery or future pregnancy
i. Avoidance of baby
History of Past Traumatic Delivery
Symptoms of psychological stress / PTSD
YES NO
Refer FMS Follow routine

for initial consult & antenatal follow up
counselling
If require further intervention or has Look for symptoms of

unresolved issues, to refer to one psychological stress /
or more of the following: PTSD
Counsellor Psychiatrist YES NO
*Referral to
Clinical O&G O&G as per
Psychologist obstetric
indication
REFERRAL PATHWAY FOR PAST TRAUMATIC DELIVERY
113
10.3 Breech and Malpresentation
1 Subsequent • Refer O&G if malpresentation/ breech at 36 weeks.
antenatal follow- • Rule out placenta praevia, fetal anomalies, oligohydramnios
up / polyhydramnios, pelvic tumour and other possible factors
causing malpresentation.
• Breech with successful ECV:
➢ To be seen in Health Clinic within one week to assess
presentation.
➢ Refer back to O&G if recurrent malpresentation.
➢ If cephalic, continue routine antenatal follow up with
timing and mode of delivery as per obstetric indication.
• Outlined by O&G team if indicated.
3 Postpartum • Contraception.
• Advise early booking for next pregnancy.
REMARKS:
• Breech presentation
o If patient has underlying previous scar, refer O&G to get date for elective
caesarean section.
o If no previous scar, refer for admission to Daycare Unit at 37-38 weeks for O&G
to assess suitability for external cephalic version (ECV).
• Malpresentation (other than breech)
o If patient has underlying previous scar, to admit ward for assessment and given
date for elective caesarean section.
o If no previous scar, refer for assessment and delivery plan.
• External Cephalic Version (ECV) Counseling
a. Manipulation of the fetus through the maternal abdomen to a cephalic
presentation.
b. Offered from 36 weeks in nulliparous, 37 weeks in multiparous.
114
c. Procedure can be uncomfortable.
d. Success rate 30-80%, trained operator 50%.
e. 0.5 % of cases need immediate caesarean section & no excess perinatal
morbidity and perinatal mortality.
f. Spontaneous reversion to breech presentation after successful ECV <5%.
g. Had very low complication rate.
h. Risk of complications:
▪ Placental abruption
▪ Uterine rupture
▪ Feto-maternal haemorrhage
i. Contraindication:
▪ SGA fetus with abnormal doppler parameters
▪ Hypertensive disorder in pregnancy
▪ Oligohydramnios
▪ Major fetal abnormalities
▪ Scarred uterus
▪ Unstable lie
▪ Where caesarean delivery is required
▪ APH within 7 days
▪ Abnormal CTG
▪ Major uterine anomaly
▪ Ruptured membranes
▪ Multiple pregnancy (except delivery of second twin)
Reference(s):
2. Royal College of Obstetricians & Gynaecologists (Green Top Guideline No 20b), March 2017
3. External cephalic version and reducing the incidence of breech presentation. RCOG guideline
No.20a, Dec 2006, review 2010
115
10.4 Chickenpox in Pregnancy
1 Booking • Pregnancy with symptoms:
➢ Refer to O&G and Medical team if
▪ Developed complications.
▪ Women with underlying risk factors or co-
morbidities.
➢ Outpatient management if no severe presentation
➢ Treatment:
▪ Isolation
▪ Oral Acyclovir 800mg 5 times daily for 7 days
(if onset <72 hours and >20 weeks gestations)
▪ if <20 weeks POG need to discuss risk &
benefit of Acyclovir
➢ Education:
▪ To prevent spread of disease until the lesions
have crusted (usually about 5 days after the
onset of rash)
▪ Hygiene care to prevent secondary bacterial
infection of the lesions
2 Subsequent • Refer O&G for detail scan if infection occurred ≤20 weeks
antenatal follow-up of gestation
3 Delivery • Preferably to delay delivery 7 days after onset
4 Postpartum • Encourage breast feeding
• Refer baby to Paediatrician after delivery, irrespective
of the gestation when maternal varicella zoster
infection developed
• Refer baby to paediatrician if born to mothers with
chickenpox within 7 days before to 7 days after delivery -
receive prophylaxis VZIG (Varicella Zoster
Immunoglobulin) with or without acyclovir
116
REMARKS:
1. Causative agent: Varicella zoster virus.
2. Mode of transmission: Direct contact with vesicle fluid & respiratory droplet (Two
days before appearance of rash up to the healing of active rash)
3. Maternal complication*
a. 5-20% pneumonia (40% risk of death)
b. Hepatitis
c. Encephalitis
4. Fetal complications*
a. Congenital Varicella Syndrome (0.4 to 2%) early 2nd trimester (< 20 week)
▪ Skin scarring in dermatomal distribution
▪ Eye defects (microphthalmia, chorioretinitis, cataracts)
▪ Limb hypoplasia
▪ Neurological abnormalities (microcephaly, cerebral cortical atrophy,
mental retardation or dysfunction of bowel and bladder sphincters)
5. Neonatal complication*
a. Neonatal varicella (within 10 DOL) – if mother developed rash 5 days before or
2 days after delivery
▪ If maternal infection occurs 1-4 weeks before delivery, up to 50% of
infants are infected and up to 23% develop clinical varicella
▪ Severe chicken pox may occur if infants are born within 7 days of onset of
mother’s rash or if mother develops rash up to 7 days after delivery
• Risk of death - 30%
6. Severe presentation needs immediate referral+
a. Dense rash
b. Immunosuppression use
c. Respiratory symptoms
d. Neurological symptoms
e. Haemorrhagic rashes
7. Risk factor & comorbid^
a. Smoker
b. Chronic lung disease
c. Corticosteroids use in the preceding 3 months
117
d. In the second half of pregnancy
2. Aim of treatment - to reduce maternal complication. Significant varicella infection
such as pneumonitis should be treated.
Reference(s):
1. Royal College of Obstetricians & Gynaecologists (Green Top Guideline No 13), January 2015.
2. Society of Obstetricians & Gynaecologists of Canada, Clinical Practice Guideline, March 2012
3. Public Health England. Varicella: the green book, chapter 34. London: Public Health England;
2012[ht tps ://www.gov.uk/government/publ icat ions /varicella-the-green-book-chapter-34].
118
10.5 Fetal Movement Assessment
1 At diagnosis • If reduced fetal movement perceived < 28 weeks, if fetal
heart rate present, normal ultrasound assessment and
without underlying risk factors – reassurance.
• If reduced fetal movement perceived ≥ 28 weeks, refer
O&G for;
➢ Detailed clinical assessment.
➢ May require hospital admission.
2 Subsequent • Monitoring and follow-up plan as per routine
antenatal follow- • To refer O&G if history of repeated reduced FM for time of
up delivery
3 Delivery • Time of delivery as per obstetric indication
REMARKS:
1. Perceived fetal movements are defined as the maternal sensation of any discrete
kick, flutter, swish or roll.
2. Most women are aware of fetal movements by18-20 weeks of gestation
(Quickening)
a. Multiparity: as early as 16 weeks
b. Primiparity: around 20 weeks
3. Fetal heart assessment using Daptone after 28 weeks gestation (over 1 minute):
a. Normal (FHR 110-160 bpm)
b. Absent
c. Abnormal:
▪ Bradycardia (FHR <110 bpm)
▪ Tachycardia (FHR >160 bpm)
▪ Irregular
4. Consider reduce fetal movement:
a. <10 movements in a day
119
b. Progressively longer in a day to reach 10 kicks
c. No movement in 2 hours
d. Any subjective feeling of reduced fetal movement (including strength and
frequency of fetal movement)
5. It is important to educate women to record fetal movement in Daily Fetal
Movement Chart (DFMC). Women are advised to lie on left side and focus on the
counting of fetal movement for 2 hours. If they do not feel 10 or more discrete
movement should seek for consultation.
Reference(s):
1. Martin L Gimovsky MD, Gene Freylikhman MD and Kenneth A Kappy MD. Fetal Heart Rate
Monitoring Casebook: Decreased Fetal Movement. Journal of Perinatology (2002) 22, 333.
2. Predicting poor perinatal outcome in women who present with decreased fetal movements.
O'Sullivan O, Stephen G, Martindale E, Heazell AE. Obstet Gynaecol. 2009 Nov;29(8):705-
10
3. Reducing stillbirths: screening and monitoring during pregnancy and labour.
Haws RA, Yakoob MY, Soomro T, Menezes EV, Darmstadt GL, Bhutta ZA. . BMC Pregnancy
Childbirth. 2009 May 7;9 Suppl 1: S5.
4. Methods of fetal movement counting and the detection of fetal compromise. Heazell AE, Frøen
JF. J Obstet Gynaecol. 2008 Feb;28(2):147-54
5. Stillbirth: Preventable tragedy or a lethal “act of nature”? Robert L. Barbieri, MD Editor in Chief.
OBG Management | February 2010 | Vol. 22 No. 2
6. Review: Reduced Fetal Movements. Julia Unterscheider/Richard Horgan/ Keelin
O’Donoghue/Richard Greene. The Obstetrician & Gynaecologist 2009:11: 245 -251.
7. Royal College of Obstetricians & Gynaecologists (Green Top Guideline No 57), February
2011.
120
10.6 Group B Streptococcus Carrier in Pregnancy
1 Pre-pregnancy • No role for GBS screening
2 At booking • Routine screening for antenatal GBS carrier in not
recommended.
• Refer to O&G if previous history of newborn GBS infection.
3 At diagnosis • For GBS positive vaginal swab:
➢ It is not beneficial to give antibiotics during pregnancy
before labour starts if asymptomatic
➢ Treat with antibiotic if symptomatic
➢ Intrapartum antibiotic prophylaxis is recommended
• For GBS bacteriuria:
➢ Treat with antibiotics during pregnancy
➢ Intrapartum antibiotic prophylaxis is recommended
4 Subsequent • Routine antenatal follow up.
antenatal follow- • Symptoms of UTI should be assessed.
up • Intrapartum antibiotic prophylaxis (IAP) should be given
to pregnant women with:
➢ Previous infant with neonatal GBS disease
➢ GBS bacteriuria in current pregnancy
➢ GBS positive vaginal swab in current pregnancy
➢ Intrapartum pyrexia (≥38°C)
➢ Amniotic membrane rupture ≥18 hours
➢ Previous colonization with GBS
• For women who required GBS prophylaxis in labour, infants
should be referred to Paediatrics team for assessment
Reference(s):
1. Liz Horsley. CDC Updates Guidelines for the Prevention of Perinatal GBS Disease. Am Fam
Physician. 2011 May 1:83(9):1106-1110
121
10.7 Low Lying Placenta
1 Pre pregnancy • Identification of Risk Factor & Counselling:
➢ Past history of uterine surgery (e.g. LSCS, myomectomy,
cornual pregnancy)
➢ Increasing maternal age
➢ Use of assisted reproductive technology
➢ Maternal Smoking
➢ Uterine structural anomaly
2 At diagnosis • Risk Factor identification (as above).
• Ultrasound assessment: dating & placenta localization after
16 weeks. If placental position covers or is less than 2cm
from the internal os, to repeat transabdominal ultrasound at
28 weeks (by MO or FMS).
• Baseline Hb.
3 Subsequent • Refer O&G if anterior low-lying placenta with previous history
antenatal follow- of uterine scar at 28 weeks.
up • Refer O&G at 32 weeks if placental edge persistently less
than 2cm from internal os at 28w
• Refer O&G at 28 weeks, if placenta covering os
• Discuss with patient potentially need of hospitalisation,
consider these factors:
➢ Distance between home & hospital
➢ Availability of transportation
➢ Previous episodes of per vaginal bleed
➢ Hb result <11 lower threshold to start parenteral iron in
IDA patient
• Counselling:
➢ Risk of preterm delivery
➢ Risk of antepartum haemorrhage
➢ Safety precaution: availability of someone if emergency
happened at home & access to hospital
122
4 Delivery • Hospital delivery with specialist
6 Lactation • Encourage breast feeding
REMARKS:
1. For pregnancies of more than 16 weeks of gestation, the term low lying placenta
should be used when the placental edge is less than 20mm from the internal os on
transabdominal or transvaginal scanning.
2. Low lying placenta: placenta edge is less than 20mm from the internal os or previa
(covering the os).
3. Placenta previa: when the placenta lies directly over the internal os.
Reference(s):
1. Guideline on management of placenta previa. RCOG. 2018
2. Perinatal care manual 3rd edition
3. Placenta previa: Management. Charles J Lockwood, Karen Russo-Stieglitz. 28th Jan 2020
123
10.8 Multiple Pregnancy
1 Booking / • First trimester ultrasound is recommended (best at 14
diagnosis weeks) - difficult to determine chorionicity after 14 weeks.
• Refer O&G within 1 week to determine chorionicity,
counselling and outline of antenatal follow-up plan
• Urgent referral if:
➢ Monoamniocity
➢ Suspected Twin-twin Transfusion Syndrome (TTTS)
➢ Fetal structural abnormality
➢ Suspected discordance in weight >18%
➢ Higher order pregnancy (>3)
➢ Single fetal demise
2 Subsequent • If Monochorionic (MC) twins or higher order pregnancy (≥3):
antenatal follow- to follow up O&G Clinic of hospital (high risk pregnancy)
up • If Dichorionic (DC) twins without growth discrepancy, patient
will be followed-up both at health clinic and hospital (general
O&G clinic)
• All multiple pregnancies require 2- 4weekly growth scan
depends on chorionicity
• Higher order pregnancy (≥3) will require inpatient
surveillance after 26 – 28 weeks till delivery.
3 Delivery • Outlined by O&G:
➢ Higher order: soon after diagnosis is confirmed
➢ Uncomplicated MCMA: deliver by 32 – 34 weeks.
➢ Uncomplicated MCDA: deliver by 36 -37 weeks
• Uncomplicated DCDA – deliver by 37- 38 weeks
4 Postpartum • Delivery in hospital with specialist
5 Lactation • Discuss option of contraception with patient/ couple
• Contraception
• Breastfeeding
124
REMARKS:
1. Multiple pregnancy is one of the moderate risk factors for pre-eclampsia.

2. Calculation of growth discrepancies between twin:
EFW (larger fetus) - EFW (smaller fetus) / EFW larger fetus x 100%
3. Estimated gestational age from the largest fetus based on the earliest scan.
4. Document the position fetus position according to relationship to maternal position,
e.g. maternal left/ right/ upper/ lower
5. Determine chorionicity and amnionicity at the earliest ultrasound scan:
a. The number of placental masses
b. The presence of separating amniotic membrane
c. The lambda or T-sign
d. Discordant fetal sex in dichorionic diamniotic pregnancy
6. Refer to O&G clinic for assessment if abnormal amniotic fluid volume:
a. The amniotic sac of one baby has DVP less than 2cm
b. The amniotic sac of one baby has DVP more than 8cm
7. Vaginal delivery can be offered if:
a. Uncomplicated pregnancy and has progressed beyond 32 weeks
b. No obstetric contraindication to vaginal delivery
c. Leading twin is cephalic presentation
d. No significant size discordance between the twins
Reference(s):
1. SOSCG 2018
2. NICE guideline: Twin & Triplet Pregnancy, Sept 2019.
125
10.9 Previous Uterine Scar(s)
1 Pre pregnancy • Adequate spacing from previous delivery.
2 At booking • Review patient medical record to determine the causes of
previous LSCS / myomectomy.
➢ To look for contraindication for VBAC from previous
uterine surgery.
3 Subsequent • Scan for placental site is essential.
antenatal follow- • To distribute VBAC brochures by 24 weeks.
up • Refer to O&G team:
➢ Low lying placenta
➢ Inter-pregnancy < 18 months
• 1 previous scar:
➢ VBAC counselling 32 - 34 weeks by MO/ FMS at health
clinic (refer to VBAC counselling form in appendix)
▪ To give option regarding mode of delivery.
▪ If opt for repeat CS, to call O&G team at 36 weeks to

get elective CS date.
▪ If opt for vaginal delivery, to go to hospital if in labour.
• Untested scar without operative record - refer O&G clinic

after 28 weeks.
• 2 previous scars, refer O&G team at 32 – 34 weeks.
• Delivery at tertiary hospital for any previous history of scar.

• VBAC is contraindicated in women with previous uterine
rupture or classical scar and in women who have absolute
contraindication to vaginal delivery such as placenta
praevia.
4 Delivery • Timing and mode of delivery as per obstetric indication.
• Hospital delivery with specialist.
126
5 Postpartum • Ensure compliance to thromboprophylaxis treatment if
underwent caesarean section.
• Discuss options of contraception with patient / couple if not
completed family.
• Encourage breast feeding.
REMARKS:
1. VBAC is appropriate for and may be offered to the majority women with singleton
pregnancy of cephalic presentation at 37 weeks or beyond who had single previous
caesarean with or without previous vaginal delivery.
2. Success rate of VBAC is 72-75%.
3. Absolute contraindication for trial of vaginal delivery after caesarean:
a. Previous uterine rupture
b. Previous upper segment uterine incision (hysterotomy, classical uterine incision)
c. Previous cornual pregnancy
d. Previous complex myomectomy
Reference(s):
1. SOSCG, 3rd Edition, 2018.
127
CONSENT FORM FOR VAGINAL BIRTH AFTER CAESEREAN SECTION
(MALAY VERSION)
BORANG PERSETUJUAN:
1. Saya telah diberi penerangan tentang pilihan saya untuk bersalin kali ini dan saya
memahami semua risiko dan kebaikan bagi pilihan-pilihan saya. Saya telah diberi
peluang bertanya dan semua soalan saya telah dijawab.
2. Saya telah menerima, membaca dan memahami isi kandungan risalah tentang VBAC
dan pembedahan ulangan untuk bersalin.
3. Saya memilih
a. VBAC (bersalin biasa/normal selepas pembedahan caeserean)
b. Pembedahan ulangan untuk bersalin kali ini
4. Saya fahami sekiranya saya mempunyai tanda-tanda bersalin sebelum tarikh yang
diberi, saya harus pergi ke hospital dengan segera.
5. Saya fahami sekiranya saya memilih pembedahan ulangan dan saya memasuki
proses bersalin sebelum tarikh pembedahan, saya akan diberi kaunseling sekali lagi
dan jika saya masih mahukan pembedahan, saya akan melalui pembedahan
kecemasan yang berisiko lebih tinggi.
6. Saya fahami sekiranya saya memilih VBAC dan perlu dipaksa bersalin awal untuk
sebab-sebab tertentu, saya menghadapi risiko parut atas rahim terbuka/koyak 2-3 kali
ganda lebih tinggi daripada VBAC biasa, dan juga risiko pmbedahan kecemasan 1.5
kali ganda lebih tinggi daripada VBAC biasa.
7. Tarikh untuk masuk wad adalah pada ________________.
Nama Doktor: Nama Ibu:

Tarikh: No IC/ Pasport:
Tarikh:
128
BERSALIN NORMAL SELEPAS BERSALIN MENGAPA VBAC DISARANKAN?
SECARA PEMBEDAHAN Biasanya 75% ibu yang mencuba VBAC akan berjaya dan 80-
(VAGINAL BIRTH AFTER CAESAREAN- VBAC) 90% akan berjaya jika ibu tersebut pernah bersalin biasa
selepas pembedahan dahulu.
Puan dijemput untuk menghadiri sesi kaunseling untuk
menentukan kaedah berslain bagi kehamilan ini KEBAIKAN BERSALIN NORMAL
Puan diberi temujanji ini kerana puan melalui pembedahan 1. Lebih cepat sembuh
untuk melahirkan anak sebelum ini 2. Dapat balik rumah lebih cepat
3. Kurang sakit selepas bersalin
APAKAH PILIHAN PUAN? 4. Lebih tinggi peluang untuk bersalin biasa selepas ini
1. VBAC- bersalin secara normal 5. Tidak melalui pembedahan
2. Pembedahan semula untuk melahirkan bagi kali ini 6. Tiada risiko bius
APAKAH ITU VBAC? APAKAH RISIKO JIKA MEMILIH ULANGAN

VBAC adalah cara bersalin seperti biasa/normal melalui laluan PEMBEDAHAN UNTUK BERSALIN?
peranakan selepas pembedahan caeserean untuk melahirkan
1. Pembedahan mungkin lebih rumit dan mengambil masa
anak sebelum ini
lebih lama
2. Risiko untuk mendapat darah beku di kaki dan paru-paru
APAKAH RISIKO VBAC?
lebih tinggi
1. Parut atas rahim terbuka/koyak. Tetapi ini jarang berlaku.
3. Mengambil masa lebih lama untuk sembuh dan akan
Risiko yang dijangka adalah <0.5% iaitu 2-6 daripada 1000
berada di wad untuk tempoh masa yang lebih lama
ibu mencuba VBAC
4. Kecederaan pada organ berdekatan, seperti pundi
2. Risiko ini akan meningkat kepada 0.6-2.4% sekiranya
kencing dan usus
melibatkan proses pencetusan kelahiran
5. Risiko bahawa bayi puan akan menghadapi kesusahan
3. Risiko bayi lemas atau kerosakan otak adalah sangat
untuk mula bernafas
rendah 0.2%
6. Puan akan memerlukan pembedahan untuk kandungan
yang selanjutnya jikalau puan memilih kelahiran secara
pembedahan kali ini
7. Menghadapi risiko bius
129
8. Bilangan anak yang di rancang adalah terhad
disebabkan bilangan ulangan pembedahan caesarean
adalah terhad (dinasihatkan tidak melebihi 3 kali). Untuk
itu puan akan dinasihatkan agar menjalani proses
pemandulan pada pembedahan selanjutnya.
JIKA PUAN SETUJU UNTUK VBAC, APAKAH PROSES

YANG AKAN DILALUI?
• Puan mesti bersalin di hospital yang mempunyai pakar

dan dewan pembedahan.
• Puan akan diberi tarikh untuk masuk ke dalam wad
(bergantung kepada risiko lain dalam kandungan kali ini).
• Jika puan masuk bersalin sebelum tarikh jangkaan,
puan harus datang ke hospital segera.
• Sepanjang proses kelahiran, jantung bayi akan dipantau
rapi dan juga tanda - tanda parut lemah akan
diperhatikan dengan rapi.
• Sekiranya terdapat indikasi - indikasi yang memerlukan
pembedahan, prosedur akan dijalankan seperti kes-kes
Caesarean yang lain.
INFORMASI PENTING:
DOKTOR ANDA AKAN MEMBINCANGKAN KESESUAIAN
ANDA UNTUK BERSALIN SECARA NORMAL KERANA
TERDAPAT FAKTOR-FAKTOR YANG TIDAK
MEMBENARKAN KELAHIRAN NORMAL SELEPAS
PEMBEDAHAN CAESAREAN
130
10.10 Recurrent Miscarriages
1 Pre pregnancy • Screening (to be assessed in O&G clinic):
➢ Pelvic ultrasound assessment
➢ APS antibodies, if indicated
➢ Thrombophilia screening, if indicated
➢ Thyroid Function Test(s) if indicated
➢ Karyotyping (if clinically indicated)
• Diabetic screening.
• Advised for folic acid.
2 At booking • Screening as per pre-pregnancy, except APS, thrombophilia
screening and karyotyping.
• Consider low dose T. Aspirin 75mg OD and T.

Dydrogesterone (Duphaston) 10-20mg OD until 20 weeks if
indicated after discussed with FMS or O&G specialists.
➢ Refer O&G team for cervical length assessment (if

recurrent second trimester miscarriage or preterm birth).
3 Subsequent • Appointment for detailed scan 22 – 24 weeks.

antenatal follow-
• Routine antenatal, follow up at health clinic unless specific
up
causes identified, e.g. previous second trimester loss, APS –
to refer O&G.
• Refer O&G at 34 weeks for delivery plan.

4 Delivery • Outlined by O&G team.
• Timing and mode of delivery as per obstetric indication.
5 Postpartum • Discuss options for contraception with patient.
• Encourage breastfeeding.
131
REMARKS:
1. Definition
a. Miscarriage:
Spontaneous loss of pregnancy before fetus reaches viability. Includes all
pregnancy losses from the time of conception until 24 weeks of gestation or
500g.
b. Recurrent Miscarriage:
The loss of three or more consecutive pregnancies
2. Causes of miscarriages according to phase:
Phase Causes
1st trimester Genetic: parental chromosomal rearrangements, embryonic
miscarriage chromosomal abnormalities
Infection, APS, inherited thrombophilia defects
Endocrine: DM, thyroid disease
Epidemiological: e.g. advanced maternal age, h/o previous
miscarriage(s)
2nd trimester Epidemiological: e.g. advanced maternal age, h/o previous
miscarriage miscarriage(s)
Anatomical: e.g. congenital uterine malformation, cervical
weakness
Reference(s):
1. RCOG, Greentop Guidelines No.17 (2011)
2. SOSCG, third edition 2018
132
10.11 Recurrent Preterm Deliveries
1 Pre pregnancy • Identified the risk factors for preterm birth.
➢ Infective causes
➢ Structural causes
➢ Previous obstetric history
➢ Fetal causes
➢ Maternal causes
2 At booking • Refer O&G team at booking or before 14 weeks.
• Required to send (depends on clinical indication);
➢ Urine C&S
➢ HVS gram stain and C&S
➢ Diabetic screening - MOGTT
➢ Thyroid function test (if needed) - TSH
• Treat underlying abnormal investigation results.
• Refer Dental clinic for oral hygiene assessment.
• Refer Quit Smoking Clinic (if needed).
• Consider progesterone supplement between 16 – 24 weeks,

after discuss with O&G team.
3 Subsequent • Review all C&S result. All infections found should be treat
antenatal follow- accordingly
up
• O&G team to decide on management If patient having
cervical incompetence
• Follow guideline on management of DM, HPT, thyroid in

pregnancy if diagnosed
133
• Antenatal corticosteroids as per outlined by O&G as
outpatient in KKIA if feasible. (IM dexamethasone 12mg
BD for one day)
4 Delivery • Timing and mode of delivery as per obstetric indication
5 Postpartum • Emphasize on the importance of contraception and pre

pregnancy care
• Encourage breast feeding
REMARKS:
1. Recurrent preterm birth is frequently defined as two or more deliveries before 37
completed weeks of gestation.
2. Preterm birth is a concern because babies who are born too early may not be fully
developed. They may be born with serious health problems.
3. Some health problems, like cerebral palsy, can last a lifetime. Other problems, such
as learning disabilities, may appear later in childhood or even in adulthood.
4. Consider vaginal swab for wet mount microscopic examination for bacterial
vaginosis if clinically suspicious:
a. Homogenous, thin, white discharge that smoothly coats the vaginal wall
b. A fishy odour of vaginal discharge
c. pH of vaginal fluid > 4.5 if available kit to test
5. Identified the risk factors for preterm birth.
A Infective causes i. Bacterial vaginosis

ii. Periodontal disease (poor oral hygiene)
iii. Sexually transmitted infections (i.e., chlamydia,
gonorrhoea, and trichomoniasis)
iv. Chorioamnionitis
134
v. Infections of the urinary and genital tracts (UTI,
PID)
B Structural causes i. Shortened cervix (< 25 mm before 28 weeks'
gestation)
ii. History of cervical surgery or intervention (e.g. con
biopsy or a loop electrosurgical excision procedure
of the cervical transformation zone)
iii. Uterine anomalies
C Maternal causes i. Low pre pregnancy body mass index (≤ 19.8 kg per
m2)
ii. Medical disorders such as thyroid disease, diabetes
mellitus, or hypertension
iii. Mother's work is physically strenuous
iv. Tobacco use
v. Cocaine or heroin use
D Fetal causes i. Multiple gestation pregnancy
ii. Polyhydramnios or oligohydramnios
E Previous obstetric i. Vaginal bleeding caused by placental abruption or
history placenta previa
ii. Short pregnancy interval (< 18 months between
pregnancies)
iii. History of preterm delivery
Reference(s):
1. Kristen R, Bethany P. Preterm Labour: Prevention and Management. Am Fam Physician.
2017 Mar 15;95(6):366 – 372.
135
SECTION 11 PRE-PREGNANCY & ANTENATAL CARE
11.1 Alcohol Use Disorder in Pregnancy
1 Pre-pregnancy • Pregnant women / women planning a pregnancy should
be advised to avoid alcohol in the first 3 months in
pregnancy
• If the woman chooses to drink alcohol during pregnancy,
they should be advised to drink no more than 2 units per
intake and not more than twice per week (after 3 months
of gestation)
• Assess for other substance (ASSIST), other associated
infections, psychosocial issues and support
• Explore high risk behavior and screen accordingly
2 Booking/
Diagnosis • SCREENING - Need to ask all women for alcohol use
• Diagnosis using DSM 5 criteria.

If positive, need to screen with ‘AUDIT-10’ questionnaire (by
interview) and stratify according to zones
Score Risk Zone
0-7 Low risk 1
8-15 Hazardous drinker 2
16-19 Harmful & dependency 3
20-40 High risk for alcohol related harm 4
• ASSESSMENT during first contact

➢ History should include alcohol pattern, complication,
comorbid, MSE & social support
➢ Physical examination including general, sign of chronic
alcohol, GI/ abdomen & CNS.
➢ Investigation including; FBC-Hb, MCV, LFT (GGT, AST,
ALT), (Ultrasound hepatobiliary system, OGDS, x-ray &
EEG if indicated)
• COUNSELLING for those screened positive women

regarding risks of alcohol use.
➢ Advise maternal cessation of alcohol intake to reduce
complications to mother and fetus.
136
➢ Intervention involving MULTIDISCIPLINARY TEAM
approach depending on zone.
Zone Intervention
1 Health education
2 Simple advice
3 Extended intervention (MO/FMS)
4 Refer specialist in addiction (Psychiatrist or
FMS with subspecialty in addiction
3 Subsequent • Frequent antenatal follow up to monitor maternal and fetal

antenatal follow- status (maternal alcohol consumption habits and
up complications such as withdrawals, fetal surveillance for
pregnancy complications).
• Emphasize on maternal cessation of alcohol intake.
• Serial growth scan under FMS/O&G for
Zone 3 and Zone 4.
4 Delivery plan • Similar to normal pregnancy
6 Postpartum • Refer baby of women with (zone 3 and zone 4) to
paediatrician (possibility of neonatal withdrawal).
• Refer psychiatric follow-up and social welfare if needed.
• Edinburgh Postnatal Depression Scale (EPDS)
screening for depression.
REMARKS:
1. Quantification of alcohol according to local policy (SABAH)
a. Alcohol - Contains ethanol (depressant drug)
i. 1 unit = 10 ml @ 10 gm ethanol (Malaysia)
ii. DSM V classification of alcohol use disorder (Appendix 2)
b. 1 unit of alcohol = 1 standard drink (MINUMAN ALKOHOL)
c. Formula for standard drink
i. Standard drink = Alcoholic beverage (litres) x % alcohol content x 0.789 *
(density of ethanol at room temperature)
d. Examples of standard drink in Malaysia
137
i. Beer: 1 tin of 440 ml, (3.6% alcohol), 1 tin of 320 ml (5% alcohol)
ii. Wine: 1 glass of 140 ml (12% alcohol)
iii. Todi/bahar: 1 cup of 150 ml (8.5% alcohol)
iv. Tuak beras: 1 glass of 100 ml (13.5% alcohol)
v. Montoku: 1 cup of 80 ml (17% alcohol)
Prevalence: 13.5% age 13 years and above ever consumed alcoholic beverages in
year 2014 in Malaysia (NHMS 2015).
2. There is NO safe level of alcohol consumption during pregnancy. It is best to
abstain from alcohol during pregnancy & breastfeeding.
a. There is also no exact dose relationship between amount of alcohol
consumed during prenatal period and extent of damage caused by alcohol in
infant.
b. Avoid binge drinking (>6 unit per occasion)
3. Complications of alcohol to the mother & baby:
a. Spontaneous miscarriage
b. Stillbirth
c. FGR
d. Low birth weight
e. Fetal alcohol spectrum disorder (FASD), which includes fetal alcohol
syndrome (FAS), partial fetal alcohol syndrome, alcohol-related
neurodevelopmental disorder, alcohol-related birth defects
** Risk is progressively increased with greater alcohol consumption
Reference(s):
1. Royal College of Obstetricians & Gynaecologist- health & care information (February 2015)
2. NICE Antenatal care- routine care for the healthy pregnant woman (March 2008)
3. Nykjaer.C, et al. J. Epidemiol Community Health 2014;0:1-8, doi:10.1136/jech-2013- 202934
4. Garis Panduan: Penilaian risiko dan intervensi primer kemudaratan alkohol, NCD, KKM 2010
5. Maklumat kesihatan- intervensi, pencegahan dan pengurangan kemudaratan alkohol, Unit
alkohol & substans, NCD, KKM (2013)
6. Alcohol Use Disorder: A Comparison Between DSM–IV and DSM–5, National Institute on
Alcohol Abuse and Alcoholism, www.niaaa.nih.gov • 301.443.3860
7. SOSCG Alcohol Use and Pregnancy Consensus Clinical Guidelines 2010
138
A. AUDIT FORM-10
The Alcohol Use Disorders Identification Test: Interview Version
Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask
you some questions about your use of alcoholic beverages during this past year”. Explain what is meant
by “alcoholic beverages” by using local examples of beer, wine, vodka etc. Code answers in terms of
“standard drinks”. Place the correct answer number in the box at the right.
1. How often do you have a drink containing 6. How often during the last year have you
alcohol? needed a first drink in the morning to get yourself
going after a heavy session?
(0) Never (Skip to questions 9-10)
(1) Monthly or less (0) Never
(2) 2 to 4 times a month (1) Less than monthly
(3) 2 to 3 times a week (2) Monthly
(4) 4 or more times a week (3) Weekly
(4) Daily or almost daily
2. How many drinks containing alcohol do you 7. How often during the last year have you had a
have on a typical day when you are drinking? feeling of guilt or remorse after drinking?
(0) 1 or 2 (0) Never

(1) 3 or 4 (1) Less than monthly
(2) 5 or 6 (2) Monthly
(3) 7, 8 or 9 (3) Weekly
(4) 10 or more (4) Daily or almost daily
3. How often do you have six or more drinks on 8. How often during the last year have you been
one occasion? unable to remember what happened the night
before because you had been drinking?
(0) Never
(1) Less than monthly (0) Never
(2) Monthly (1) Less than monthly
(3) Weekly (2) Monthly
(4) Daily or almost daily (3) Weekly
Skip to Questions 9 and 10 if Total Score for (4) Daily or almost daily
Questions 2 and 3 = 0.
4. How often during the last year have you found 9. Have you or someone else been injured as a
that you were not able to stop drinking once you result of your drinking?
had started
(0) No
(0) Never (2) Yes, but not in the last year
(1) Less than monthly (4) Yes, during the last year
(2) Monthly
(3) Weekly
5. How often during the last year have you failed 10. Has a relative or friend or a doctor or another
to do what was normally expected from you health worker been concerned about your drinking
because of drinking? or suggested you cut down?
(0) Never (0) No

(1) Less than monthly (2) Yes, but not in the last year
(2) Monthly (4) Yes, during the last year
(3) Weekly
Record total specific items here
139
B. DSM-5 criteria for Alcohol Use Disorder
In the past year, have you

1. Had times when you ended up drinking more, or
longer than you intended?
2. More than once wanted to cut down or stop drinking,

or tried to, but couldn’t?
3. Spent a lot of time drinking? Or being sick or getting

over other aftereffects?
4. Wanted a drink so badly you couldn’t think of

anything else?
5. Found that drinking – or being sick from drinking –

often interfered with taking care of your home or
family? Or caused job troubles? Or school problems? The presence of at least 2 of these
symptoms indicates an Alcohol Use
6. Continued to drink even though it was causing disorder (AUD)
trouble with your family or friends?
The severity of the AUD is defined as:
7. Given up or cut back on activities that were
important or interesting to you, or gave you pleasure,
Mild:
in order to drink?
The presence of 2-3 symptoms
8. More than once gotten into situations while or after
drinking that increased your chances of getting hurt Moderate:
(such as driving, swimming, using machinery, walking The presence of 4-5 symptoms
in dangerous area, or having unsafe sex)?
Severe:
9. Continued to drink even though it was making you The presence of 6 or more symptoms
feel depressed or anxious or adding to another health
problem? Or after having had a memory blackout?
10. Had to drink much more than you once did to get
the effect you want? Or found that your usual number
of drinks had much less effect than before?
11. Found that when the effects of alcohol were

wearing off, you had withdrawal symptoms, such as
trouble sleeping, shakiness, restlessness, nausea,
sweating, a racing heart, or a seizure? Or sensed
things that were not there
140
11.2 Advanced Maternal Age (more than 35 years old)
1 Pre-pregnancy ⚫ Counsel regarding risk of pregnancy in advanced
maternal age:
➢ Generally good pregnancy outcome.
➢ Obstetrics risk:
▪ Miscarriage
▪ Pre-eclampsia
▪ Gestational Diabetes Mellitus
▪ Increased risk of chromosomal and genetic
abnormality e.g. trisomy 21 (especially more
than 40 years old)
▪ Increased risk caesarean section from
dysfunctional labour
• Assessment of pre-existing medical condition and
manage accordingly.
2 Booking • Early booking.
• Screening for GDM.
• If more than 40 years old - appointment to O&G/MFM
clinic for screening of Nuchal Thickness around 11
weeks to 13 weeks 6 days to women who are keen
(availability of service may differ from different specialist
hospitals)
• Offer prenatal screening to women who are keen (refer
to prenatal screening test in primary care section).
• Refer O&G for detailed scan if more than 40 years old
according availability of service in specialist hospitals)
3 Subsequent • According to normal antenatal follow up.
antenatal follow- up
141
• Time and mode of delivery as per obstetric indication.
5 Postpartum • Advise for permanent sterilization if completed family.

• Contraception according to MEC eligibility.
• Continuation of underlying medical illness at health
clinic.
REMARKS:
1. At booking, prenatal genetic screening test should be offered to
a. Women with advanced maternal age (> 35 years)
b. Ultrasound findings of fetal anomaly
c. IVF/ICSI conception
d. Woman or her partner with history of fetus or child with chromosomal
abnormality or is a carrier of a chromosome rearrangement
2. Refer FMS for initial counselling for prenatal screening, then refer MFM if women
keen for screening test.
3. Special charges apply for the screening test, to inform women who keen for
screening test. Encourage women to attend MFM clinic with spouse for
counselling.
Reference(s):
1. NICE Antenatal care 2008 (CG62). Chapter 9.2 Screening for Down Syndrome Author.
2. SOGC- CCMG Clinical Practice Guideline - Prenatal screening for fetal aneuploidy in single
pregnancies 2011
142
11.3 Counselling of Prenatal Screening Test in Primary Care
1 Pre-pregnancy • Identify high risk group*
• Counsel about availability of prenatal genetic screening.
• Advice early booking once pregnancy confirmed.
2 Booking • Identify high risk group.
• Confirm gestational age on USS.
• Counsel about prenatal genetic screening.
• After counselling, refer early to MFM/O&G if keen for
screening or diagnostic test. Attach HIV, Hepatitis B and
Rhesus results.
• Preferably come with partner/spouse.
3 Subsequent • Outlined by MFM/ O&G team.
antenatal follow-up
REMARKS:
1. Who to offer to?
a. All pregnant women
b. High risk group*
i. Advanced maternal age (>40 years old)
ii. Previous pregnancy with aneuploidy
iii. USS finding of soft markers (choroid plexus cyst, echogenic foci etc.)
2. Key points for counselling:
a. Most commonly occurring fetal aneuploidies are trisomy 21 (Down syndrome),
18 (Edward syndrome), and 13 (Patau syndrome).
b. Miscarriage or stillbirth occurs in 80% of trisomy 18 or 13; 40% of trisomy 21.
c. Down syndrome
i. Is the most common form of inherited intellectual disability
ii. Clinical spectrum is variable, e.g. congenital heart defects, intestinal
atresia, seizures, childhood leukaemia, early-onset Alzheimer disease
143
d. ALL women have some risk of having an affected fetus. The risk increases with
age. However, most fetuses with Down syndrome occur in younger mothers
because most pregnancies occur in them.
Age (years) Risk of trisomy 21 Risk of any Chromosome Abnormality

25 1:1340 1:475
30 1:940 1:384
35 1:353 1:178
40 1:85 1:62
45 1:35 1:18
e. Mid-trimester USS will show normal findings in 50% of fetuses with trisomy 21.
f. Screening tests are available in early pregnancy to assess her individualised
risk of having a fetus with aneuploidy.
g. Cost of test is self-paid, ranging from RM200 to RM1000.
h. Screening tests are NOT diagnostic:
i. Screen positive (high-risk): a confirmation test (CVS, amniocentesis) is
indicated.
ii. Screen negative: no further test is indicated; but this does not guarantee
a healthy baby. Can still have aneuploidy (false negative) or other
conditions not detected through screening.
i. Aim is to make an informed choice. If tests confirm fetal aneuploidy, mother
has the option of continuing or terminating the pregnancy.
j. TOP in MOH hospitals is only done up to 22 weeks gestation.
3. What screening tests are available?

Test name Gestational age to do? Procedure Accuracy
First trimester 11+0 to 13+6 weeks Blood test DR 85%
screening CRL 42-84mm USS FPR 5.0%
Quadruple screen 15 to 22 weeks Blood test DR 81%
FPR 5.2%
Non-invasive ≥ 10 weeks Blood test DR >99%
prenatal screening FPR 5.0%
(NIPT)
CRL: crown-rump length; USS: ultrasound scan
DR: Detection rate; FPR: False positive rate
144
Workflow to refer pregnant women for prenatal test from primary care
At booking, screening should be offered to Pregnancy must be

➢ Women with advanced maternal age (> 35 years) correctly dated
➢ Ultrasound findings of foetal anomaly
➢ IVF/ICSI conception
➢ Woman or her partner with history of foetus or Counselling process
child with chromosomal abnormality or is a should include:
carrier of a chromosome rearrangement
1. Balance and adequate

information about Down’s
Refer FMS for counselling Syndrome
2. Screening does not
provide definite diagnosis
3. Screening pathway for
Refer MFM SWACH if patient keen for screen positive and
screening screen negative result
4. Information regarding
the possible need for
diagnostic test
Screening test (Non-invasive test)
1st trimester: NT scan + biochemical test Continue routine

High Risk Low Risk
antenatal care
Offer diagnostic test

test
Chorionic villous sampling Amniocentesis

(Following first trimester) (Following second
trimester screening)
Disadvantages
Disadvantages
1. Foetal loss 1-2%
2. Infection 1. Foetal loss 1%
2. PPROM
3. Infection
Reference(s):
1. Counselling Considerations for Prenatal Genetic Screening. SOGC Committee Opinion. J
Obstet Gynaecol Can 2012; 34 (5): 489-493.
2. Screening for Fetal Aneuploidy. ACOG, SMFM Practice Bulletin. Number 163, May 2016.
145
11.4 History of Postpartum Haemorrhage
1 Pre-pregnancy • Pre-pregnancy advice:
➢ Healthy balanced diet
➢ Adherence to haematinics
➢ Effective family planning to allow iron stores to
replenish
➢ Recurrence risk (refer to remarks)
➢ Early first trimester booking
• Pre- Pregnancy plan:
➢ Patients with clotting disorders should have
multidisciplinary input and a detailed peripartum plan
outlined
➢ Folate
➢ Cause specific intervention
➢ Persistent anaemia should be investigated
2 Booking • Determine the cause of PPH: atony, trauma, retained
POC, clotting disorders
➢ History and careful review of past notes
• Counselling to patient regarding risks of PPH
• HCV screening if history of multiple blood transfusion
• Refer to O&G for assessment if history of suspected
transfusion reaction or known antibody detected
towards blood products
3 Subsequent Refer to Chapter Anaemia in Pregnancy
antenatal follow- up
➢ Peripartum care plan: hospital delivery, active 3rd
stage management and PP H prophylaxis measures.
146
REMARKS:
1. Counselling during booking:

a. PPH from atony / retained placenta has recurrence risk: 5% after one episode,
15% after 2 episodes and 40% after 3 episodes.
b. Women with history of blood transfusion have a remote chance of HIV and
Hepatitis infection.
2. Women with blood transfusions may have developed antibody towards blood products.
3. Other risk factors for PPH may present antenatally or intrapartum; care plans must be
modified as and when risk factors arise:
a. Multiple pregnancy
b. Pre-eclampsia
c. Fetal macrosomia
d. Failure to progress in second stage
e. Prolonged third stage of labour
f. Retained placenta
g. Low lying placenta or placenta praevia
h. Episiotomy
i. Perineal laceration
j. General anaesthesia
Reference(s):
1. Prevention and Management of Postpartum Haemorrhage, RCOG December 2016.
147
11.5 Smoking in Pregnancy
1 Pre-pregnancy • All women who are smokers – should be counselled to quit
before pregnant to avoid complications.
• Those who have quit smoking – regular follow up to
prevent relapse.
2 Booking • Smoking history should be elicited in all pregnant women.
• If smoking, need to assess:
➢ Willingness to quit
▪ Pre-contemplation
▪ Contemplation
▪ Action
▪ Maintain
▪ Relapse
➢ Level of addiction using ‘Fagerstrom’ score (Table 1)
➢ Analyse level of CO in blood by breath test
▪ Level >3 ppm (suspect smoking), (usually smoker
>7ppm)
*ppm- part per million
▪ Available at Quit Smoking Clinic
3 Subsequent • No safe smoking level in pregnancy
antenatal follow- • Stopping smoking at any time during pregnancy is
up beneficial to mother and baby
• Advise all pregnant women to avoid smoky
environment during pregnancy.
• Refer O&G if complications develop
➢ For serial growth scan
• Refer quit smoking program (need support to cope with
withdrawal and craving)
• Treatment:
148
➢ Non-pharmacological
▪ Quit plan (set date for quit smoking)
▪ Counselling
▪ Motivation - 5R
 Relevance
 Risks
 Rewards
 Roadblock
 Repetition
➢ Pharmacological (Refer FMS for pharmacological
therapy)
▪ NRT - Safer than smoking (no tar and CO)
▪ NRT helps to manage craving
▪ Need to discuss risks & benefits
▪ Indicated when non-pharmacological treatment
failed
▪ Only prescribe NRT once quit date is set
 Prescribe NRT for 2 weeks then reassess
 Continue NRT if they have quit smoking
 Be cautious of NRT use in CVD
• Bupropion and Varenicline should not be offered to pregnant
or breastfeeding women.
• Electronic cigarettes are not recommended in pregnancy
because long term risk to baby is unknown.
4 Delivery plan • Similar as normal pregnancy.

6 Postpartum • Stop smoking - better quality of breast milk
lactation
149
REMARKS:
1. Prevalence of smoking in pregnancy - 25% Malaysian smoker.
2. Male partners of smoking women who are also smokers should be included in
treatment plan because:
a. Strong association with smoking behaviour and relapse among the women in
regards with their male partner’s smoking behaviour
b. To avoid environmental tobacco exposure to the women.
c. Preconception period – excellent interval before pregnant to give
pharmacotherapy that are contraindicated in pregnancy.
3. Complications of active smoking
a. Miscarriage
b. Ectopic pregnancy
c. Stillbirth (1/3 caused by smoking)
d. Congenital abnormalities (face - cleft lips & palate)
e. FGR
f. Abruptio placenta
g. Premature birth
h. Risk of SIDS
i. Asthma, chest infection & ear infection
j. Risk of ADHD
k. Toddler – poor performance at school
2. Complications of passive smoking
a. Stillbirth
b. Premature birth
c. IUGR
150
A. Fagerstrom’ score
PLEASE TICK () ONE BOX FOR EACH QUESTION

How soon after waking do you smoke your first Within 5 minutes  3
cigarette 5-30 minutes  2
31-60 minutes  1
Do you find it difficult to refrain from smoking in Yes  1
places where it is forbidden? E.g. Church, Library, No  0
etc.
Which cigarette would you hate to give up? This first in the morning  1
Any other  0
How many cigarettes a day do you smoke? 10 or less  0
11 – 20  1
21 – 30  2
31 or more  3
Do you smoke more frequently in the morning? Yes  1
No  0
Do you smoke even if you are sick in bed most of Yes  1
the day? No  0
Total score
1 – 2 = low dependence 5 – 7 = moderate dependence
SCORE
3 – 4 = low to mod dependence 8+ = high dependence
Reference(s):
1. MIMS Stop smoking cessation guidelines 2014
2. Smoking: Stopping in pregnancy and after childbirth, National Institute for Health and Care
Excellence (PH 26) June 2010
3. Royal College of Obstetricians & Gynaecologists - health & care information, December
2015
4. Rosenthal et al, Treatment of Tobacco Use in Preconception Care, Matern Child Health J.
2006 Sep; 10(Suppl 1): 147–148
151
11.6 Substance Abuse in Pregnancy
1 Pre-pregnancy • Assessment:
➢ Types of substance abuse
➢ Duration of substance abuse
➢ Status-withdrawal, intoxication
➢ Psychosocial support
➢ Associated infectious diseases
➢ High risk behaviour
• Inform Cure and Care.
• Psychiatric referral for management.
• Defer pregnancy until remission with optimal contraception.
2 At booking / • Assessment
diagnosis ➢ Status of Substance use disorder
➢ Screening for STIs
• If patient on medication assisted therapy, continuation of
therapy is advised.
• Combined care with psychiatrist, FMS and O&G team.
3 Subsequent • Discuss with O&G or MFM the need for detailed scan based
antenatal follow- on the type of substance abuse.
up • Monthly growth scan after 28 weeks.
• Admission is required for following cases:
➢ Develop withdrawal symptoms during pregnancy
➢ Psychological implication
4 Delivery plan • May consider to taper down opioid agonist.
• Pain management during intrapartum.
6 Postpartum • Neonatal assessment by paediatric team for Neonatal
Abstinence Syndrome.
➢ Breastfeeding is not contraindicated
152
➢ Psychiatric assessment before discharge
➢ Edinburgh Postnatal Depression Scale (EPDS)
screening for depression
7 Upon discharge • High risk discharge to health clinic
from hospital
REMARKS:
1. History taking:
a. Patterns of substance use (The ASSIST [Alcohol, Smoking and Substance

Involvement Screening Test]) helps identify current or potential problems
resulting from substance use and motivate those at risk to change their
substance use behaviour)
b. Medical or psychiatric co-morbidity
c. Blood borne and other infectious diseases
d. Psychosocial problems such as relationship with partner/other people living in

the same household, homelessness, poverty and violence
2. Physical examination
Include general, signs of chronic substance use (difficulty caring for self, poor
dentition, parasitic skin infections such as lice or scabies, malnutrition), injection
marks, GI/abdomen &CNS
3. Investigations
a. Urine for drug screen: whenever intoxication, withdrawal, or overdose is
suspected.
b. HIV, hepatitis B and C screening if the person has been injecting drugs
c. Testing for sexually transmitted infections, including HIV, syphilis, chlamydia,
gonorrhea, and human papilloma virus (HPV) if available
d. Obtain a tuberculosis test, sputum sample, and a chest X-ray if tuberculosis is
suspected.
Reference(s):
1. Guidelines for the identification and management of substance use and substance use
disorders in pregnancy (WHO 2014)
2. Mental Health Gap Action Programme Intervention Guide Version 2.0 (WHO 2016)
3. Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence
(WHO 2009)
4. The ASSIST Project-Alcohol, Smoking and Substance Involvement Screening Test (World
Health Organization 2009).
153
A. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)
Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) Questionnaire
1. In your life, which of the following substances have you ever tried (non-medical use only)
• Tobacco products Yes No • Inhalants Yes No
• Alcoholic beverages Yes No • Sedatives/ sleeping Yes No
pills
• Cannabis Yes No • Hallucinogens Yes No
• Cocaine Yes No • Opioids Yes No
• Amphetamine type stimulants Yes No • Others Yes No
2. During the past 3 months, how often have you used the substances you mentioned (first drug,
second drug etc.
Never (0) Once/Twice (2) Monthly (3) Weekly (4)
Daily/Almost Daily
(6)
3. During the past 3 months, how often have you had a strong desire or urge to use (first drug, second
drug, etc)?
Daily/Almost Daily
(6)
4. During the past 3 months, how often has your use of (first drug, second drug etc) led to health,
social, legal or financial problems
Daily/Almost Daily
(7)
5. During the past 3 months, how often have you failed to do what was normally expected of you
because of your use of (first drug, second drug etc)?
Daily/Almost Daily
(8)
6. Has a friend or relative or anyone else ever expressed concern about your use of (first drug, second
drug etc)?
Never (0) Yes, in the past 3 months (6) Yes, but not in the past 3 months
(3)
7. Have you ever tried and failed to control, cut down or stop using of (first drug, second drug etc)?
(3)
8. Have you ever used any drug by injection (non-medical use only)
(3)
154
B. Interpretation of ASSIST risk score and intervention
ASSIST risk score and associated risk level and intervention
All other
Alcohol Risk level Intervention
substances
0-10 0-3 Lower risk • General health advice
• Brief intervention
11-26 4-26 Moderate risk
• Take home booklet and intervention
• Take home booklet and information
27+ 27+ High risk
• Referral to specialist assessment and
treatment
• Risk of injecting card
Injected drugs in last 3 Moderate and High
• Take home booklet and information
months risk
• Referral to specialist assessment and
treatment.
155
11.7 Weight Gain in Pregnancy
11.7.1 Obesity or Morbid Obesity
1 Pre-pregnancy • Refer pre-pregnancy care clinic for assessment and
counselling in healthcare clinic
• Advise on weight loss and lifestyle modification.
• Counsel regarding complications of obesity in pregnancy.
• Advise Tablet folic acid 5mg daily (at least 3 months prior to
conception and continue during the first trimester of
pregnancy.)
• Identify and screen for any co-morbidities
• Contraception until ready for conception
• Effective family planning for those morbid obesity women
plan for bariatric surgery (at least 2 years)
2 Booking • Clinical assessment
➢ Ideally BMI should be calculated using pre-pregnancy
weight
➢ BP check using an appropriately sized cuff
➢ VTE assessment and thromboprophylaxis according to
risk
➢ To do STOP-Bang scoring (Table 3)
• Refer O&G clinic if:
➢ STOP- Bang score ≥3 and/ or BMI ≥40
• Arrange for early MOGTT.
• Refer dietician.
• Inform regarding weight gain recommendation during
pregnancy.
• Start PE prophylaxis in women with BMI>35 with one
additional moderate risk factor (e.g. primigravida).
• Offer detail scan if indicated.
3 Subsequent • Monitor maternal weight gain throughout pregnancy.
antenatal follow- • Screen for GDM.
up • Continue exercises and diet control (under dietician review).
• Reassess VTE risk throughout pregnancy.
• Monitor fetal growth scan.
4 Delivery • Hospital delivery, based on standard obstetric indications.
• Refer O&G team for plan of delivery.
5 Postpartum • Contraception as per MEC.
156
• Advise and support breast feeding
• Thromboembolism prophylaxis
6 Lactation • Encourage to breastfeed
• Continue lifestyle and dietary modification
REMARKS:
1. Obesity during pregnancy defined as BMI > 30kg/m2 measured at 1st antenatal
visit.
2. Pre- pregnancy care:
a. Discuss with women who are obese/ morbidly obese about weight reduction,
which may include information about diet, exercise, and weight loss programs,
if needed referral to dietitian for diet advices
3. Subsequent antenatal follow-up:
a. Monitor weight accordingly - If weight gain between antenatal visits is
excessive, evaluate the woman's eating habits and other potential etiologies of
excessive weight gain (e.g., preeclampsia, increased maternal adiposity)
4. Complications of obesity
Antenatal Intrapartum Anaesthetic risk
• Miscarriage • IOL/prolong labour/ failure • Difficulty with labour
• Gestational Diabetes to progress analgesia
• Fetal anomaly • Instrumental delivery • Use of GA
• Stillbirth • Failure of instrumental • Failed intubation
• Pre-eclampsia delivery • Increase risk ICU care
• Thromboembolism • Shoulder dystocia post-op
• Abnormalities fetal • Caesarean section
growth • Difficult fetal heart
• Obstructive sleep monitoring
apnoea • Postpartum haemorrhage
• Preterm birth Peripartum death
• Maternal death
Post-partum Neonates
• Delayed wound • Macrocosmic baby
healing • Neonatal obesity and
• Thromboembolic metabolic syndrome
disease
• Need support for
breastfeeding
initiation and
continuation
• Postnatal depression
157
5. Weight gain in pregnancy (from Manual Perkhidmatan Kesihatan Ibu & Anak
2016)**
Rates of Weight Gain in
2 Total weight
Classification BMI (kg/m ) 2nd and 3rd Trimester
gain range (kg)
[Mean (Range), kg/wk]
Underweight <18.5 12.5 – 18.0 0.51 (0.44-0.58)
Normal 18.5 – 24.9 11.5 – 16.0 0.42 (0.35-0.50)
Overweight 25.0-29.9 7.0 – 11.5 0.28 (0.23-0.33)
Obese (≥30) 5.0 – 9.0 0.22 (0.17-0.27)
6. STOP Bang Questionnaires

1. S Snoring (Do you snore loudly, louder than talking or loud Yes/No
enough to be heard through closed doors?)
2. T Tired (Do you often feel tired, fatigue, or sleepy during Yes/No
daytime?)
3. O Observe apnoea (Has anyone observed you stop breathing Yes/No
during your sleep?)
4. P Blood Pressure (Do you have or are you treated for high Yes/No
blood pressure?)
5. B BMI more than 35kg/m2? Yes/No
6. A Age (Age more than 50 years old?) Yes/No
7. N Neck circumference (Greater than 40cm?) Yes/No
8. G Gender (Male?) Yes/No
High risk of Obstructive Sleep Apnoea (OSA): answering yes to 3 or more items
Low risk of OSA: answering yes to fewer than 3 items
Reference(s):
1. Weight gain during pregnancy, ACOG, 2013
2. Weight management before, during and after pregnancy, NICE, 2010
3. Care of Women with Obesity in Pregnancy, RCOG, November 2018
4. Manual Perkhidmatan Kesihatan Ibu & Anak (2016)
5. Management of obesity in pregnancy, RANZCOG (Sept 2013)-reviewed 2017
158
11.7.2 Underweight
1 Pre-pregnancy • All women in the reproductive age group and plan to
conceive should be referred to the pre-pregnancy care
clinic for assessment and counselling
• Encourage them to reach a normal BMI before pregnancy.
• Advise on healthy and balanced diet, consider refer to
nutritionist
• Screen for TB with CXR
2 Booking • Clinical assessment:
➢ Ideally BMI should be calculated using pre-pregnancy
weight.
➢ Assess regarding nutrition, physical activity,
hyperemesis. symptoms.
• Inform regarding weight gain recommendation during
pregnancy**.
• Refer dietitian for diet advices.
3 Subsequent • Monitor maternal weight gain throughout pregnancy
antenatal follow-up • Advise on healthy diet
• Monitor fetal growth scan.
5 Delivery • Based on standard obstetric indications
6 Postpartum • Advise for healthy and balanced diet
• Contraception as per “Medical Eligibility Criteria for
Contraceptive Use”
7 Lactation • Encourage to breastfeed
159
REMARKS:
1. Pre- pregnancy care
a. Discuss with underweight women regarding:
Risk of spontaneous preterm birth and small for gestational age infants
associated with little weight gain during pregnancy
b. Assess regarding nutrition, excessive physical activity, history of weight loss,

smoking status.
5. Subsequent antenatal follow- up
a. Monitor weight accordingly
b. If weight gain between antenatal visits is inadequate, evaluate the woman's
eating habits and other potential aetiologies of deficient weight gain and to
assess fetal growth.
Reference(s):
1. Weight gain during pregnancy, ACOG, 2013.
2. Manual Perkhidmatan Kesihatan Ibu & Anak (2016).
3. Gestational weight gain, Am J Obstetric Gynecology. 2017; 64-651.
160
SECTION 12 RESPIRATORY DISEASES IN PREGNANCY
12.1 Bronchial Asthma in Pregnancy
1 Pre-pregnancy • Assess level of asthma control as per GINA guideline.
• Control of asthma should be optimized before conception.
• Women with asthma should be specifically advised not to
stop or decrease their asthma medication when they find
they are pregnant.
• Those with poorly controlled asthma to advise defer
pregnancy and use appropriate contraception method until
optimum control achieved.
2 Booking • Adjust asthma treatment in a continuous cycle: assess,
adjust treatment and review response.
• Check diagnosis, inhaler technique and adherence
before considering any step-up in treatment.
• If asthma is controlled:
o follow-up by MO at health clinic
• If asthma is partly controlled or uncontrolled:
o step up treatment as per GINA guideline and
reassess after 2 weeks
• Continue treatment once asthma is controlled after stepping
up treatment.
• Refer FMS/ visiting physician at nearest district
hospital (for non-FMS areas) if asthma remains partly
controlled or uncontrolled.
• Any patient partly controlled on Step 3 treatment MUST
be referred to Combined Clinic for reassessment and
management.
• Acute exacerbations require acute management and
admission*
161
3 Subsequent • Assess level of asthma control and manage accordingly.
antenatal follow- • Monitor PEFR every visit.
up • 4-6 weekly review depending on the level of asthma control.
• Women who are smoking to be referred to Quit Smoking
Clinic.
• Advice to avoid known trigger factors.
• Encourage personalised self-management, use of asthma
diary and written asthma action plan.
• Serial growth scans starting at 28 weeks in women with
severe asthma.
4 Delivery plan • As per obstetric indication.
6 Postpartum • Continue asthma medications until review in own clinic.

• Discuss options of contraception with patient / couple.
• Step-down treatment to pre-pregnancy doses or using
stepwise approach if asthma is well controlled
7 Lactation • Encourage breastfeeding. Medicines used to treat asthma
can be used normally during breastfeeding.
8 Upon discharge • Notification of high-risk cases discharge as per guideline for
from Hospital uncontrolled asthma.
REMARKS:
1. Definition: Asthma is a heterogeneous disease, usually characterized by chronic

airway inflammation. It is defined by the history of respiratory symptoms such as
wheeze, shortness of breath, chest tightness and cough that vary over time and in
intensity, together with variable expiratory airflow limitation.
2. Incidence:
e. It affects 1–18% of the population in different countries. Asthma control often
changes during pregnancy:
i. one-third of women asthma symptoms worsen
ii. one-third of women improve
iii. one-third remain unchanged
162
f. Exacerbations are common in pregnancy, particularly in the second trimester.
Exacerbations and poor asthma control during pregnancy may be due to:
i. mechanical changes or
ii. hormonal changes, or
iii. cessation or reduction of asthma medications due to concerns by the
mother and/or the health care provider
Diagnosis of bronchial asthma in pregnancy (flow chart) in clinical practice
Patient with respiratory symptoms

Are the symptoms typical of asthma? No
Yes
Further history
and tests
Detailed history/examination for asthma
History/examination supports asthma No
Yes
Perform spirometry/PEF with reversibility test

Results support asthma diagnosis?
Yes No Consider alternative diagnosis
Refer FMS/ visiting physician

Treat for ASTHMA
3. Diagnostic criteria for bronchial asthma in adult

a. History of variable respiratory symptoms (increased probability of asthma
diagnosis)
i. Wheeze, shortness of breath, chest tightness and cough (generally more
than one respiratory symptoms)
ii. Symptoms occur variably over time and vary in intensity; often worse at
night or on waking
iii. Symptoms are often triggered by exercise, laughter, allergens and cold
air; worsen with viral infections
b. Confirmed presence of airflow limitation or variable expiratory airflow limitation:
i. Reduced FEV1/FVC
ii. Excessive variability (> 10%) in twice daily PEF over 2 weeks
iii. Positive bronchodilator reversibility test- increase in FEV1 of > 12% and
200ml from baseline
4. GINA assessment of asthma control in adult
163
GINA ASSESSMENT OF ASTHMA CONTROL
A. Symptom control Level of asthma symptom control
Well- Partly
In the past 4 weeks, has the patient had: Uncontrolled
controlled controlled
• Daytime asthma
symptoms more than Yes  No
twice a week
• Any night waking due to Yes  No
asthma? None of
1-2 of these 3-4 of these
• Reliever needed for Yes  No these
symptoms more than
twice a week?
• Any activity limitation due Yes  No
to asthma?
B. Risk factors for poor asthma outcomes
• Assess risk factors at diagnosis and periodically
• Measure FEV1 at start of treatment, after 3- 6 months of controller treatment to record the
patient’s personal best, then periodically for ongoing risk assessment
ASSESS PATIENT’S RISKS FOR:
• Exacerbations
• Fixed airflow limitation
• Medication side-effects
5. Risk factors for poor asthma outcomes. Having one or more of these risk factors
increases the risk of exacerbations even if symptoms are well controlled:
a. Uncontrolled asthma symptoms
b. High SABA use (> 1 canister 200 doses/month)
c. Inadequate ICS, not prescribed ICS, poor adherence, incorrect inhaler
technique
d. Low FEV1 especially if <60% predicted
e. Major psychological or socioeconomic problems
f. Exposures: smoking, allergen exposure if sensitized
g. Comorbidities: obesity, rhinosinusitis, confirmed food allergy
h. Pregnancy
6. Severity of asthma is assessed retrospectively from the level of treatment
required to control symptoms and exacerbations.
a. Mild asthma: controlled with Step 1 or 2
b. Severe asthma: required Step 3, 4 or 5
164
7. Preparation of inhaled corticosteroid
Inhaled corticosteroids / Low Moderate High

total daily dose (mcg)
Beclomethasone dipropionate 100-200 >200-400 >400
Budesonide 200-400 >400-800 >800
Fluticasone propionate 100-250 >250-500 >500
Reference(s):
1. Global Strategy for Asthma Management and Prevention (2019 update) by Global Initiative
for Asthma (GINA)
2. Clinical Practice Guidelines Management of Asthma in Adults Academy of Medicine of
Malaysia (2017)
165
A. The control base asthma management cycle with stepwise
approach in management
Personalised asthma management
Confirmation of diagnosis
Symptom control and modifiable risk factors
Comorbidities
Assess Inhaler technique and adherence
Patient goals
Symptoms Treatment of modifiable risk

Exacerbations factors and comorbidities
Side-effects Nonpharmacological strategies
Lung function Review Adjust Education and skills training
Patient satisfaction Adjustment of asthma medications
Asthma medication Step 5

options:
Adjust treatment up and High-dose
Step 4
down for individual patient ICS/LABA
needs Medium-
Step 3 dose Refer for
ICS/LABA phenotypic
Low-dose assessment
Step 2 ±add on
ICS/LABA
therapy,
PREFERREDD Step 1 Daily low-dose
e.g.
CONTROLLER ICS or as-needed
tiotropium,
To prevent exacerbations As-needed low- low-dose ICS-
anti-IgE,
dose ICS- formoterol
and control symptoms anti-IL-
formoterol 5/5R, anti-
IL-4R
Other controller options Low-dose ICS LTRA or low-dose Medium- High-dose Add low-
taken whenever ICS taken dose ICS ICS, add- dose OCS,
SABA is taken whenever SABA or low- on but
taken dose tiotropium consider
ICS+LTRA or add-on side-effects
LTRA
PREFERRED RELIEVER As-needed low dose ICS-formoterol As-needed low dose ICS-formoterol for
patients prescribed maintenance and
reliever therapy
Other reliever option As-needed short-acting ß2-agonist (SABA)
ICS – Inhaled corticosteroid

LTRA – Leukotriene receptor antagonist
OCS – Oral corticosteroids
SABA – Short acting ß2-agonist
(Adapted from GINA Pocket Guide for Asthma Management and Prevention)
166
12.2 Chronic Lung Disease in Pregnancy
1 Pre-pregnancy • Detail history taking, vital signs and physical examination.
• Assess degree of functional disability due to dyspnoea
(MMRC dyspnoea scale).
• Review pulmonary function test and peak flow meters.
• Pregnancy is contraindicated in the presence of pulmonary
hypertension
• To refer to respiratory team for joint management.
• Encourage patient to get Pneumococcal and Influenza
vaccine.
2 Booking • Detail history taking, vital signs and physical examination.
• As clinically indicated, to do investigations such as FBC,
ECG, CXR, sputum AFB, sputum C&S and
Echocardiography.
• To do pulmonary function test and peak flow meters.
• Assess MMRC dyspnoea scale.
➢ MMRC score 0: follow up by MO at health clinic.
➢ MMRC score 1-4: follow up by FMS and Combined Clinic
for multidisciplinary team management.
▪ Review use of medications and step up accordingly.
3 Subsequent • Strongly encourage smoking cessation and avoidance of
antenatal follow- triggering factors.
up • Refer for chest physiotherapy if needed.
• Review monthly by FMS/ Combined Clinic depending on
severity.
• Monthly fetal growth scan starting at 28 weeks.
• Consider inactivated influenza vaccination if not given within
past 1 year.
4 Delivery • Delivery plan as per obstetric indication.
• Consider early referral to Anaesthesiologist if poor
pulmonary function.
• May require early delivery if worsening symptom or
deteriorate pulmonary function.
• Consider stress dose steroids during intrapartum if patient is
on long term steroid therapy.
5 Postpartum • Hospital with specialist.
167
6 Lactation • To continue Pre-pregnancy clinic follow-up.
• Continue medications until review in clinic.
• Discuss options of contraception with patient / couple.
7 Upon discharge • Allow breastfeeding if there is no contraindication.
from hospital
REMARKS:
1. Some women will have pre-existing chronic lung diseases such as chronic
bronchitis, bronchiectasis, cystic fibrosis, and less commonly restrictive lung
diseases such as kyphoscoliosis, myasthenia gravis, sarcoidosis and diffuse
interstitial lung disease.
2. Pulmonary hypertension (PH) is defined as a resting mean pulmonary artery
pressure greater than 25 mmHg.
3. Irrespective of aetiology, pulmonary hypertension carries a grave prognosis during
pregnancy (50% mortality). The increase in blood volume and cardiac output during
pregnancy is poorly tolerated and precipitates right heart failure with severely
decreased cardiac output and sudden death.
4. Termination of pregnancy is advised in women with even mild pulmonary
hypertension of any aetiologies who do get pregnant.
5. Use of anticoagulants and bed rest with multidisciplinary team management by
obstetricians, cardiologists, and anaesthesiologists are recommended if the patient
chooses to continue with the pregnancy.
6. The Modified Medical Research Council (MMRC) Dyspnoea Scale
Reference(s):
1. Catherine Nelson Piercy Handbook of Obstetric Medicine, edition 2007.
2. Bhatia P, Bhatia K. Pregnancy and the lungs. Postgraduate Medical Journal 2000;76: 683-
689.
168
SECTION 13 RENAL DISEASES IN PREGNANCY
13.1 Chronic Kidney Disease in Pregnancy
1 Pre-pregnancy • All female patients of reproductive at any stage of CKD
should receive pre-pregnancy care counselling by FMS.
• Pregnancy may be considered in women with:
➢ mild renal impairment (serum creatinine <124µmol/L),
➢ well controlled blood pressure, and
➢ without significant proteinuria (<1g/day)
• Pregnancy should be avoided in women with either:
➢ moderate to severe renal impairment (refer remarks)
➢ poorly controlled hypertension
➢ heavy proteinuria
➢ active systemic disease
• Rule out relative contraindication to pregnancy:
➢ ESRF
➢ Haemodialysis
➢ Recent transplant < 1-2 years
➢ Renal transplant with recent rejection
• Pre-pregnancy optimisation:
➢ Stop medications not compatible with pregnancy (e.g.
statins, ACEi, ARB)
➢ Optimisation of pre-existing disease (e.g.: lupus inactivity
for 6 months)
➢ Ensure disease stability for 3 months on pregnancy-safe
immunosuppression (if applicable)
➢ Intensive hypertension control with pregnancy-safe
antihypertensive agents (target <140/90 mm Hg)
➢ Weight reduction if necessary and encourage active
lifestyle
• Baseline pre-pregnancy investigations: FBC, Renal profile,
serum albumin, urine protein.
169
2 Antenatal • All pregnant women with CKD should be co-managed by a
multi-disciplinary team (early referral for combined specialist
care).
• First trimester dating scan.
• For aspirin 100-150 mg taken at bedtime starting from 12
weeks up to 16 weeks of gestation until delivery.
• Calcium Carbonate 1 gm bd commenced at booking (before
20 weeks gestation).
• At every visit, women should be screened for complications,
hypertension, proteinuria and pre-eclampsia.
• Levels of renal profile, uric acid, liver enzymes, platelet
count and urine protein should be documented to use as a
baseline in the case that superimposed pre-eclampsia is
suspected later in pregnancy.
• UTI screening for asymptomatic bacteriuria (refer section
13.3)
• Renal function checked at each trimester or more frequent if
needed.
• Anomaly scan at 24 weeks (Indication: types of drug
exposure in pregnancy).
• Ultrasound for fetal growth every 4 weeks starting from 24
weeks POA till delivery.
3 Delivery • Delivery as near term as possible.
• Vaginal delivery is the preferred mode of delivery if there are
no obstetric contraindications.
4 Postpartum • Encourage breastfeeding.
• Contraception:
➢ Avoid estrogen-containing preparations (if possible) in
women with hypertension, vascular disease, or
significant proteinuria or who are smokers
➢ Intra-uterine devices (IUCD/IUS) are not contraindicated
in women on immuno-suppression.
➢ DM Nephropathy (Refer MEC for Contraceptive Use)
• Pre-pregnancy clinic in O&G for future pregnancy.
5 Lactation • Breastfeeding is not contraindicated.
170
REMARKS:
1. Severity grading in chronic kidney disease:
Severity Serum Creatinine Level (µmol/l) eGFR (ml/min)
Mild 90-123 >70
Moderate 124-220 40-70
Severe >220 <40
2. Pregnancy in women with moderate to severe renal impairment (serum creatinine

>124µmol/L) results in increased risk of adverse maternal and fetal outcomes.
3. Complication related to CKD in pregnancy
a. Maternal complications - accelerated decline in renal function, hypertension,
proteinuria and pre-eclampsia
b. Fetal complications - spontaneous abortion/ neonatal death, prematurity, low
birth weight/ SGA baby
4. Commonly used drugs in pregnant women with CKD (please refer table below)
Safe in
Drug Teratogenicity Safe in pregnancy FDA
breastfeeding
Antihypertensive
Methyldopa X Often used first line. Safe B
Beta-Blockers X Safe. Excreted into C
*Fetal growth breastmilk, but
restriction in some widely used
studies. without reports of
Fetal bradycardia with neonatal side
Atenolol in first effects.
trimester.
Ca-Channel X Usually used second Excreted into C
Blocker (e.g. line in conjunction with breastmilk but
Nifedipine, methyldopa or widely used
Amlodipine) labetalol. without reports of
neonatal side
effects.
Hydrochlorothi X Theoretically, may Excessive thirst in C
azide cause intra-vascular breastfeeding
volume contraction and women; large
reduce placental doses may
perfusion, but can be suppress
used with caution for lactation.
fluid overload or
difficult-to-control
hypertension.
171
Hydralazine X Usually used in Excreted in C
combination with breast milk, but
sympatholytic agent to no adverse
prevent reflex effects reported.
tachycardia.
ACEi/ ARB Oligo- X Enalapril and D
hydramnios, Captopril are
neonatal anuria Stop at conception. excreted in small
and renal Prolonged exposure amounts with no
failure, limb can result in fetal renal adverse effects
contractures, insufficiency and reported
cranio-facial impairment in the
abnormalities, urine-concentrating
pulmonary ability, likely due to
hypoplasia, and papillary atrophy and
patent ductus disturbed formation of
arteriosus the medullary
(PDA) concentration gradient
Immuno-suppressants
Prednisolone Possible Maternal side effects: Safe C
increase in oral bone loss and possible (breastfeeding is
cleft palate osteo-necrosis, not encouraged if
gestational diabetes, dose >60mg
hypertension, cataract, daily)
adrenal insufficiency.
Fetal effects: rare-

except at large doses
(cataract, infection and
adrenal insufficiency)
Azathioprine Possible Safe Safe D
sporadic
congenital Fetal/ neonatal effects:
abnormalities Transient immune
alterations in neonates
Tacrolimus and X Safe Excreted into C
Cyclosporine breast milk, but
Usually increased 0.23%- 0.5% of
doses required to maternal weight-
achieve pre-pregnancy adjusted dose
target levels.
Hyperkalemia,
worsening
172
hypertension and
nephrotoxicity are
possible.
Fetal/ neonatal effects:

Hyperkalemia and
renal impairment.
Mycophenolate Congenital X X D
Mofetil (MMF) abnormalities in
22.9%: cleft lip Stop at conception
and palate,
absent auditory
canal,
hypertelorism,
microtia,
brachydactyly
of the fifth
finger, limb
abnormalities,
and hypoplastic
toenails
Cyclophospha Teratogenic X X D
mide
Fetal/ neonatal
effects:
Chromosomal
abnormalities and
cytopenia
Reference(s):
1. Clinical Practice Guidelines on Management of Chronic Kidney Disease in Adults (Second
Edition), 2018, page 22-23
2. Penggunaan Calcium Carbonate Dalam Pencegahan “Pre-Eclampsia” Bagi Pesakit Hamil
Yang Berisiko, (38) JKN(SB)(P)/100-1/6 Bertarikh 12 November 2019
3. Pregnancy across the Spectrum of Chronic Kidney Disease, www.kidney-
international.org,Michelle A. Hladunewich, published online 24 March 2016, page 995-1007
4. Risk of Adverse Pregnancy Outcomes in Women with CKD, Giorgina Barbara Piccoli, Journal
of American Society of Nephrology, October 2014, page 2011-2015
5. Pregnancy in Chronic Kidney Disease and Kidney Transplantation, Philip Webster, Kidney
International, published online February 2017, page 1047-1056
6. Pregnancy in Women with Non-dialysis Chronic Kidney Disease, UpToDate
7. CPG Management of Hypertension (5th edition) 2018, page 85-86
173
13.2 Hypokalemia in Pregnancy
1 Pre-pregnancy • Patient should be investigated for causes of hypokalemia.
• Classification
➢ mild 3.0 – 3.5 mmol/L
➢ moderate 2.5 -3.0 mmol/L
➢ severe <2.5 mmol/L
• Keep serum K+ >3.0 mmol/L.
➢ If suspected/diagnosed RTA, to refer MOPD for further
management.
2 Booking • Identify patient at risk/ established diagnosis if not known.
• Keep serum K+ >3.0 mmol/L.
• Discuss with FMS on frequency of serum K+ monitoring.
• Refer Combined Clinic if moderate to severe hypokalemia.
• Admit if symptomatic.
➢ Treat underlying cause first (e.g. Nausea & vomiting in
pregnancy)
3 Subsequent • Keep serum K+ >3.0 mmol/L.
antenatal follow- ➢ Refer Combined Clinic if moderate to severe
up hypokalemia
• Assess compliance to potassium supplement.
• Admit if symptomatic*
4 Delivery Deliver at hospital with specialist.
5 Postpartum • Keep serum K+ >3.0 mmol/L

➢ Refer medical team if not investigated earlier.
174
REMARKS:
1. Causes of hypokalaemia
Inadequate • Eating disorders: Anorexia, bulimia, starvation, pica,

potassium intake and alcoholism
• Poverty: Inadequate quantity or quality of food
• Hospitalization: Potassium-poor TPN
• Dental problems: Impaired ability to chew or swallow
Increased • Renal tubular acidosis type 1 or 2
potassium • Diuretics: Thiazide, Loop diuretics, Mannitol
excretion • ↑ gastrointestinal losses: vomiting, diarrhea, fistula
• ↑ from skin loss: burns, excessive sweating
• ↑ Aldosterone excretion: primary and secondary
hyperaldosteronism (Liver failure, heart failure, renal
artery stenosis, salt losing nephropathy)
• Non-aldosterone mineralocorticoid excess
(endogenous or exogenous): CAH, Cushing syndrome
• Renal tubular damage: Acute leukaemia, post-
obstructive uropathy, nephrotoxic drugs (Amphotericin
B, aminoglycosides, etc.)
• Genetic disorders; Bartter’s syndrome, Gitelman’s
syndrome, Liddle’s syndrome, Hypokalemic periodic
paralysis
• Hypomagnesaemia: Alcoholism
Redistribution into • Insulin treatment: DKA
cells • Exogenous glucose
• Alkalosis
2. Symptomatic hypokalemia
a. Weakness and fatigue (most common)
b. Muscle cramps and pain (severe cases)
175
c. Worsening diabetes control or polyuria
d. Palpitations
e. Psychological symptoms (e.g. psychosis, delirium, hallucinations, depression)
3. Baseline investigations can be done at primary care:
a. FBC
b. Renal profile
c. Serum magnesium
d. LFT
e. TSH
f. UFEME
g. ECG
h. VBG (if service available)
4. Medication options for hypokalemia treatment:
a. Potassium Chloride SR Tablet (Slow K 600mg/tablet) 1.2-1.8 g/day
b. Potassium Chloride Mixture (Mist KCL 1g/15ml) 15ml daily/ twice daily
2. 4. Common side effects of Potassium chloride SR tablet:
a. Stomachache/ stomach upset / bloatedness
b. Nausea
c. Vomiting
d. Diarrhea
e. Skin rash
f. Lethargy
g. Tingling, prickling, burning, tight, or pulling sensation of arms, hands, legs, or
feet
Reference(s):
1. The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum,
Green-top Guideline No.69, June 2016
2. Medscape, Hypokalaemia, December 2018.
176
13.3 Urinary Tract Infection in Pregnancy
1 Pre-pregnancy • Advise prevention steps such as:
➢ Avoid delayed voiding habit
Empty bladder at least 4-hourly during the day
➢ Avoid douching
➢ Avoid tight clothing. Use cotton underwear
➢ Increase fluid intake
➢ Empty bladder after sexual intercourse
Double voiding to ensure no residual urine
➢ Always wipe from front to back after using toilet
➢ Take shower & avoid prolonged long-bath
2 Booking Asymptomatic Bacteriuria:
• Screening in early pregnancy or at booking with urinalysis.
• If routine dipstick shows proteinuria or glycosuria – proceed
with multi-reagent dipstick.
• Perform MSU C&S if multi-reagent dipstick is positive for
nitrite or leucocyte.
• Positive detection of nitrite +/- leucocyte is strongly
suggestive of significant bacteriuria and enough for
commencement of empirical antimicrobial treatment.
• Positive urine culture should be treated with antibiotic for 5-7
days.
• Repeat urinalysis or urine C&S 1 week after completion of
antibiotic.
Acute Cystitis:
• Symptoms include dysuria, frequency and urgency.
• Perform urine analysis and MSU C&S if patient is
symptomatic.
• Treat empirically with 5-7 days antibiotics.
177
• Simple analgesics can be considered for symptom relief.
• Choice of antibiotics
Antibiotics Dose
Nitrofurantoin 50-100mg QID (macrocrystals) OR
100mg BD (monohydrate/
macrocrystals)
Cephalexin 500mg BD
Alternative
Cefuroxime 250mg BD OR
Augmentin 625mg TDS OR
Unasyn 375-750 mg BD
➢ Avoid nitrofurantoin at 3rd trimester due to small risk of
haemolytic anaemia in newborn.
• Trace urine C&S and manage accordingly
• Repeat MSU C&S 1-2 weeks after completion of antibiotics
to ensure eradication.
• Treat with antibiotic for 7 days if recurrent.
• Judicious use of alkalinising products (e.g. Ural, potassium
citrate) in pregnancy (FDA category: C).
Recurrent UTI
• Perform USS KUB and renal profile
• Advise on prevention steps as above
• For those who have had no improvement after behavioural
and personal hygiene measures, consider continuous
antibiotic prophylaxis.
Antibiotic Dose
Nitrofurantoin 50-100mg ON OR
Cephalexin 250mg ON
178
Acute Pyelonephritis
• Suspect if patient presented with fever, flank pain, nausea,
vomiting and/or costovertebral angle tenderness.
• Symptoms of cystitis are not always present.
• Perform urinalysis and MSU C&S.
• If suspected acute pyelonephritis, admit for further
management.
• Assess patient for
➢ Dehydration
➢ Maternal & fetal complications
• USS KUB may be required for further assessment.
3 Delivery • Timing & mode of delivery as per obstetric indication.
4 Postpartum • To discuss options of contraception with patient/ couple.
• Pre-pregnancy clinic appointment.
5 Lactation • Exclusive breastfeeding for 6 months.
REMARKS:
1. Prevalence on UTI
2. Asymptomatic bacteriuria occurs in 2-10% of pregnant women.
3. Without treatment 20-35% will develop symptomatic UTI including pyelonephritis
during pregnancy.
4. Acute cystitis occurs in approximately 1-2% of pregnant women.
5. Acute pyelonephritis incidence is 0.5-2%. Most occurs in second or third
trimesters.
6. Diagnosis:
a. Asymptomatic bacteriuria
Two consecutive voided urine specimens with isolation of the same bacterial
strain in quantitative counts of ≥105 colony-forming units (cfu)/mL or a single
catheterized urine specimen with one bacterial species isolated in a
179
quantitative count of ≥102 cfu/mL). Treatment started after confirmed by urine
culture.
b. Recurrent UTI
Recurrent UTI defined as two UTIs within the previous six months, or 3 or
more episodes in a year. At least one symptomatic episode should be verified
by urine culture.
c. Risk for recurrent UTI

i. Sexual intercourse 3 or more / week
ii. Spermicide use
iii. New or multiple sex partner
iv. Having UTI before 15 years of age
7. Untreated bacteriuria associated with:
Mother: Fetal
a. Pyelonephritis h. Prematurity
b. Preterm birth i. Low birth weight
c. Anaemia j. Perinatal mortality
d. Sepsis
e. Respiratory distress
f. Chorioamnionitis
g. Hypertension/ pre-eclampsia
e.
8. Urinalysis:
a. Presence of nitrites is highly predictive of a positive urine culture
(Positive predictive Value = 75% to 95%);
b. Absence of leukocyte esterase has high negative predictive of positive urine
culture
(Negative predictive value = 82% to 91%)
c. Presence of both (nitrites and leucocyte) is almost conclusive
(Positive Predictive Value = 98%)
180
9. Organisms that cause UTIs during pregnancy are the same as those found in
non-pregnant women:
a. Escherichia coli (80 – 90%)
b. Proteus mirabilis
c. Klebsiella pneumonia
d. Group B streptococcus
e. Staphylococcus saprophyticus
f. Enterococci
g. Gardnerella vaginalis
h. Ureaplasma ureolyticum
Reference(s):
1. Review Urinary tract infection in pregnancy (2008)
2. John L Brusch. Medscape: Prevention of Urinary Tract Infection (UTI) in Women. Oct 10,
2017.
3. Hooton MT, Gupta K. Up To Date: urinary tract infections and asymptomatic bacteriuria in
pregnancy. last updated Dec 19, 2019
4. Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria: Update by the
Infectious Diseases Society of America, 2019
5. NICE guideline (2018): Urinary tract infection (recurrent): antimicrobial prescribing guidance
6. AAFP. Common questions about recurrent urinary tract infections in women, 2016
7. National Antibiotic Guideline, 2019
8. WHO recommendation on antibiotic prophylaxis to prevent recurrent urinary tract infections.
9 March 2018.
9. WHO recommendation on the method for diagnosing asymptomatic bacteriuria in pregnancy.
8 March 2019.
10. AAFP. Dysuria: Evaluation and differential diagnosis in adults, 2015
181
SECTION 14 SOCIAL PROBLEMS IN PREGNANCY
14.1 Domestic Violence
1 Pre-pregnancy • Refer FMS for assessment.
2 Booking • Woman-centered care: Be non-judgmental, maintain
confidentiality when possible, privacy and not pressure
woman to leave the relationship.
• Offer first line support:
➢ ask about her history of violence, listen carefully, but not
pressuring her to talk (care should be taken when
discussing sensitive topics when interpreters are
involved).
➢ help her access information about resources, including
legal and other services that she might think helpful.
➢ assist her to increase safety for herself and her children,
where needed.
➢ provide or mobilize social support.
• Assessment for the safety to the mother and her other
children.
• Safety plan as the patient is at risk of serious harm or death
(Refer to remarks).
• Explain about sources of support:
➢ Establish if they have any friends/family that know or
could support them
➢ Counselling/support and helplines (Refer to remarks)
➢ Shelter is available if they cannot go home
• Assist in referrals (and explain how they can help)
➢ Police
➢ OSCC
➢ Counselling/support services
➢ Social services (JKM)
• Consent is needed if the victim is an adult with capacity
(unless an underage teenager or vulnerable adults).
3 Subsequent • Screen for mental illness (Refer to chapter antenatal mental
antenatal follow- health screening)
up • Urgent referral to psychiatrist if suicidal ideation or attempt
• Involve O&G if any obstetric concern
182
5 Postpartum • Home visit to evaluate the social and family support
• Mental health screening
• Contraception
6 Lactation • Encourage breast feeding
REMARKS:
1. NGO services available in Sabah:
a. SAWO (Sabah Daya Tindakan Wanita Sabah) – 088-269291
b. AWAM (All Women’s Action Society Malaysia) – 03-78770224
c. WAO (Women Aid Organisation) – 03- 79563488 or Whatsapp/ SMS 018-
9888058
d. AGAPE- 088-254515
e. Talian Kasih – 15999
f. Befrienders – 088-255788
2. Safety plan:
a. Preparing an emergency kit with important documents, keys, money, and other
essential items, to be stored outside the home in case they need to escape
urgently
b. A place to go (friends, family, shelter)
c. A signal to alert children or neighbors to call 999
d. During times of escalating conflict, avoiding rooms with potential weapons
(kitchen) or risk for increased injury (hard bathroom surfaces)
3. “Universal screening” or “routine enquiry” (i.e. asking women in all health-care
encounters) should not be implemented.
Reference(s):
1. OSCC: One Stop Crisis Center: Policy and Guidelines for Hospitals, Ministry of Health,
Malaysia 2015
2. Responding to intimate partner violence and sexual violence against women. WHO clinical
and policy guidelines. 2013.
3. Amy Weil (2018). Intimate partner violence: Intervention and patient management. In
Elmore, J.G. (Ed.), UpToDate.
183
14.2 Teenage Pregnancy or Single Parent
1 Pre-pregnancy • Refer FMS for assessment
2 Booking • Single adult mother (≥18 years)
➢ Referral to MSW
➢ If any element of sexual assault or physical violence –
advise that police report should be made (by patient) and
refer OSCC if safety is an issue
• Teenage mother (16-18 years)
➢ Referral to MSW and report to Pelindung JKM (Borang 9
to be filled up by first-contact doctor)
➢ If any element of sexual assault or physical violence –
police report should be made (by doctor) and refer
OSCC
➢ If safety of the patient is an issue – refer OSCC
➢ To get parental/ husband consent for treatment and
referral (to refer Pelindung if not available)
• Teenage mother (<16 years old)
➢ Doctor’s legal responsibility to ensure that police report
is made (statutory rape)
➢ Referral to MSW and report to Pelindung JKM (Borang 9
to be filled up by first-contact doctor)
➢ Refer OSCC in hospital- multidisciplinary care (O&G,
psychologist, SCAN team)
➢ To get parental/ husband consent for treatment and
referral (to refer Pelindung if not available)
• Implementation of HEADSS framework during interview of
teenage mother:
Home
Education/Employment
184
Activity – hobbies, leisure, peers
Drugs/Diet
Sexual
Suicide/safety
• Future plan: parenthood/ abortion/ adoption
3 Subsequent • Antenatal care as in perinatal care manual
antenatal follow- ➢ Complete history on psychosocial support
up ➢ To be seen by FMS at least once throughout pregnancy
• Maternal assessment
➢ Anaemia
➢ Pre-eclampsia
➢ Mental health assessment (please refer chapter mental
health screening)
➢ Psychosocial support - referral to MSW if not done during
booking
➢ Repeat HIV screening test /RPR in 3rd trimester (see
remarks- high risk group)
• Fetal assessment
➢ Monthly growth assessment
• Inform MSW before discharge if needed
5 Postpartum • Discuss and emphasize importance of contraception and
good pregnancy spacing
• Counsel on importance of safe sex
• HIV/ STI education
6 Lactation • Encourage breast feeding on demand
185
REMARKS:
1. All pregnant women will be registered for antenatal care regardless of their marital
status.
2. Medical social worker (Pegawai Kesihatan Sosial Perubatan) in Hospital or Health
Clinic
3. Pegawai Pelindung (Pegawai Kebajikan Masyarakat) in Pejabat Kebajikan of
every district.
4. Definition
a. Child refers to a person under the age of 18 years
b. Teenage pregnancy is defined as pregnancy below 19 years old
c. Single mother is defined as pregnant women who are unmarried or unable to
prove their marital status
5. Legal age for marriage for Malaysian women is 16 years old
6. Marital status confirmation is by producing valid official document by Jabatan
Pendaftaran Negara or Mahkamah Anak Negeri
7. Verbal confidentiality contract (VCC):
Inform the teenager/single mother about the confidentiality and privacy except in 3
situations where the confidentiality will be breached when:
a. Risk of harm to self
b. Risk of harm from others
c. Risk of harm to others
*Be non-judgmental
8. Teenage pregnancy <18 year old/ mentally incompetence:
a. Unmarried: consent from parents/guardian.
b. Married: consent from husband if ≥18 year old. If husband <18 year old –
consent from parents/ guardian.
9. Teenage mothers are at higher risk of:
a. Pre-eclampsia
b. Anaemia
c. Fetal growth restriction
186
d. Prematurity
e. Puerperal endometritis/ systemic infection
f. Infant death
g. Low birth weight babies
h. Postpartum depression
10. High risk group mother
a. RPR reactive upon booking
b. Teenage pregnancy
c. Single mother
d. Indigenous mother
e. Immigrant mother
f. History of more >1 sexual partner
g. History of stillbirth/ miscarriage
h. History of unbooked/ unscreened
i. History of alcohol/ drug use
Reference(s):
1. Garis Panduan Pengendalian Masalah Kesihatan Seksual dan Reproduktif Remaja di Klinik
Kesihatan, Bah. Pembangunan Kesihatan Keluarga, Kementerian Kesihatan Malaysia, 2012
2. Kanun Keseksaan (Akta 574) Seksyen 375 – Rogol
3. Akta Kanak-kanak (Pindaan) 2016 (Akta 1511)
4. Akta Kesalahan-Kesalahan Jenayah Seksual Terhadap Kanak-Kanak 2017 (Akta 792)
5. Akta Umur Dewasa 1971 (Akta 21)
6. Kerahsiaan – Majlis Perubatan Malysia, Julai 2008
187
SECTION 15 THYROID DISORDERS IN PREGNANCY
15.1 Hyperthyroidism in Pregnancy
1 Pre-pregnancy • Refer for counselling by FMS / O&G (Pre-pregnancy clinic)/
MO (health clinic without FMS).
• Thyrotoxic women should be rendered euthyroid before
attempting pregnancy.
• Defer pregnancy at least 6 months after Radioiodine (131 I)
and biochemically euthyroid.
• Effective contraception if woman is planned for RAI.
• Consider switching to PTU if on carbimazole. For benefit of
any existing doubt, women in reproductive age group should
be commenced on PTU.
• In patient with thyroid nodule(s):
➢ Perform thyroid sonography and survey of cervical
lymph nodes
➢ Refer for FNAC (SOPD) if ultrasound features reveal
complex thyroid nodule
➢ Thyroid nodule diagnostic FNAC is not required if
nodule(s) is purely cystic or no sonographic suspicion
2 Booking • Refer to FMS for assessment and commencement of
antithyroid drug (ATD).
• Refer Combined Clinic for shared care.
• Treatment of hyperthyroidism in pregnancy:
➢ PTU is preferred during 1st trimester and can continue
up to 16 weeks’ gestation (For patients diagnosed
hyperthyroidism in pregnancy)
➢ Patients who have already on Carbimazole pre-
pregnancy, can continue with current regime without
switching to PTU.
188
➢ After first trimester, Carbimazole is recommended.
➢ FT4 and TSH level:
▪ to be done monthly after initiation of therapy
▪ 4-6 weekly after achieving the target value
➢ Aim to maintain the FT4 levels at, or just above upper
limit of normal.
➢ Propanolol (shortest possible duration if indicated) for
symptomatic control.
➢ Check FBC, LFT and TFT 4 weeks after commencement
of ATD.
➢ In patients with past or present history of Grave’s
disease, to measure serum TRAb during second
trimester (will be decided by Combined Clinic team or
endocrinologist).
• In gestational transient hyperthyroidism:
➢ Supportive treatment for hyperemesis gravidarum is
indicated (including treatment of dehydration).
➢ ATD is not indicated, since serum T4 returns to normal
by 14-18 weeks.
• In subclinical hyperthyroidism:
➢ ATD is not recommended as it is usually transient in first
trimester & gradually improves in later gestation.
3 Subsequent • Shared care between FMS and Combined Clinic team.
antenatal follow- • Detailed scan by O&G/ MFM team at 24 weeks if indicated.
up • Monthly serial growth velocity scans with vigilance for high
output cardiac failure: tachycardia, effusions or fetal goitre
• Maintain the FT4 levels at, or just above upper limit of
normal.
• Monitor TFT once per trimester if controlled.
• Urgent consultation with endocrinologist if hyperthyroidism
189
difficult to control.
4 Delivery • May allow postdate, unless specified otherwise.
5 Postpartum • Arrange FMS appointment within one month.
• Pre-pregnancy Clinic appointment at 3 months postnatal (if
future pregnancy possible).
• Carbimazole in doses up to 20-30mg/d is safe for lactating
mothers and infants.
• 2nd line: PTU at 300mg/d (concerns of hepatotoxicity).
• To administer ATDs following a feeding, in divided doses.
• Refer all babies born to mothers with hyperthyroidism to
Paediatric team.
• Type 1 DM, Grave’s disease in remission and chronic viral
hepatitis:
➢ at risk of developing post-partum thyroiditis
➢ To measure TSH level at 6-12 weeks gestation and 6
months postpartum
• Women known to be thyroid antibody positive:
➢ To measure TSH level at 6-12 weeks gestation and 6
months postpartum, or as clinically indicated.
• Contraception advice as per MEC.
• To continue follow up for hyperthyroidism under local clinic
or specialist clinic as per pre pregnant.
REMARKS:
1. Important to distinguish Grave’s disease from gestational transient
thyrotoxicosis (GTT)
a. GTT Defined as transient hyperthyroidism, limited to the first half of pregnancy,
characterized by elevated serum Free T4 and suppressed or undetectable
serum TSH, in the absence of thyroid autoimmunity.
b. The usual presentation is hyperemesis gravidarum (due to high levels of HCG).
190
c. The presence of autoimmunity, goitre, ophthalmopathy, family history,
would suggest Graves, therefore recommended to treat with ATD.
2. Management of GTT
Supportive, treat dehydration, ATDs not recommended, low-dose short-term
beta-blockers may be considered.
3. Uncontrolled hyperthyroidism can cause:
Mother Fetal/ Neonatal
• Miscarriage • Prematurity
• Pre-eclampsia • Small size for gestational age
• Preterm delivery • Intrauterine fetal death
• Congestive Heart Failure (CHF) • Goitre
• Thyroid storm • Thyrotoxicosis
• Placental abruption • Transient Hyperthyroidism (neonates)
• Hydrops
4. TRAb: helps assess fetal risk

a. TRAb negative: no antithyroid drugs needed as very low risk of fetal/ neonatal
thyrotoxicosis
b. TRAb positive: Follow up pregnancy by fetal US, monitor TFTs
c. 1-5% of neonates born to women with Graves’ disease have fetal
hyperthyroidism/ thyrotoxicosis due to trans-placental transfer of TRAb.
5. Adverse effects drugs used in hyperthyroidism:
Propylthiouracil (PTU) Carbimazole Propanol
Initial: 150 – 400mg TDS Initial: 14 – 40mg OD
Maintenance: Maintenance: 20 - 40mg OD
3. 50 – 150mg TDS 4. 5 – 15mg OD
Side effects: Side effects: Side effects:
Rash, fever, Rash, fever, Bronchospasm,
agranulocytosis, risk of agranulocytosis, aplasia Intrauterine growth
liver toxicity cutis, methimazole restriction, neonatal
5. embryopathy hypoglycemia
6. If patient is allergic to Carbimazole, to change to PTU.

7. Maintaining Free T4 levels in the upper normal of non-pregnant reference range
usually protects the fetus from hypothyroidism.
8. Subtotal thyroidectomy may be indicated if:
a. Patient has severe reaction to ATD
b. Persistent high doses of ATD are required (Carbimazole> 30mg or PTU >
191
450mg/day)
c. Non-adherence or uncontrolled hyperthyroidism.
d. The optimal timing of surgery is in the second trimester
9. Women with history of Post-partum Thyroiditis (PPT) have a markedly increased
risk of developing permanent primary hypothyroidism in the 5 to 10 years period
after the episode of PPT.
10. An annual TSH level should be performed in these women in local clinic.
11. If TSH <0.1 mIU/L in the first trimester, to proceed with FT4.
a. Clinical hyperthyroidism is confirmed in the presence of a suppressed or
undetectable TSH and an elevated FT4.
Reference(s):
1. Stagnaro-Green, A., Abalovich, M., Alexander, E., Azizi, F., Mestman, J. Wiersinga, W.The
American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and
Postpartum, (2011). Guidelines of the American Thyroid Association for the Diagnosis and
Management of Thyroid Disease During Pregnancy and Postpartum. Thyroid, 21(10), 1081–
1125. http://doi.org/10.1089/thy.2011.0087
2. Erik K. Alexander, Elizabeth N. Pearce, Gregory A. Brent, Rosalind S. Brown, Herbert Chen,
Chrysoula Dosiou, William A. Grobman, Peter Laurberg,John H. Lazarus, Susan J. Mandel,
Robin P. Peeters,11 and Scott Sullivan.2017 Guidelines of the American Thyroid Association
for the Diagnosis and Management of Thyroid Disease During Pregnancy and the
Postpartum.
3. THYROID, Volume 27, Number 3, 2017 ª American Thyroid Association ª Mary Ann Liebert,
Inc. DOI: 10.1089/thy.2016.0457
4. Erik K. Alexander, Keith C. Bible, et al 2015 American Thyroid Association Management
Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Bryan
R. Haugen. The American Thyroid Association Guidelines Task Force on Thyroid Nodules
and Differentiated Thyroid Cancer.
192
15.2 Hypothyroidism in Pregnancy
1 Pre-pregnancy • Counselling by FMS/ O&G (Pre-pregnancy Clinic)/ MO (clinic
without FMS).
• Thyroid sonography and survey of cervical lymph
nodes should be performed in all patients with thyroid
nodule(s).
• Women with thyroid nodule(s) should be referred for
FNAC (SOPD) if ultrasound features reveal complex
thyroid nodule.
• Thyroid nodule diagnostic FNAC is not required if
nodule(s) is purely cystic or no sonographic suspicion.
• Maintain TSH < 2.5 mIU/L for known case of
hypothyroidism under treatment.
2 Booking • Overt hypothyroidism (OH) should be treated.
• Consult O&G if subclinical hypothyroxinemia or isolated
hypothyroidism.
• In woman with hypothyroidism, the dose of L-
Thyroxine should be increased by 30 to 50% once
UPT is positive.
• Serum TSH should be obtained early in women with risk
factor (refer remarks).
• Refer to FMS/ Combined Clinic.
• Rapid normalizing of TSH level is advised.
3 Subsequent • Shared care between FMS and Combined Clinic team.
antenatal follow- • Detail scan in MFM Clinic at 18-22 weeks in maternal
up autoimmune thyroid disease.
• Combined Clinic follow-up once per trimester.
• L-Thyroxine should be given and titrated up to the
optimal TSH level (according to trimester):
193
➢ 1st trimester: 0.1-2.5 mIU/L
➢ 2nd trimester: 0.2-3.0 mIU/L
➢ 3rd trimester: 0.3-3.0 mIU/L
• Monitor TSH at every 4 to 6 weeks.
• During each visit, to check on compliance and correct
ingestion of levothyroxine (to take with empty stomach).
4 Delivery • Generally, may allow postdates, unless specified otherwise
5 Postpartum • After delivery, most hypothyroid women may need to
decrease the L- Thyroxine dose to the pre-pregnancy levels.
• Serum TSH should be done at 4 to 6 weeks post-partum.
• Refer all babies born to mother with hypothyroidism to the
Paediatric team.
• FMS/ MO appointment to review TSH result at 2 months
• Endocrinology appointment, if indicated.
• Pre-pregnancy Clinic appointment at 3/12 postpartum (if
future pregnancy possible).
• Refer MEC for contraception.
6 Lactation • L-thyroxine should be continued in lactating women
REMARKS:
1. Prepregnancy counselling should include:
a. Counsel on importance to achieve euthyroidism before conception (risk of
reduce fertility and miscarriage)
b. Counsel on importance of early booking for immediate monitoring of TSH level.
2. Serum TSH should be obtained early in women with risk factor below:
a. History of thyroid dysfunction or thyroid surgery
b. Symptoms of thyroid dysfunction or presence of goiter
c. Current thyroid therapy
d. History of head or neck radiation
194
e. Use of amiodarone or lithium, or recent administration of iodinated
radiologic contrast.
f. Family history of autoimmune thyroid disease
g. Previous delivery of infant with thyroid disease
h. History of autoimmune disorder
i. History of T1DM
3. There is an association between maternal hypothyroidism and child’s
developmental delay.
4. Isolated hypothyrosinemia - Defined as low FT4 (in lower 2.5th to 5th percentile of
population) with Normal TSH
5. Overt Hypothyroid:
a. An elevated TSH (>2.5 mIU/L) in conjunction with a decreased FT4
concentration or
b. Women with TSH level >10 mIU/L, irrespective with their FT4 level
6. Subclinical Hypothyroid (in pregnancy):
Defined as serum TSH above the upper limit of the trimester-specific reference
range with a normal Free T4.
7. The thyroxine dose usually needs to be increased by 4-6 weeks of gestation and
may require 30-50% increase in dosage.
8. Complications of hypothyroidism during pregnancy:
Mother Child
• Pre-eclampsia • Neurocognitive defects
• Need for Caesarean • Malformations
• Gestational diabetes • Respiratory problems
• Placental abruptions • Anaemia
• Infertility • Sepsis
• Miscarriage • Need for ICU treatment
• Anaemia • Large or small for gestational age
• Postpartum haemorrhage • Pre-term delivery
• Goitre
195
• Postpartum maternal thyroid
dysfunction
9. TRab crosses the placenta and can cause fetal hyperthyroidism.

10. Women with thyroid autoimmunity who are euthyroid in early pregnancy are at
risk of hypothyroidism.
11. Dose adjustment of L-thyroxine based on TSH level:
Thyroid-stimulating hormone level Levothyroixine dosage increase
(mIU per L) (mcg per day)
5 to <10 25 to 50
10 to 20 50 to 75
>20 75 to 100
Reference(s):
1. Lazarus J, Brown R, S, Daumerie C, Hubalewska-Dydejczyk A, Negro R, Vaidya B, 2014
European Thyroid Association Guidelines for the Management of Subclinical Hypothyroidism
in Pregnancy and in Children. Eur Thyroid J 2014; 3:76-94.
2. Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, et al. 2017 Guidelines of
the American Thyroid Association for the Diagnosis and Management of Thyroid Disease
During Pregnancy and the Postpartum. Thyroid : official journal of the American Thyroid
Association. 2017;27(3):315-89.
3. Carney LA, Quinlan JD, West JM. Thyroid disease in pregnancy. Am Fam Physician.
2014;89(4):273-8.
4. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015
American Thyroid Association Management Guidelines for Adult Patients with Thyroid
Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines
Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid : official journal of
the American Thyroid Association. 2016;26(1):1-133.
196
SECTION 16 VENOUS THROMBOEMBOLISM IN PREGNANCY
1 Pre-pregnancy • Refer early to pre-pregnancy clinic for patients who are
contemplating pregnancy and have a significant risk of
developing VTE during pregnancy. This should include
patients with:
➢ Previous VTE
➢ Thrombophilia
➢ Mechanical valve in heart disease
➢ Antiphospholipid syndrome
• Other risk factors – obesity (≥ 30 kg/m2), malignancies,
cardiac failure, active SLE, IVDU/TB, nephrotic syndrome,
DM with nephropathy, thalassemia major or intermedia post
splenectomy.
• These patients should be seen by dedicated pre-pregnancy
care team.
• Refer Very high-risk patients or who are already on
warfarin to O&G for assessment and counselling prior to
conception – aim to convert warfarin to therapeutic dose of
LMWH to reduce fetal risk.
2 Booking • ALL women should have their VTE risk assessment done
using a VTE checklist* during pre-pregnancy, booking,
inter-current illness and immediate postnatal period.
• Document the VTE risk assessment in numerical score and
to commence thromboprophylaxis accordingly (refer
flowchart)
• Low risk (score ≤ 2)
➢ Continue non-pharmacological thromboprophylaxis
measures (anti-embolic stockings/avoid
dehydration/early mobilization) - follow up in Health Clinic
197
• Moderate risk (score 3)
➢ The initial assessment at booking, can be performed by
nurses. If the score is ≥ 3, referred to the medical officer
immediate if possible or within 72 hours to confirm the
risks
➢ Refer FMS for counselling ≤ 26 weeks
➢ Refer O&G Specialist at 28 weeks for VTE prophylaxis
• High risk (score ≥4) or Very high risk (previous VTE,
antithrombin deficiency, APS with previous VTE)
➢ Refer O&G Specialist/FMS on the same day and start
VTE prophylaxis as soon as possible
➢ High risk patients on warfarin:
▪ If present in the first trimester – refer O&G for
conversion of warfarin to LMWH, assessment and
counselling, arrange for detail scan at 22-24
weeks of gestation
▪ If present after first trimester – refer O&G for
assessment and counselling, arrange for detail
scan at 22-24 weeks of gestation
3 Subsequent • Shared care between Health Clinic and O&G clinic.
antenatal follow- • Look for symptoms and signs of VTE at every antenatal visit
up for moderate, high risk and very high-risk patients. If present,
refer Hospital immediately.
• Further details on follow-up regime will be outlined on case-
to-case basis.
• Risk stratification should be repeated at every hospital
admission for ALL patients* and commence
thromboprophylaxis accordingly.
198
4 Delivery • Will be outlined by multidisciplinary team (physician,
anaesthetist and MFM), addressing timing, mode and place
of delivery.
• Patients should be advised to omit their LMWH dose if they
have.
• signs or symptoms of labour or bleeding and to seek medical
attention immediately.
• Anti-coagulant must be stop 24 hours for the therapeutic
dose and 12 hours for prophylactic dose BEFORE planned
delivery).
5 Postpartum • ALL mothers who delivered in the hospital, alternative

birthing centre, health clinics, home delivery or birth before
arrival should have a documented VTE risk assessment* and
commence thromboprophylaxis accordingly.
• Inform high risk discharge to Health clinic.
• For patient who indicate for thromboprophylaxis, the
treatment can be initiated post-delivery between 4-6 hours
following delivery.
• Referral to O&G specialist for high risk patients (VTE, APS
or Thrombophilia) who need longer thromboprophylaxis
regarding the options of conversion to warfarin.
• Patients on UFH will require platelet monitoring weekly until
heparin is stopped or unless abnormal result.
• Contraception – to discuss options of contraception with
patient / couple, according to MEC recommendation.
• Future pregnancy – Advise for Pre-pregnancy clinic visit and
early booking in next pregnancy
6 Lactation • Encourage breastfeeding – there is no contraindication to
warfarin or LMWH.
199
REMARKS:
1. LMWHs are the agents of choice for antenatal and postnatal thromboprophylaxis.
2. Below are the anti-coagulants that available in KKM setting.
Weight a Enoxaparin Unfractionated Heparin
< 50 kg 20 mg OD 5000 units BD
50-90 kg 40 mg OD 7500 units BD
91-130 kg 60 mg OD Insufficient evidence of
131-170 kg 80 mg OD efficacy (discuss with
> 170 kg 0.6 mg/kg/day heamatologist)
a. Based on booking weight unless high risk
b. Women with anti-thrombin III deficiency and anti-phospholipid syndrome
require higher prophylactic dose
c. Anti-dote:
i. Protamine sulphate (10mg/ml) for unfractionated Heparin with dose of 5
ml slow IV injection over 10 minutes.
ii. No antidote available for LMWH (Enoxaparin)
3. If a woman develops a haemorrhagic problem while on LMWH or UFH, the
treatment should be stopped, and expert haematological advice sought
4. VTE risk factors:
a. Previous VTE (except those with a single previous VTE related to major surgery
and no other risk factors)
i. If no documentation is available, the previous diagnosis of VTE can be
assumed in cases where the woman gives a good history and received
prolonged (greater than 6 weeks) therapeutic anticoagulation.
b. Thrombophilia-associated VTE
i. Heritable thrombophilia
▪ Women with previous VTE associated with antithrombin deficiency-
offered thromboprophylaxis with higher dose LMWH
▪ Other heritable thrombophilic defects are lower risk- managed with
standard doses of thromboprophylaxis
ii. Acquired thrombophilia
▪ Women with VTE associated with the antiphospholipid syndrome
(APS) -offered thromboprophylaxis with higher dose LMWH (either
50%, 75% or full treatment dose)
▪ Pregnant women with APS and prior VTE or arterial thrombosis - refer
Combined Clinic with a haematologist and/or rheumatologist
c. Type 1 Diabetes Mellitus with nephropathy
d. Tuberculosis in acute (within 2 months intensive treatment) and/or severe
infection (disseminated TB) – transient risk factor
e. Cardiac failure - decompensated and symptomatic
200
A. PREGNANCY AND PUERPERIAL VTE CHECKLIST (KKM 2017) *
Tick
VTE
VTE risk factors Pre-pregnancy/ Admission/ Post
score
Booking New Illness delivery
Date
Pre-existing risk factors
Previous VTE 4
High risk thrombophilia 3
Medical comorbidities 3
(malignancies, cardiac failure, active
SLE, IVDU/TB, nephrotic syndrome,
DM with nephropathy, thalassemia
major or intermedia post
splenectomy)
BMI ≥ 40kg/m2 2
BMI 30-39 kg/m2 1
Family history of VTE 1
Low risk thrombophilia 1
Current smoker (≥10 per day) 1
Obstetric risk factors
Caesarean section (emergency & 2
elective)
Pre-eclampsia 1
Mid-cavity rotation instrumental 1
delivery
Prolonged labour (> 24hours) 1
Postpartum haemorrhage 1
(> 1000mls or requiring blood
transfusion
Stillbirth(current) 1
IVF (first trimester only) 1
Transient risk factors*
Surgical procedures 4
(except episiotomy repair, repair of
1st and 2nd degree perineal tear,
evacuation of products of conception)
Hyperemesis gravidarum/OHSS 4
Admission beyond 3 days 1
Systemic infection/infection requiring 1
IV antibiotics
Long distance travel (> 4 hours) 1
Immobility/ dehydration 1
Note: Thromboprophylaxis is recommended during the transient period. Consider stopping once the
transient risks are deemed no longer significant.
201
B. FLOWCHART VTE Risk Assessment in Primary Health Care
Booking
VTE Risk Assessment

YES (Reconfirm by MO/FMS)
Risk Factors
High Risk Moderate Risk Low Risk

(Score ≥ 4) (Score 3) (Score ≤ 2)
Refer O&G Refer FMS for

Specialist/ FMS Counselling ≤ 26/52
Continue Non-
Pharmacological
Refer O&G specialist at
Start VTE Prophylaxis Thromboprophylaxis**
28/52 for VTE
(as soon as possible)
Prophylaxis
ANTENATAL
POSTNATAL
Continue Prophylaxis Continue Prophylaxis

B
for 3/52* for 3/52
* Consider additional 3 weeks prophylaxis in certain high-risk patients (at the discretion
of O&G specialist)
** Non-pharmacological thromboprophylaxis measures e.g. anti-embolic stockings, avoid
dehydration, early mobilization
(Taken from Training Manual: Prevention and Treatment of Thromboembolism in Pregnancy and Puerperium, 2018)
202
B
Postnatal VTE Risk

Assessment
Score > 2 Score 2 Score < 2
VTE Prophylaxis for VTE Prophylaxis for General Advice

10 Days 10 Days ▪ Early
Mobilization
VTE Risk ▪ Anti-Embolic
Reassessment Stockings
▪ Avoid
Dehydration
Low Risk (no further

High Risk (to
VTE prophylaxis
complete for 3 weeks)
required)
RESPONSIBILITY
▪ O&G Specialist
▪ Family medicine specialist/ Medical officer
▪ Nurses
(Taken from Training Manual: Prevention and Treatment of Thromboembolism in Pregnancy and Puerperium, 2018)
Reference(s):
1. Training Manual Prevention and Treatment of Thromboembolism in Pregnancy and
Puerperium, second edition (2018)
2. RCOG Green-Top Guideline No. 37a, Reducing the Risk of Venous Thromboembolism during
Pregnancy and the Puerperium 2015
203
SECTION 17 APPROACH TO COMMON PRESENTATIONS IN
PREGNANCY
17.1 Elevated Liver Enzymes in Pregnancy
Abnormal Liver Enzyme
History
• Fever, pain, masses

• Alcohol, medication
• Risk factors for viral hepatitis, leptospirosis, dengue, malaria
• Personal family history
Examination
• Jaundice
• Stigmata of liver Disease
• Abdominal mass, ascites
• Breast Lump
Pregnancy specific
Isolated Cholestatic Liver
Enzymes – elevated ALKP
and GGT
Infection
Isolated Elevated Bilirubin

with otherwise normal liver
Hepatic liver enzymes test
Elevated AST or ALT
Synthetic failure
Jaundice low albumin,
prolonged INR
Or
Urgent referral Suspected malignancy

Weight loss
Whilst outside of pregnancy, it would be acceptable to perform serial repeats of liver function
test at predefined intervals to see improvement before furtherMarked
testing ischolestasis
done. However, due to
the short interval of pregnancy to delivery time, it becomes important that a diagnosis is made
sooner than later and to allow adequate time for treatment, optimisation of disease and planning
of delivery in a multi-disciplinary manner so as to avoid or minimise complications. Early referral
to relevant speciality is advised. Where in doubt, always discuss with FMS, O&G specialist or
physician.
204
Hyperemesis
1st Trimester
Gravidarum
Pregnancy
specific Pre-Eclampsia
>20 weeks HELLP

Acute Fatty Liver
Obstetric Refer to O&G /
Cholestatsis Medical physician
Hep A, B, C
Viral
Infection Hepatitis CMV
EB Virus
Others Herpes Simplex
Leptospirosis
Malaria
Dengue
Cholecystitis
Autoimmune
Hepatic liver enzymes Iron Excess
Elevated AST or ALT • Thalassemia
• Hemochromatosis
Copper excess
Ultrasound
Isolated Cholestatic
Cholelithiasis
Liver Enzymes – Autoimmune
elevated ALP and GGT Autoimmune Screen
Isolated cholestatic liver Commonly Gilbert Syndrome (unconjugated)

enzymes – elevated ALP
and GGT Less likely haemolysis – consider LDH,
Reticulocyte count, haptoglobulin
Reference:
Newsome P, Cramb R, Davison S et al. Guidelines on the management of abnormal liver
blood test. Gut 2018; 67(1):6 - 19
205
17.2 Headache in Pregnancy
RED FLAG Common causes of maternal death in Sabah in

conjunction with headaches relate to pre-eclampsia,
• Pregnant or puerperium intracranial haemorrhage, cerebral vein thrombosis,
• Thunderclap onset meningitis and on rare occasions brain tumour
• Fever and meningism
• Papillooedema with focal signs or reduced consciousness
• Acute glaucoma
• Temporal arteritis
• Relevant systemic illness
• Elderly
No Yes
Possible indicators of secondary headache
• Unexplained focal signs

• Atypical headache
• Unusual headache precipitants
Yes
• Unusual aura symptom’s Refer urgently
• Onset after 50 years old for further
• Aggravation by neck movement: abnormal neck evaluation
examination findings
• Jaw symptoms: abnormal jaw examination findings
No
MIGRAINE
Yes
Headache with 2 or more of following:
• Nausea Refer physician for

• Light sensitivity advice
• Interference with activity • Behavioural
No management
• Prophylactic
TENSION TYPE HEADACHE Yes medication
Headache with no nausea but 2 or more of • Monitor medication
overuse
following:
• Bilateral headache Yes

• Non pulsating pain
• Mild to moderate pain No Uncommon headache
• Not worsened by activity syndromes
Reference: Werner JB, Ted F, Carmen M, et al. Guideline for primary care management of headache in
adult. Canadian Family Physician Aug 2015, 61(8):670-679
206
17.3 Nausea and Vomiting in Pregnancy
Nausea and vomiting in first trimester
Take history to exclude causes* and perform examination

(vital signs, weight, signs of dehydration)
Check urine dipstick for ketone
Mild NVP and patient can Severe NVP

tolerate oral intake
• Persistent symptoms & unable to
take oral antiemetics
Manage at community level: • Persistent symptoms & ketonuria
and/or >5% weight loss
• Antiemetics
• Oral hydration
• Dietary advice
Refer O&G for inpatient management
• Support
• Reassess in 1 – 2 weeks in
primary care
Remarks:
1. Hyperemesis gravidarum is diagnosed based on triad of >5% pre-pregnancy
weight loss, dehydration and electrolyte imbalance.
2. First line antiemetics:
a. PO Cyclizine 50mg 8 hourly (e.g. veloxine)
b. PO Prochlorperazine 5-10mg 6-8 hourly
c. PO Promethazine 12.5-25mg 4-8 hourly
d. PO Chlorpromazine 10-25mg 4-6 hourly
e. PO metochlopramide 5-10mg 8 hourly
3. Withhold iron tablet
4. VTE scoring if inpatient (transient risk factor)
5. If women presented with recurrent episodes of NVP, further workup is required.
207
Differential Diagnosis for Nausea and Vomiting in Pregnancy*
Gastrointestinal disorders Metabolic disorders
Gastroenteritis Diabetic ketoacidosis
Biliary tract disease Renal tubular acidosis
Hepatitis Addison's disease
Intestinal obstruction Hyperthyroidism
Gastroesophageal reflux disease Neurologic disorders
Pancreatitis Pseudotumor cerebri
Appendicitis Vestibular lesions
Acute fatty liver of pregnancy Migraine headaches
Genitourinary tract disorders Central nervous system tumours
Pyelonephritis Others
Uraemia Ovarian hyperstimulation syndrome
Degenerating uterine leiomyoma Hypercalcemia
Torsion Dehydration
Renal stones Psychological disorder
Molar Pregnancy
Drug toxicity or intolerance
Iron supplement
Reference:
1. The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum. Green-top
Guideline No. 69, June 2016. Royal College of Obstetricians and Gynaecologists.
2. Sumona S, Catherine W, Niharika M, et al. Approach to Hyperemesis Gravidarum. De Swiet’s Medical
Disorder in Obstetric Practice 5th Edition.
208
17.4 Palpitation in Pregnancy
Woman reports palpitation
Take full history and conduct physical examination,

including cardiopulmonary examination
Physiological palpitation + no Palpitation + significant

significant tachycardia tachycardia
OR OR
Occasional ectopic beat Severe/ persistent palpitations
Carry out baseline investigations in health clinic:
• FBC
• TFT
• 12-lead ECG (+/- Holter)
• ECHO if detected murmurs
Refer O&G team
Remarks:
Features requiring further attention:
a. Fast and irregular heart beat
b. Palpitations waking from sleep or palpitations at work
c. Dizziness following onset of palpitations
d. Breathlessness, chest pain, syncope
e. Associated headache, sweating or abdominal pain and/or hypertension
f. Personal history of pre-existing cardiac disease
g. Family history of cardiac disease
Reference:
1. Roberts A, Mechery J, Mechery A, Clarke B, Vause S. Management of Palpitations and Cardiac
Arrhythmias in Pregnancy. The Obstetrician & Gynaecologist 2019; 21:263-70.
209
17.5 Persistent Proteinuria in Pregnancy
Persistent proteinuria on urine dipstick test in different occasions
Send mid-stream urine for urinalysis, microscopic examination and

culture. Blood for baseline serum creatinine
Yes Treat urinary tract

Positive urine
culture? infection then repeat
No urine dipstick
No
Normal urinalysis and normal Abnormal urinalysis or

creatinine abnormal creatinine
Benign causes Further workup
• Transient proteinuria • Quantification of urine protein

• Orthostatic proteinuria • Ultrasound KUB appointment in
radiology department, SWACH
Reassurance
Disease-related causes
• Primary renal – nephritic, nephrotic

• Systemic
o Hypertension/ pre-eclampsia
o Postinfectious GN
o Diabetes
o Drugs
o Infection etc.
Refer O&G clinic +/- Combined Clinic

Reference:
1. Margaret A. Miller. Approach to proteinuria identified remote from term. De Swiet’s Medical Disorder
in Obstetric Practice 5th Edition
210
17.6 Pre-syncopal or Syncopal Attack in Pregnancy
ESSENTIAL DIAGNOSIS TO BE EXCLUDED:
CARDIAC ARRYTHMIA
SEIZURES
CVA
History:
• Onset
• Associated symptoms
• Triggering factors including association with position
• Underlying conditions e.g. Diabetes, cardiac arrythmias and anxiety
• Seizures or transient ischaemic attack
Physical examination:
• Blood pressure standing and supine

• Pulse rate and characteristic
• Respiratory rate and pulse oxymeter
• Cardio-Respiratory & Neurological system
• Foetal wellbeing
Investigations:
• FBC, electrolytes, capillary glucose

• ECG
Refer O&G if after >20 weeks (if ≤20 weeks refer

FMS/Medical) for further evaluation & admission:
• Holter/ event monitor

• EEG
• Glucose monitoring
211
Differential Diagnosis of Syncopal Attack:
Causes Characteristic
Cardiac
a. Vasovagal • Gradual onset.
Investigation: • Associated with nausea, hot flushes, sweating, visual
• History graying, mild palpitation.
• Clinical examination • Onset while lying flat in late pregnancy, and recovers
• ECG with assumption of lateral recumbent position
• Absent of post-event confusion.
b. Arrythmias • Associated with palpitations, may precipitate
Investigation: presyncope or syncope.
• 12-leads ECG • Tachycardia with syncope is a particular risk in women
• 48hours Holter with pre-existing conduction abnormalities such as
Wolff- Parkinson’s – White syndrome or Long QT
syndrome.
• Bradycardia with syncope in pregnancy is rare, usually
associated with beta- blockers or calcium- channel
blockers e.g. Diltiazem or Verapamil.
c. Structural • Cardiac syncope is more likely to be sudden onset.
Investigation: • Clinical findings might be apparent in long standing
• History diseases such as clubbing, cyanosis, oedema and
• CVS examination murmurs.
• ECHO
Endocrine
a. Hypoglycaemia • Type 1 DM patients are particularly at risk of
Investigation: hypoglycaemia.
• DXT • Clinical findings of profuse sweating, lethargy might
• BSP lead to syncope, seizure and coma if unrecognized or
untreated.
Neurological/ Psychosomatic
212
a. Seizures • A collateral history of convulsive activity with a history
Investigation: of epilepsy would support a diagnosis of seizure as the
• History cause of syncope.
• EEG • Supported by transient confusion following a tongue
biting or incontinence.
• Pregnant women with epilepsy are at higher risk of
breakthrough seizures due to noncompliance or
changes is pharmacokinetics leading to subtherapeutic
level of medications.
b. TIA/CVA (rare) • TIA/CVA is rare in pregnancy.
Investigation: • Often associated with neurological deficits.
• History • In young women, need to rule out aneurysm and
• CVS examination connective tissue diseases.
• CT brain/MRI
c. Hyperventilation • Usually there will be no physical abnormality

Investigation: • Commonly associated with emotional stress
• History
• ABG
d. Generalized anxiety • Atypical or inconsistent symptoms, a psychiatric
disorders aetiology should be considered.
Investigation:
• History
References:
1. Handbook of Obstetrics Emergencies; Rajan G., Ganeshan M, Tang BN et al; 1998.

Obstetrical and Gynaecological Society of Malaysia.
2. Approach to adult patient with Syncope; McDermott D, Quinn J. 2019. Uptodate: topic 293
version 33.0.
213
17.7 Shortness of Breath in Pregnancy
ESSENTIAL DIAGNOSIS TO BE EXCLUDED:

PULMONARY EMBOLISM
CARDIAC FAILURE
ACUTE PULMONARY OEDEMA
SEPSIS
History:
• Sudden onset or progressively worsening symptoms.

• Associated symptoms related to cardiovascular or respiratory
systems.
• Occurs at rest or exertion.
Physical examination:
• Blood pressure, pulse rate, respiratory rate & temperature

• Pulse oxymeter
• Cardiovascular & Respiratory examination
• Foetal wellbeing
Investigations:
• ECG
• FBC
• CXR with abdominal shield if indicated
• Peak flow if history of asthma
Refer O&G if >20 weeks, if ≤20 weeks refer to

medical, for further evaluation & admission:
• ECHO
• CTPA or V/Q SCAN
• Cardiac enzymes and Troponin T
214
DIFFERENTIAL DIAGNOSIS FOR SHORTNESS OF BREATH IN PREGNANCY
Causes Characteristics
Respiratory
a. Asthma • Known asthma with triggering factors
b. Pneumonia • History of fever with respiratory symptoms
• History of travelling & contact with sick patients
should be obtained
• Acute PTB should be considered
c. Acute pulmonary oedema • underlying hypertensive disorders e.g.
preeclampsia or cardiac disease
Cardiac
a. Congenital cardiac diseases • Corrected or non-corrected diseases
b. Acute on CRHD/ myocarditis • Latest ECHO or cardiologist input
c. Arrythmia • Accompanying cardiac symptoms & signs:
d. Peripartum cardiomyopathy palpitation, oedema, elevated JVP, murmurs
• Abnormal ECG
Endocrine/ Metabolic
a. Metabolic acidosis • E.g. Sepsis, DKA, severe dehydration, poisoning
• Further history & investigations need to be
carried out to look for the cause of metabolic
acidosis
Haematological
a. Symptomatic anaemia • Anaemia work-out should be obtained
Physiological
a. Breathlessness in • Diagnosis of exclusion
pregnancy
215
SECTION 18 SUMMARY CHART OF WHO MEDICAL ELIGIBILITY CRITERIA FOR
CONTRACEPTIVE USE
Condition Sub-Condition Cu-IUD LNG-IUD Implant DMPA POP CHC
I C I C I C I C I C I C
Cardiac disease
Valvular heart disease a) Uncomplicated 1 1 1 1 1 2
b) Complicated 1 1 1 1 1 4
Peripartum a) Normal or mildly impaired cardiac
cardiomyopathy function
i) < 6 months 2 2 1 1 1 4
ii) ≥ 6 months 2 2 1 1 1 3
b) Moderately or severely impaired 2 2 2 2 2 4
cardiac function
Connective tissue disease
Rheumatoid arthritis a) On immunosuppressive therapy 2 1 2 1 1 2/3* 1 2
b) Not on immunosuppressive therapy 1 1 1 2 1 2
Systemic lupus a) Positive (unknown) antiphospholipid 1* 1* 3* 3* 3* 3* 3* 4*
erythematosus antibodies
b) Severe thrombocytopenia 3* 2* 2* 2* 3* 2* 2* 2*
c) Immunosuppressive therapy 2* 1* 2* 2* 2* 2* 2* 2*
d) None of the above 1* 1* 2* 2* 2* 2* 2* 2*
Other medical disorders
Diabetes a) History of gestational disease 1 1 1 1 1 1
b) Nonvascular disease
i) Non-insulin dependent 1 2 2 2 2 2
ii) Insulin dependent 1 2 2 2 2 2
c) Nephropathy/retinopathy/neuropathy* 1 2 2 3 2 3/4*
d) Other vascular disease or diabetes 1 2 2 3 2 3/4*
of >20 years duration*
Anemias a) Thalassemia 2 1 1 1 1 1
b) Sickle cell disease 2 1 1 1 1 2
c) Iron-deficiency anemia 2 1 1 1 1 1
History of high blood 1 1 1 1 1 2
pressure during
pregnancy
Hypertension a) Adequately controlled hypertension 1* 1* 1* 2* 1* 3*
216
b) Elevated blood pressure levels
(properly taken measurements)
i) Systolic 140-159 or diastolic 90-99 1* 1* 1* 2* 1* 3*
ii) Systolic ≥ 160 or diastolic ≥ 100 1* 2* 2* 3* 2* 4*
c) Vascular disease 1* 2* 2* 3* 2* 4*
Thyroid disorder Simple goiter/hyperthyroid/hypothyroid 1 1 1 1 1 1
Epilepsy (see also Drug Interactions) 1 1 1* 1* 1* 1*
Infectious disease
HIV a) High risk for HIV 1* 1* 1 1 1 1
b) HIV infection 1* 1* 1* 1*
i) Clinically well receiving ARV 1 1 If on treatment, see Drug Interactions
therapy
ii) Not clinically well or not receiving 2 1 2 1 If on treatment, see Drug Interactions
ARV therapy
Tuberculosis a) Non-pelvic 1 1 1 1 1* 1* 1* 1*
(see also Drug b) Pelvic 4 3 4 3 1* 1* 1* 1*
Interactions)
Viral hepatitis a) Acute or flare 1 1 1 1 1 3/4* 2
b) Carrier/Chronic 1 1 1 1 1 1 1
Malignancy
Breast disease a)Undiagnosed mass 1 2* 2* 2* 2* 2*
b)Benign breast disease 1 1 1 1 1 1
c)Family history of cancer 1 1 1 1 1 1
d)Breast cancer
i) Current 1 4 4 4 4 4
ii) Past and no evidence of current 1 3 3 3 3 3
dese for 5 years
Cervical cancer Awaiting treatment 4 2 4 2 2 2 1 2
Cervical intra-epithelial 1 2 2 2 1 2
neoplasia
Ovarian cancer 1 1 1 1 1 1
Endometrial cancer 4 2 4 2 1 1 1 1
Endometrial hyperplasia 1 1 1 1 1 1
Mental disorder
Depressive disorders 1* 1* 1* 1* 1* 1*
Venous thromboembolism
Deep venous thrombosis a) History of DVT/PE, not receiving
(DVT) / Pulmonary anticoagulant therapy
embolism (PE) i) Higher risk for recurrent DVT/PE 1 2 2 2 2 4
217
ii) Lower risk for recurrent DVT/PE 1 2 2 2 2 3
b) Acute DVT/PE 2 2 2 2 2 4
c) DVT/PE and established
anticoagulant therapy for at least 3
months
i) Higher risk for recurrent DVT/PE 2 2 2 2 2 4*
ii) Lower risk for recurrent DVT/PE 2 2 2 2 2 3*
d) Family history (first-degree relatives) 1 1 1 1 1 2
e) Major surgery
i) With prolonged immobilization 1 2 2 2 2 4
ii) Without prolonged immobilization 1 1 1 1 1 2
f) Minor surgery without immobilization 1 1 1 1 1 1
Other factors
Age Menarche Menarche Menarche Menarche Menarche Menarche
to to to to to to
<20 y:2 <20 y:2 <18 yrs:1 <18 y:2 <18 y:1 <40 y:1
≥20 y:1 ≥20 y:1 18-45 y:1 18-45 y:1 18-45 y:1 > 40 y: 2
> 45 y: 1 > 45 y: 2 45 y: 1
Parity a) Nulliparous 2 2 1 1 1 1
Smoking a) Age <35 1 1 1 1 1 1
b) Age ≥35, < 15 cigarettes/day 1 1 1 1 1 3
c) Age ≥35, > 15 cigarettes/day 1 1 1 1 1 4
Obesity a) Body mass index (BMI) ≥ 30 kg/m2 1 1 1 1 1 2
b) Menarche to <18 years and BMI ≥ 30 1 1 1 2 1 2
kg/m2
Post-abortion a) First trimester 1* 1* 1* 1* 1* 1*
b) Second trimester 2* 2* 1* 1* 1* 1*
c) Immediate post- septic abortion 4 4 1* 1* 1* 1*
Postpartum a) <21 days 1 1 1 4
(non-breastfeeding b) 21 days to 42 days
women) i) With other risk factors for VTE 1 1 1 3*
ii) Without other risk factors for VTE 1 1 1 2
c) >42 days 1 1 1 1
Postpartum a) < 10 minutes after delivery of the
(in breastfeeding or non- placenta
breastfeeding women, i) Breastfeeding 1* 2*
including caesarean ii) Non-breastfeeding 1* 1*
delivery) b) 10 minutes after delivery of the 2* 2*
placenta 10 <4 weeks
218
c) ≥ 4 weeks 1* 1*
d) Postpartum sepsis 4 4
Adapted from: Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (Updated in 2020)
Categories of medical eligibility for contraceptive use

1 A condition for which there is no restriction for the use of the contraceptive method.
2 A condition for which the advantages of using the method generally outweigh the theoretical or
proven risks.
3 A condition for which the theoretical or proven risks usually outweigh the advantages of using the
method.
4 A condition that represents an unacceptable health risk if the contraceptive method is used.
* Consult the appendix for this contraceptive method for a clarification to this classification.
NOTE:
• This summary sheet only contains a subset of the recommendations from the U.S. MEC
• For complete guidance, see https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm
• Most contraceptive methods do not protect against sexually transmitted diseases (STDs). Consistent and correct use of the
male latex condom reduces the risk of STDs and HIV
219
220
SECTION 19 POSTPARTUM INTRAUTERINE CONTRACEPTIVE DEVICE
1 Counselling • All women should be ideally counselled regarding contraception.
• A note should be made in the antenatal card regarding patient’s
contraceptive choice.
• A specific PPIUCD counselling should be given in potential
users.
• Timing of counselling:
➢ Antenatal visits
➢ During admission in early labour
➢ During admission for elective caesarean delivery
➢ In postnatal period less than 48 hours after vaginal delivery
(Refer Remarks)
2 Eligibility • Inclusion:
criteria ➢ Any age
➢ Desiring copper IUD or Mirena-IUS
➢ Anticipated vaginal delivery (including vaginal birth after
caesarean section) or elective caesarean delivery
➢ Any language for which adequate translation can be obtained
• Exclusion:
➢ History of sexually transmitted infection during the index
pregnancy
➢ Recent (within 3 months) or active intrauterine infection
➢ Standard absolute contraindication (Wilson’s disease, uterine
anomaly)
• Exclusion criteria arise during labour:
➢ Intrapartum fever
➢ Postpartum haemorrhage (EBL more than 500mls via SVD,
or more than 1000mls vis LSCS)
➢ Prolonged ruptures of membrane of more than 18 hours
221
➢ Retained placenta requiring manual removal of placenta or
Dilatation & Curettage
➢ Withdrawal of consent
3 Consent • Antenatal PPIUCD consent should be taken and attached in the
antenatal book for keen potential user
• A copy of consent shall be kept in case note after IUCD has been
inserted (Refer Remarks)
4 PPIUCD • Health providers should receive training before inserting the
insertion PPIUCD
protocol • All PPIUCD users should be given post-insertion counselling and
follow-up date before discharge from hospital
5 Follow – up • The patient should be arranged for follow up call in 4-8 weeks
post insertion
• “Missing strings” is the more common following postpartum
insertion than interval IUD insertion.
• During follow-up, ask the patient:
➢ Any complaint
➢ If she feels any spontaneous expulsion
➢ Clinical assessment of anaemia if she complaint of prolonged
or heavy per vaginal bleeding
• Perform speculum examination to see whether the IUCD strings
has descended. IUCD strings might be visible at the introitus after
several weeks and it can be shortened during the visit to reduce
risk of ascending infection.
• If any clinical evidence of STD infection, consider removal of
IUCD followed by treatment.
• If the patient has no complaint or concern, she need not any
further follow up solely related to IUCD. (Refer Remarks)
222
Remarks:
A. PPIUCD COUNSELLING CHECKLIST
(TO BE REFERRED BY THE HEALTH CARE PROVIDERS)
Name: __________________________________ ID/RN: _____________________

STEP/ TASK ASSESSMENT COMMENTS
Determine reproductive goals and use of other contraception
Ask about any previous experiences with
contraception: any problems and reasons for
discontinuing; her knowledge about the return of
fertility and the benefits of spacing pregnancies
Assess partner’s/ family attitude about family
planning
Ask about reproductive goals
Ask if patient is interested in a particular family
planning method
Provide the patient with information about the postpartum family planning
method
Educate patient about benefits of spacing
pregnancies.
• Advice that this is to ensure her health and
health of the family that she should wait at
least 2 years before trying to get pregnant
again
• Advice about the return of fertility postpartum
and the risk of pregnancy
Educate regarding birth spacing methods
• Briefly explain and show available methods
i.e LAM, condoms, DMPA etc. To correct any
misconceptions about contraception.
Help the patient to choose a method. Do not decide for her. For potential PPIUD
users, determine if patient can safely use the method and explain how to use
the method.
223
Evaluate patient’s health and determine if she can
safely use the method. (UKMEC criteria).
Discuss key information about PPIUD
• should know insertion will involve a pelvic
examination and a minor procedure to insert the
IUCD into her uterus
• Effectiveness 97-99%
• How does IUD prevents pregnancy: causes a
chemical change that damages sperm before it
meets the egg.
• How long can it be used? In our setting
depending on type 3-5 years.
• The IUD can be removed at any time by trained
personnel if the women wants and fertility will
return immediately.
Discuss advantage of PPIUD
• Immediate and simple placement after delivery
• No further action by patient
• Immediate return to fertility on removal;
• Does not affect breast feeding
• Long acting and reversible: can be used to
prevent pregnancy for a short time or as long as
5 years
Discuss limitations of PPIUD
• Heavier and more painful periods especially the
first few cycles. May not be noticed after PPIUD
insertion.
• Does not protect against STI and HIV
• Risk of expulsion 3% when inserted postpartum
Discuss warning signs and explains that she should
return to the health facility as soon as possible if she
has any of the following:
224
• Foul smelling vaginal discharge different from the
usual lochia
• Lower abdominal pain, especially if accompanied
by feeling unwell, fever or chills, especially during
the first 3 weeks following insertion.
• Has doubt that she might be pregnant
• Has doubts that IUCD has fallen out
Discuss regarding return visit
• Inform that she has to come for routine check-up
in 6 weeks
• Tell them that they will also have a pelvic
examination to check for infection and expulsion
in the first follow-up visit
Makes a note in her ANC card about her postpartum contraceptive choice or
which method interests her.
# If patient cannot arrive at a conclusion on this visit, ask her to discuss with her
family and discuss again during her next visit.
225
B. PPIUCD consent – Malay
JABATAN OBSTETRIK & GINEKOLOGI

HOSPITAL WANITA DAN KANAK-KANAK SABAH
KOTA KINABALU, SABAH
BORANG PERSETUJUAN POSTPARTUM INTRAUTERINE DEVICE (PPIUD)

NAMA PESAKIT: NO KAD PENGENALAN:
NO PENDAFTARAN:
Sila baca borang ini dengan teliti. Sila juga baca risalah informasi pesakit yang menghuraikan
segala kebaikan serta risiko menjalani rawatan yang telah dicadangkan. Sekiranya anda ada apa-
apa soalan, sila kemukakan kepada kami. Kami di sini untuk membantu anda. Anda berhak
menukar fikiran pada bila-bila masa termasuklah setelah menandatangani borang keizinan ini.
KENYATAAN PESAKIT
1. Saya mengesahkan bahawa maklumat yang saya beri adalah benar.

2. Saya telah membaca risalah maklumat mengenai alat dalam rahim selepas bersalin (PPIUD).
3. Butiran mengenai PPIUD, risiko, faedah dan kesan sampingan prosedur telah dijelaskan
kepada saya oleh Dr.______________________________
4. Saya memahami bahawa risiko yang boleh berlaku selepas pemasangan IUD termasuklah
jangkitan, perdarahan, alahan, tebukan kecil pada rahim atau alat IUD terkeluar dengan
sendirinya.
5. Saya mungkin mengalami kekejangan perut dan perdarahan yang tidak teratur pada 3 bulan
pertama selepas pemasangan IUD. Simptom ini dapat dikurangkan dengan ubat penahan
sakit atau kompresi hangat.
6. Saya paham bahawa IUD tidak melindungi saya dari penyakit kelamin (STDs). Saya perlu
menggunakan kondom untuk tujuan ini.
7. Alternatif kaedah perancangan keluarga yang lain telah dijelaskan kepada saya.
8. Saya perlu menghadiri temujanji klinik pada 4-6 minggu selepas bersalin untuk pemeriksaan
IUD.
9. Saya setuju untuk menggunakan IUD sejurus selepas bersalin sebagai kaedah
perancang keluarga.
Tandatangan pesakit: Tandatangan Pegawai Perubatan:

_________________________ ________________________
Nama: Nama:
_________________________ ________________________
Tarikh: __________________ Tarikh: _________________
226
C. PPIUCD consent – English
OBSTETRICS & GYNAECOLOGY DEPARTMENT

SABAH WOMEN’S AND CHILDREN’S HOSPITAL
KOTA KINABALU, SABAH
POSTPARTUM INTRAUTERINE DEVICE (PPIUD) CONSENT FORM
PATIENT NAME: ID NUMBER:
MRN:
Please read this form carefully. You must also read the information sheet carefully which
describes the benefits and risks of the proposed treatment. If you have any further questions,
please ask. We are here to help you. You have the right to change your mind at any time, including
after you have signed this form.
STATEMENT OF PATIENT
1. I confirm that the information given by me is correct.
2. I have read the information leaflet on postpartum intrauterine device (PPIUD).
3. Details about the PPIUD, risks, benefits and side effects of the procedure and the device have
been explained to me by Dr.______________________________
4. I understand the possible risks of the intra uterine device placement include infection,
bleeding, allergic reaction, perforation of (poking a hole in) the womb, and expulsion (falling
out) of the intrauterine device.
5. I may have irregular bleeding and cramping for the first 3 months after the IUD is inserted. I
understand that simple pain killers or a hot pack may help with these symptoms.
6. I understand the IUD does not protect against STDs. I have to use condoms for this purpose.
7. Other alternatives of family planning methods have also been explained to me.
8. I understand that I need to reviewed at the clinic at 4-6 weeks after delivery to check on the
postpartum intrauterine device.
9. I agree that postpartum intra uterine device be inserted for me.
Patient’s signature: Doctor’s signature:

_________________________ ________________________
Name: Name:
_________________________ ________________________
Date: ____________________ Date: ___________________
227
D. PPIUD Follow -up checklist
POSTPARTUM IUCD FOLLOW-UP CHECKLIST HOSPITAL WANITA & KANAK-

KANAK SABAH
Name : _________________________________
IC : _________________________________
Parity : _________________________________
Postpartum period : __________ day/weeks/months Date: _______________

No Step/Ask Assessment Yes No
1. PPIUCD data a) Type of IUCD:
b) Date of insertion:
c) Effective until:
d) Type of insertion:
2. Patient’s well- a) Complain:
being
• Frequent cramping/pelvic discomfort
• PV discharge:
• PV bleeding/spotting
• Concern of dislodge
• Concern of dyspareunia
• Concern of elongated string
• Concern generally feeling unwell
• History of seek medical help for the
above concerns from discharge till
today?
b) Satisfaction:
• Happy to continue
• Request for removal
• Reason for removal
3. Pelvic a) Per speculum findings:
examination
• PV discharge *HVS
228
• String present * trim
b) Pap smear:
4. Ultrasound a) IUCD in situ:
(TAS with full • Fundal/ near fundal
bladder, or • Lower end of uterus/cervix
TVS) b) IUCD not in situ (not seen)
*AXR
5. Management a) Analgesia
of concerning
b) Antibiotics
issues
c) Hysteroscopy
d) Admission for further management:
• Non-operative mx
• Operative mx
6. Further a) PRN
follow- up
b) TCA:
Filled – up by:
_____________________
Stamp:
229
SECTION 20 APPENDIX
20.1 Caesarean Section Summary
HL/WA/OG/83
Jabatan Obstetrik & Ginekologi, Hospital Likas, Kota Kinabalu, Sabah
CAESAREAN SECTION SUMMARY
Name: ___________________________ IC: ____________________RN: ___________
Date: _______________ Elective  Emergency 
Indication: ______________________________________________________________
Type of Incision: LSCS  Classical 
Others  specify: ________________________________
Associated Medical Complication(s):
Pre-eclampsia  GDM  Heart Disease 
Others  specify_________________________________________________
Surgical/ Intra-operative Complication(s):
Yes  No 
Specify __________________________________________________________
Blood loss: ____________________
Postoperative Complication:
Yes  No 
Specify __________________________________________________________
Condition of baby: Alive  Apgar Scores: ____/1min____/5min
Intrauterine death  Fresh Stillbirth 
Macerated stillbirth 
Plan for future pregnancy/ delivery: Allow trial of scar 
Elective Caesarean Section 
Others 
Specify _______________________
Additional remark:
Surgeon: _____________________
CarolLim/HL/Aug 2005
230
20.2 Emergency Obstetric Retrieval
20.2.1 O&G Retrieval in Kota Kinabalu From Public/ Primary Health
Care (Malay Version)
Orang Awam/ Klinik Swasta/ Klinik Kesihatan Kerajaan
Panggilan 999 bagi perkhidmatan pra hospital
Panggilan ambulans
MECCKK (999)
Menerima panggilan ambulans
Maklumat
Koordinasi pergerakan ambulans
Kecemasan
YA
TIDAK O&G
Maklumkan
Respond panggilan PHC MO HWKKS Ambulans samada dari:

ambulans dilakukan oleh
pasukan PHC HWKKS Bertindak sebagai pasukan • HQE
ambulans • HQE2
Untuk fasiliti yang tidak • HWKKS
mempunyai ambulans, Menyediakan Tanggo2 untuk
• Hospital Tuaran
interfacility Transfer pasukan O&G Retrieval
Digerakkan ke lokasi
dilakukan oleh pasukan Koordinasi persediaan ETD dalam masa 5 minit
PHC HWKKS HWKKS untuk terima kes
Maklumkan
O&G Retrieval
LOKASI PESAKIT
Bersedia di ETD HWKKS dalam Pasukan PHC membuat rawatan awal kepada pesakit
masa 10 minit
Pasukan O&G Retrieval yang tiba kemudian akan
Bergerak ke lokasi dengan Tango2 melakukan rawatan definitive kepada pesakit
dalam masa 15 minit dari masa
panggilan Pesakit di bawa balik ke HWKKS oleh pasukan O&G
Retrieval
231
20.2.2 O&G Retrieval in Kota Kinabalu From District/ Private Hospital
(Within KK area)
MECCKK (999)
Ambulance Call for O&G case

DISTRICT WITHOUT O&G
SPECIALIST/ PRIVATE
CENTRES RETRIEVAL
MECCKK- HWKKS PHC MO
Directed to Specialist on call
Inform O&G MO for RETRIEVAL
(Gynae call, LR1 call)
Give detail about the case to
retrieval MO
O&G SPECIALIST ON CALL
Give special instructions to

RETRIEVAL MO Retrieval MO if any
Arrange Team (LR nurse to go Make necessary arrangement to

together) cover duties
Prepare proper retrieval kit to go

Reach ED within 10 minutes
TRANSFER
Inform specialist on call
O&G Retrieval Team resuscitate
and stabilize with PHC team
O&G RETRIEVAL TEAM

SITE
Despatch to location within 15
minutes Transfer patient back to HWKKS
by O&G Retrieval Team
RETURN KIT/ DATA

COLLECTION
Return kit and complete data by
Retrieval Nurse
232
20.2.3 SWACH O&G Medevac Retrieval Flow Chart
Obstetric emergency
Referral from Health Facilities Referral from Non-health facilities
MOH hospital with Health centres without Referral/ Request made to

O&G specialist specialist or private SWACH Emergency
hospitals in KK Physician (EP) for activation
Referral to O&G HOD Referral O&G specialist EP inform O&G HOD or

Consultant on call if
Obstetrics Emergency
Retrieval is necessary
For medevac activation, case must be discussed with If Obstetrics Emergency

O&G HOD in SWACH Retrieval required, the O&G
team will be despatched
O&G HOD activates medevac via SWACH EP

Medevac evacuation is
activated by EP
Medevac retrieval team despatch for medical

evacuation
233
20.3 Obstetric Combined Clinic Referral Flow Chart
Known case of medical disorders pre pregnancy
UPT positive
Does pregnant woman being informed pregnancy is contraindicated in current

medical disorders?
No Yes
Dating scan and confirm viability of Refer to MFM specialist or O&G

pregnancy specialist immediately
Pre-pregnancy review under specialist Defaulter or pre-pregnancy not

clinic in hospital with specialist under specialist care
Refer back respective subspecialty or

discipline for earlier appointment Refer to MFM specialist or
Medical physician cover SWACH
(West coast division)
Reassessment by medical or surgical team not or
required
Refer O&G specialist in hospital
or with specialist (East coast
Appointment date available for reassessment division)
under respective discipline
Review woman in medical

• Some uncomplicated medical illness in Combined Clinic or ID clinic
pregnancy will be reviewed in general/ visiting
O&G clinic or FMS in primary health care (to
discuss with MFM team/ O&G specialist)
234
20.4 Detailed Scan Referral Flow Chart
Viability of pregnancy and dating confirmed
Risk factors:
a. Previous affected child with congenital anomalies or diagnosed with genetic
syndrome
b. Family history of siblings or mother herself affected by congenital anomalies or
syndrome
c. Maternal overt DM with HbA1c more than 8% or Type 2 DM
d. Maternal congenital heart disease
e. Suspected fetal anomaly from the ultrasound assessment
f. Monochorionic multiple pregnancy
g. **Advanced maternal age 40 years old and above
h. IVF or ICSI pregnancy
i. **BMI at booking ≥ 40 kgm2
Pregnant women agree to have fetal anomaly scan done
Refer to MFM team (West coast) or O&G specialist (East coast) – to

refer earlier once pregnancy is confirmed and confirmed date for
appointment
Detailed scan appointment to be done around 20 – 24 weeks (MFM clinic, general

O&G clinic or visiting O&G specialist clinic in district)
**Detailed scan will be performed by O&G specialist in O&G clinic, district visiting clinic or MFM
clinic. Availability of the service may vary between O&G specialists from different specialist
hospitals.
235
20.5 Notification for High Risk Discharge (Antenatal or Postnatal
Case)
Identify high risk antenatal and postnatal women
Follow up plan lay out by O&G specialist, review under specialist clinic is mandatory for following case:
• Current admission requires ICU/ HDW care (e.g. heart disease in failure, eclampsia, severe
pre-eclampsia with HELLP, pulmonary embolism etc.)
• Antenatal or postnatal complicated medical disorders (e.g. uncontrolled thyrotoxicosis etc.)
• Complicated vaginal delivery or caesarean section
• Refusal of treatment for uncontrolled medical disorders or suboptimal recovery (antenatal or
postnatal)
(specialist clinics include FMS clinic, O&G clinic or district visiting O&G clinic)
Notification of high-risk discharge to Sister in charge of primary health care clinic by

nurse in charge from antenatal/ postnatal ward
Respective primary health care clinic to ensure home visit and review by medical officer within 1 – 2
weeks (Referral letter will be provided to women prior to discharge)
During review
Follow up appointment under specialist clinic available?
Yes No
To remind women to attend clinic during Primary care in district – to discuss with specialist
each review covering district for follow up plan
Hospital without O&G specialist – to discuss with

O&G specialist for follow up plan
Kota Kinabalu – MFM team or O&G specialist in

Defaulter charge clinic
Specialist clinic appointment available

Trace patient to discuss back with O&G
specialist regarding further follow up plan
Postpartum high-risk case to be reviewed in pre
pregnancy clinic
236
20.6 Pre-pregnancy Clinic Referral Flow Chart
Target group:
1. Women above 35 years old without medical illness, planning a pregnancy
2. Women with obesity
3. Women with bad obstetric history
4. Women with inherited abnormalities or congenital structural abnormalities
5. Women with family history of genetic disorders
6. Women with babies with congenital structural abnormalities or inherited abnormalities
Entry point (Walk in/ referral)

Maternal and child Outpatient Specialist clinic
service • Wellness services • Physician In patient
• Family planning • Premarital screening • Cardiology • O&G ward
• Child health • Thalassemia screening • Nephrology • Other
service • Adolescent services • Paediatric disciplines
• Postnatal • Referral from private • Other discipline
service medical team clinic
Referral to MO/ FMS in health clinic

Pre pregnancy service in secondary/ tertiary
level
Counseling & assessment

Assessment – disease control,
suitability for conception, mental
preparation
Advise for family planning if

suboptimal condition Relative or contraindicated to get
pregnant
Continue follow up under Option available:

family planning clinic
• Female sterilization
• Male sterilization
• Long acting reversible contraception if surgery
carries high risk (risk outweighs benefit)
For temporary contraception
until definite sterilization
done
Reference: Perinatal Care Manual Malaysia (2013)
237
20.7 Pre-pregnancy Clinic Feedback Form
PRE-PREGNANCY CLINIC
MATERNAL FETO MEDICINE UNIT
DEPARTMENT OF OBSTETRICS & GYNAECOLOGY
SABAH WOMEN’S AND CHILDREN’S HOSPITAL
TEL: 088-522600
FAX: 088-438512
PATIENT IDENTIFICATION
Name :
IC/ :
Passport :
Contact :
Address
PRE-PREGNANCY PROBLEM
Diagnosis :
: Stable Need Further Stabilization
Status
Pregnancy allowed
Medication :
INVESTIGATION
Biochemical :
Radiological :
Histological :
NEED FURTHER STABILIZATION
Medical referral : YES/ NO
Contraception choice :
Next pre pregnancy :
review
PRE-PREGNANCY ADVICE
• Folate
• Weight reduction/ Exercise
• Smoking/ Alcohol caesation
• Medications Adjustments:
PRE-PREGNANCY CARE
1) Report to MFM/ O&G specialist clinic once UPT positive
2) Antenatal booking
3) MFM clinic appointment at 18 weeks
4) Biochemical screening at 13 weeks
5) Combined Clinic care
6) Detailed scan at 22 weeks
Date: Prepared by:
238
20.8 Refusal of Treatment Form (English & Malay Version)
239
240

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CONTENTS

Section 1: Cardiac Diseases in Pregnancy

Datuk Dr. Christina Rundi

The Sabah FMSes

Contributors (In Alphabetical Order)

Dr. Anita Delilah Salahuddin Dr. Haryati binti Hamzah

Dr. Eric Henry Dr. Jusnimar binti Khairul Yusri

Dr. George G. Mathew Dr. Mirah binti Papo

Dr. Muhamad Faiz bin Mahayidin Dr. Nur Najlaa Bt Ab Aziz

Dr. Muhamad Hafiz bin Harun Dr. Nurul Akmanidar bt Zainuddin

Dr. Nasibah Tuan Yaacob Dr. Suraihan bt Sulaiman

Dr. Tan Yee Jin Dr. Yafizah Yahaya

Dr. Wong Tze Ling Dr. Zafferina binti Zulghaffar

Dr. Dayang Sofiah Ag Ahmad Dr. Nor Azila Mohd Nafiah

Dr. Fathi Laila Amir Dr. Normaliza Muhamad

Dr. Hoong Farn Weng Michael Dr. Norsa'adah Salim

Dr. Loh Yoke Ling @ Cecilia Dr. Tan Gi Ni

Dr. Melanie Kuan Lih Jiun Dr. Siti Aishah Tajudin

Dr. Sofia Annaim Bt Abdussyukur Dr. Yogeeta Gunasagran

Dr. Yew Cheng Boon

FASD Fetal alcohol spectrum IAP Intrapartum antibiotic

FAS Fetal alcohol syndrome ICS Inhaled corticosteroids

FBC Full blood count ICSI Intracytoplasmic sperm

HBV Hepatitis B virus LGA Large for gestational age

HCQ Hydroxychloroquine LMW Low molecular weight

HCV Hepatitis C virus LSCS Lower segment

NT Nuchal translucency POA Period of amenorrhea

NVP Nausea and vomiting in RP Renal profile

8 Lactation • Breastfeeding is discouraged in NYHA III/ IV (to reduce

If absent, do not classify as SLE

Classify as Systemic Lupus Erythematosus with a score of 10 or more if entry criterion

a. GDM is diagnosed in the presence of any one of these results:

7. ∞Contraception based on “Medical Eligibility Criteria for Contraceptive Use –

a. Blood Sugar Profile

Pregnancy related Diabetes related Fetal risk

• Miscarriage • Increase need for • Neural tube defects:

2. In confirmed thalassaemia carrier:

5. Recommendation of diet while taking iron supplement

6. Repeat Hb testing is required 2 weeks after commencing treatment to assess

7. Preparation of parenteral iron

8. Contraindications for parenteral iron:

Number of 100mg Ampoules to be administered (mg)

IM Iron Dextran 100mg/ 2ml IV Iron Sucrose 100mg/ 5ml

ASYMPTOMATIC SYMPTOMATIC (irrespective of

If MCH ≤ 27 or family Start trial of IDA

1. Investigate: Serum BFMP positive: Admit

Consider parenteral iron if:

2 Subsequent • Follow plan laid out by O&G / Haematology clinic.

3 Delivery plan • Hospital delivery.

4 Postpartum • Discuss options of contraception with patient / couple.

5 Upon discharge • Routine discharge procedure.

1. Definition of thrombocytopenia in pregnancy: platelet <150 x109/L

2. Thrombocytopenia occurs in 7-8% of all pregnancy:

4. Gestational thrombocytopenia should have platelet normalised by 6 weeks

3. Paternal antigen status.

Between 12 to 20 weeks of gestation:

• Advice for contraception.

➢ Past history of unexplained anaemia.

➢ Family history of anaemia (unknown cause) or