CHAPTER 22: OBSTETRICS, GYNAECOLOGY AND

FAMILY PLANNING
22.1. Obstetric Care and Obstetric Disorders
22.1.1. Hypertensive disorders in pregnancy

Brief description
 Hypertension is a common medical problem that complicates pregnancy.
 It may be manifested as chronic hypertension, chronic hypertension with superimposed pre-
eclampsia, pregnancy induced hypertension, pre- eclampsia or eclampsia.

Clinical features
 Increased BP≥ 140/90 mmHg during pregnancy. Measured 4 hours apart and after 20 weeks
of gestational age.
 The presence of other clinical signs and symptoms of hypertension in pregnancy depends on
the severity of the disease.

Investigations
 The presence of significant proteinuria greater than 300mg/24hour urine specimen or,
less accurately, o r more than 1+ protein (equivalent to approximately 100mg/dl) on
dipstick sampling of random urine specimen.
 Proteinuria is usually late manifestation of pre-eclampsia that follows the hypertension and
correlates with glomerular lesions in the kidneys.‘
 Proteinuria is usually variable and should be carefully interpreted because it can be
influenced by factors like contamination of the urine specimen with vaginal secretions,
blood, or bacteria; urine specific gravity, pH, exercise; and posture.

Classes

I. Pregnancy induced hypertension (PIH)

 Pregnancy induced hypertension is defined as a rise in BP> 140/90 mmHg after the 20th
week of gestation measured twice at least four hours apart or a single measurement of
diastolic BP>110mmHg, except in Gestational Trophoblastic Diseases (GTD) and multiple
pregnancy when this can be diagnosed before the 20th week of pregnancy. There are
different types of PIH.
A. Gestational hypertension
 This is diagnosed when the systolic BP is raised to 140 mmHg and the diastolic BP to 90
mmHg or more after the 20th week of gestational age without significant proteinuria. Mostly,
this is used until a more specific diagnosis can be assigned. Gestational hypertension may

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 represent pre-eclampsia prior to proteinuria or chronic hypertension previously
unrecognized.
B. Pre-eclampsia
 Pre-eclampsia is part of PIH which is defined as a BP > 140/90mmHg in the presence
of significant proteinuria of > 300 mg/24 hours urine specimen or, less accurately, more
than 1+ protein (equivalent to approximately 100mg/dl) on dipstick in at least two
randomly collected urine specimen at least 6 hours apart after the 20th week of gestation/
or up to 6 weeks postpartum.
C. Severe pre-eclampsia/ with
severity features
 In the presence of any one of the following clinical manifestations, severe pre-eclampsia
can be diagnosed:
 Diastolic BP > 110 mmHg and the systolic ≥160mmHg measured twice at least six hours
apart or a single measurement of >120mmHg.
 Hyperbilirubinemia, Hemolytic anemia, Thrombocytopenia (<100,000/µl), Elevated Liver
Enzymes (HELLP syndrome).
 Disseminated Intravascular Coagulation (DIC).
 Headache, visual disturbance and right upper abdominal pain.
 Oliguria (<400ml in 24hours or 30ml/hour).
 Cardiac decompensation, pulmonary edema, cyanosis.
 Exaggerated Deep Tendon Reflexes (DTR)
D. Eclampsia
 Eclampsia is the occurrence of convulsions in woman who meets the diagnostic criteria
for pre-eclampsia. There could also be atypical eclampsia. Any convulsion occurring during
pregnancy is eclampsia unless proven otherwise.
II. Chronic hypertension
 This is a hypertension existing before pregnancy or diagnosed before the 20th week of
gestation/ up to 6 weeks postpartum, or persists indefinitely after delivery. Women with
mild hypertension may have normal BP during the mid-trimester and many of these
women show greater decrease in their BP during pregnancy than normotensive women.
However, in some pregnant women the BP may become severe and develop
superimposed pre-eclampsia, which is defined as an exacerbation of the BP, i.e., an
increment of the systolic BP by 30 mmHg and diastolic BP by 15mmHg over the baseline
with development significant proteinuria.

Prevention:

 Women with the following risk factors for pre-eclampsia can benefit from taking low dose
aspirin, 81mg, oral, daily starting from 12 weeks of gestation onwards:
o Pre-eclampsia in the previous pregnancy

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 o Family history of pre-eclampsia (in mother or sister)
o Multiple pregnancy
o Chronic hypertension
o Renal disease
o Diabetes mellitus
o Anti-phospholipids syndromes or Systemic lupus erythematosis (SLE)
o Raised BMI

Treatment
Objectives
 Control BP by administering potent anti-hypertensive medicines, to keep the diastolic BP
below 100 mmHg.
 Prolong pregnancy as much as possible
 Prevent convulsion
 Monitor maternal and foetal condition frequently for worsening of disease condition and
plan treatment accordingly.
 Assure delivery of the fetus and placenta at the appropriate time, which is the
definitive treatment for PIH.

Non pharmacologic
 Bed rest at home in the lateral decubitus position. Individuals rarely require admission
unless they develop any sign and symptom of severe pre-eclampsia.
 Frequent evaluation of foetal wellbeing by foetal movement recording, biophysical
profile
 Maternal wellbeing (BP measurement four times per day, assessment LFT, RFT,
Hematocrit, proteinuria, visual disturbances, epigastric pain etc.)
 Advise patient to immediately report whenever they develop symptoms of severity
such as headache, epigastric pain, blurring of vision etc.
 Plan termination of pregnancy at term. Most authorities recommend pregnancy to be
terminated between 37-38 weeks of gestation.
 If the disease progresses to severe range, manage as severe case.

Pharmacologic
 Anti-convulsant such as Magnesium Sulphate, as well as anti-hypertensive
medications, are rarely required for patients on conservative management. However, if
the Systolic BP is >150mmHg or the diastolic BP is above 100mmHg, give:
 Methyldopa, 250-500mg P.O., 8 to 12 hourly

Alternative
 Nifedipine, 10-40mg P.O., 12hourly

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 OR

 Nifedipine, slow release 30-60mg P.O., daily

Note: Advise patient to immediately report whenever they develop severe symptoms
such as headache, epigastric pain, blurring of vision etc.

Severe pre-eclampsia

 Delivery is the appropriate/definitive treatment for mothers with severe pre-eclampsia;

other-wise it may pose significant risks to the mother and fetus.

Objectives
 The primary objective is, to forestall convulsions, prevent intracranial bleeding and
other vital organ damage and deliver a healthy fetus.
 Lower the BP but should not be under 140/90mmHg.
 Stabilize the mother and plan delivery.
 Lower the BP to a mildly hypertensive level (diastolic BP between 90-100mmHg)

Non pharmacologic
 Meticulous measurement of input and output is important part of the management.
 All non-pharmacologic measures for mild pre-eclampsia mentioned above should be
applied here.
 Delivery: The vaginal route of delivery is preferable as long as there are no
contraindications.

Pharmacologic
 Control of hypertension: The ideal medicine for this clinical scenario is the one that
reduces the BP in a controlled manner, avoiding precipitous reduction in BP that may
compromise placental perfusion.

First line
 Labetalol, 20-50mg intravenously is a useful second line medicine for women whose
hypertension is refractory to hydralazine.

Alternative
 Hydralazine, 5-10mg intravenous every 20 minutes whenever the diastolic BP>
110mmHg. As hydralazine has duration of action of several hours, adequate control of
severe hypertension is often achieved after one or two intravenous treatments.

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 OR
 Nifedipine, 10 mg sublingual whenever the diastolic BP > 110mmHg.

Prevention of convulsion
First line
 Magnesium sulphate, A loading dose of 4gm as 20% solution IV over 10-15 minutes
followed by 10gm as 50% IM injection divided on two sides of the buttock, followed by
maintenance dose of 5gm every 4 hours as 50% concentration over 2minutes, 2gm IV as
50% solution over 2minutes if convulsion recurs. Reduce the maintenance dose by half
if there are signs of renal derangement during labour and for the first 24 hours
postpartum.
 Management of Magnesium toxicity: If DTRs are depressed, discontinue MgS04 and
monitor the patient closely.
o Treatment: Calcium gluconate (if respiratory rate below 12/min), 1 gm. as 10%
in 10 ml ampoule IV over 2 minutes.
o Caution: administration of MgSo4 should be with caution in the face of renal failure,
decrease the maintenance dose by half or use alternative medication.

Alternative
 Diazepam, 30 IU/1000ml of D/W or D/S 20 drops /minutes and increase the drops as
needed depending on the patient‘s sedation status.

Note: Continuous infusion is unnecessary because the half-life of the medicine is 18

hours. When the maternal dose exceeds 30mg neonatal side-effects become prominent. These
include low Apgar score, respiratory depression, poor feeding and hypothermia.

Treatment of eclampsia

Objectives
 Prevent maternal injury
 Control convulsion: Control the acute fit and prevent further recurrence
 Control extreme hypertension
 Expedite delivery
 Prevent patient from falling

Non pharmacologic
 Turn patient on her side to minimize aspiration
 Apply mouth gag to prevent tongue injury
 Establish airway and administer adequate oxygen
 Catheterization

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Pharmacologic

 The same as for severe pre-eclampsia (see above). In addition broad spectrum
antibiotics should be given to prevent aspiration pneumonitis./as prophylaxis for
aspiration pneumonia.

Note:

 Do not give Furosemide as part of the treatment for hypertension unless there is
pulmonary edema.
 Do not give ACE-inhibitors anti-hypertensives, such as captopril, as they may
damage the developing fetus.

Post-partum management

 The first 48-hour postpartum period is critical as one in three fits can occur during this
period. No management should be altered during this period.
o Check BP and urine protein frequently
o Discontinue anti-convulsants within 48 hours
o Follow the mother for 6 weeks
22.1.2. Hyperemesis Gravidarum

Brief description
 Nausea and vomiting are common complaints in the first trimester of pregnancy and
is considered by many as diagnosis of pregnancy. The symptoms are severe in multiple
gestations and gestational trophoblastic neoplasm. Protracted vomiting associated with
dehydration, starvation, weight loss, electrolyte disturbances, acidosis and ketonuria is
known as hyperemesis gravidarum.

Clinical features
 Excessive vomiting, loss of appetite, sign of dehydration, low BP, increase pulse rate,
weight loss
 In severe cases acidotic pattern of breathing (deep and shallow) may ensue.
 In addition the clinician should look for other medical and surgical causes like
hyperthyroidism, food poisoning, diabetes, appendicitis, etc.

Investigations
 Ketonuria, Elevated AST and ALT
 Screen the patient for UTI and other medical causes
 Ultrasound examination to look for GTD, Multiple gestation

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Treatment

Objectives
 Adequate fluid, electrolyte and calorie replacement
 Arrest the vomiting with potent anti-emetics
 Manage hypovolemic shock if present
 Identify obstetric conditions that are associated with hyperemesis garvidarum
 Out other medical or surgical causes, e.g., UTI, malaria, appendicitis etc.

Non pharmacologic
 For uncomplicated nausea and vomiting of pregnancy, give reassurance.
 Advice on small, dry, high calorie frequent feeding
 Avoid fatty and spicy foods
 Emotional support
 Remove stressful home environments
 Withdraw oral nutrition and fluid for 24-48 hours
o Women with nausea should eat before, or as soon as, they feel hungry to avoid an
empty stomach, which can aggravate nausea.

Pharmacologic
Majority of Hyperemesis gravidarum cases requires admission for inpatient care. Few mild
cases can be treated as outpatient.
 Correct dehydration with up to 2 L intravenous Ringer‘s lactate infused over three to five
hours, supplemented with appropriate electrolytes and vitamins.
 Subsequently, the infusion rate is adjusted to maintain a urine output of at least 100
mL/hour and the solution is changed to dextrose 5% in 0.45% saline.
 Avoid use of dextrose in the initial rehydration fluid because of the theoretical concern of
Wernicke‘s encephalopathy with dextrose infusion in a thiamine-deficient state.
 Calorie replacement: Add 40% Glucose 2 vials (40 ml) in each bag.
o 12 vials of 40% dextrose/400calories/24hrs
 Add Vitamin B complex 3 ampoules in each bag

Control of vomiting:

First line
 Chlorpromazine, 12.5-25 mg I.M. BID until vomiting is controlled and then P.O.

Alternatives
 Promethazine, 25-50 mg IM/IV BID, followed by 25 mg P.O., BID. Maximum daily
dose,100mg

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 OR
 Metoclopramide, 5-10 mg IV/IM BID or TID.

OR
 Pyridoxine hydrochloride, oral, 25mg/day, ever y 8 hour.

In severe and refractory cases:

 Dexamethasone, IM/IV, 4-8mg daily

PLUS
 Ondansetron, IV 4-8mg over 5minutes daily

Note: If these fail to control the vomiting, pregnancy may be terminated.

22.1.3. Pain during Labour and Delivery

Brief description
 When giving analgesics and anesthetics to pregnant mothers, the safety of the
mother and fetus should be of constant concern to the health care provider. Virtually all
analgesics and anesthetics administered during pregnancy cross the placental barrier,
though to different extent; thus, a balance must be sought between pain relief for the
mother and safety of the fetus.

Treatment

Objectives
 Alleviate pain without affecting maternal and foetal condition

Non pharmacologic
 Hypnosis, attention focusing and distraction
 Maternal movement and change of position: when the mother moves she alters the
relationships between gravity, uterine contractions, the fetus and her pelvis.
 Counter pressure: Steady and strong force applied to a spot on the lower back during
contraction or pressure on the side of each hip.
 Hot compresses applied to the lower abdomen.
 Immersion in warm water during labour but not birth

Pharmacologic

Analgesics
 Opioids
First line

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  Pethidine, 50-100mg IV or IM QID to TID.
Alternatives
 Morphine, 10-15mg IM, TID
OR
 Pentazocine, 30mg IM/IV
 Local Anesthetics
 The complete relief of pain in obstetrics can be accomplished by blocking the
sympathetic pathways of eleventh and twelfth thoracic nerves and the
parasympathetic and sensory fibers of the sacral nerves.
o Epidural block: is a more effective form of pain relief than alternative forms of
analgesia.

First line
 Bupivacaine, 3-5mg of 0.75% in 8.25% dextrose.

Alternative
 Lidocaine (Xylocaine), 1-2% concentration IM, 5-10ml
22.1.4. Post-Partum Hemorrhage (PPH): Prevention and Management

Brief description
 Post-partum hemorrhage refers to bleeding of more than 500ml from the genital tract
within the first 24 hours of normal delivery or any amount of blood loss that
compromises the hemodynamic of the patient which is referred as primary.
 It usually occurs during or immediately after the third stage of labour.
 Secondary post-partum hemorrhage is defined as excessive vaginal bleeding occurring
from twenty-four hours to six weeks after delivery.
 Postpartum hemorrhage becomes life threatening if the mother is already anemic.

Causes
 Uterine atony
 Retained product of conceptus in the uterine cavity
 Infection within the uterine cavity (endo-myometritis)
 Birth canal injury
 Clotting disorders

Risk factors for PPH

 Suspected or proven abruptio placentae
 Known placenta previa
 Multiple pregnancy
 Pre-eclampsia/Gestational hypertension

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  Previous history of PPH
 Anemia
 Big baby

Clinical features
 Excessive or prolonged vaginal bleeding
 Lower abdominal pain, supra-pubic tenderness
 Bleeding from the genital tract
 Conjunctival pallor
 Rapid pulse rate
 BP may be low or normal
Investigations
 CBC
 Coagulation profile (PT, PTT, INR)
 Liver function test
 Renal function test
 Blood grouping and cross-matching
 Ultrasound scan

Prevention:
 Every woman is considered a potential risk for PPH, hence active management of the
third stage of labour must be applied, i.e., from the time of delivery of the fetus until
the delivery of the placenta. Active management of third stage of labour, is a series of
procedures applied during the third stage to speed up the delivery of the placenta,
increase uterine contractions to prevent PPH by averting uterine atony. It has the
following components:
o To give oxytocin within one minute after the birth of the baby without waiting for sign
of placental separation. OR Ergometrine, IM, 0.2mg, provided the woman is not
hypertensive.
o Clamping and cutting the cord as soon as the baby is delivered.
o Apply Controlled Cord Traction (CCT) when the uterus becomes globular and firm
and the cord lengthens.
o Continuous uterine massage, repeated every 15 minutes for 2 hours
 Note: Despite these measures, if bleeding continues, management of PPH should be
started immediately.

Treatment
Primary PPH
 Objectives
o Identify the causes

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 o Arrest bleeding as quickly as possible
o Resuscitate patient

Non-pharmacologic
 The following management options should be applied step by step:
o Continuous rubbing of the uterus
o Ensure the urinary bladder is empty
o Call for help
o If the placenta cannot be expelled in this fashion within 30 minutes, do manual
removal, preferably under anesthesia.
o If bleeding continues or is heavy which lead to derangement of the vital sign; start
blood transfusion, a minimum of 2 units.
o If the placenta has been delivered and is incomplete, explore the uterus under general
anesthesia.
o If the placenta is complete and the uterus is well contracted: examine the patient with
adequate analgesia and/or anesthesia, any lacerations in the cervix or vagina, must be
sutured using through-and-through sutures. If the tear extends into the uterine body, it
would be difficult to suture it from below and laparotomy may be required for
effective suturing.
o For ruptured uterus, repair or hysterectomy should be done.
o Avoid dextrans; they interfere with blood grouping and cross matching as well as with
coagulation of blood.
o If bleeding continues despite uterine rubbing, employ interventions such as manual
compression of the uterus and compression of the abdominal aorta, use condom
tamponade or uterine packing.
o If bleeding continues despite the above mentioned measures: Bilateral internal artery
ligation or B-Lnych procedures can be applied.
 Note: If all the above measures fail, resort to hysterectomy SOONER rather than
LATER, especially in cases of placenta accreta or uterine rupture.

Pharmacologic

First line
 Oxytocin, IM, 10 units stat.

Alternative

 Misoprostol, oral/sublingual, or rectal 600-800micrograms. Subsequently, maintain

uterine contractions by massaging the fundus and infusing Oxytocin, IV, 10 units in 500
ml 5% Glucose in sodium chloride 0.9%. Anesthesia for manual removal of placenta
Pethidine IV, 100mg and Diazepam IV, 10 mg

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OR
 Ketamine, IM/IV bolus or infusion, 6-10 mg/kg
o Set up IV infusion of Sodium Chloride 0.9% to run in fast: First 1000 ml rapidly in
15-20 minutes. Give at least 2000 ml in first hour. Aim to replace 2-3x the volume of
estimated blood loss. If condition stabilizes then adjust rate to 1000 ml /6 hourly
OR
 Oxytocin, infusion, 20 IU in 1L of Normal saline
OR
 Ergometrine, 0.25mg P.O., 8hourly for 3 days

Secondary PPH
Objectives
 Identify the cause and treat appropriately
 Prevent overwhelming infection

Non pharmacologic
 Resuscitate the patient
 Explore the uterus for retained product of conceptus
Pharmacologic
 Use of the uterotonic agents is similar as to primary PPH

Antibiotics
 Amoxicillin-Clavulanic acid, IV, 1.2 gm, 12hourly OR Ampicillin 2 gm IV QID
PLUS
 Gentamicin, IV/IM, 80mg, 8hourly
PLUS
 Metronidazole, IV, 500mg, 8hourly
OR
 Clindamycin, IV, 450mg, 8-12hourly
o When the clinical condition of the patient improves the IV antibiotics changed to PO.
22.1.5. Premature Rupture of Membranes (PROM)

Brief description
 Premature rupture of membranes is rupture of the foetal membranes after the 28th
week of gestation and before onset of labor.
 The amniotic fluid surrounding the fetus is important for the development of foetal lung
and limb, heat exchange, and protection of the umbilical cord and infant from
compression.
 In addition, the amniotic fluid has bacteriostatic chemicals.

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  Whenever the membranes rupture, there will be leakage of fluid; hence these protective
mechanisms may be compromised.
 In addition, if a dent is created a portal of entry will be established for bacteria to access
the amniotic fluid from the vagina.
 Rupture of membranes often leads to onset of labor.
 Thirty- five percent of preterm neonates result from preterm PROM.

Causes
 Preterm labour, trauma, infection

Clinical features
 Gush of fluid per vaginum.
 Sterile speculum examination reveals leakage of clear or greenish fluid through the
cervical opening.
 If immediate delivery is not planned, vaginal digital examination is not advisable.

Investigations
 Microscopic examination of the fluid reveals; Foetal products (squamous cells), fat,
lanugo hair, fibronectin, AFP, prolactin) Ferning test (arborization).
 Nitrazine paper test which changes from yellow to dark blue. But care should be taken as
blood, semen, alkaline urine and vaginal infections can give false positive results.
 Ultrasound examination: for assessing amniotic fluid, GA, foetal weight
 Vaginal swab culture and sensitivity for group B streptococcus

Classes
 Pre-term PROM: Rupture of membrane before 37th week of gestation
 Term PROM: Rupture of membrane after 37th week of gestation
 Prolonged PROM: Rupture of membranes for more than 8 hours

Treatment
 Treatment depends on the gestational age, presence of infection, condition of the fetus
and spontaneous healing of the membrane.

Objectives
 Prevent or early detect for sign of chorioamnionitis by clinical means (uterine tenderness,
malodorous amniotic fluid, fever, maternal and foetal tachycardia) and laboratory
(increase WBC, C - reactive protein).
 Prolong pregnancy until foetal maturity is assured, i.e., until 34 weeks and above.

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Types of pre-term PROM and their management

1. Preterm PROM without chorioamnionitis

Non pharmacologic
 Admit
 Bed rest and IV hydration
 Avoid vaginal examination,
 Avoid coitus
 Closely follow indications of intra-amniotic infection.

Pharmacologic

First line
 Ampicillin, 2gm IV QID for 48 hours followed by 500mg P.O., QID or 7-10 days.
PLUS
 Erythromycin, 500mg IV QID for 48 hours followed by Erythromycin 500mg P.O.,
QID for 7-10 days. OR Azithromycin 1gm PO stat at admission.
2. Pre-term/Term PROM with chorioamnionitis
 Admit to the labor ward and facilitate delivery as feasible.
 Use ampicillin, chloramphenicol or gentamicin and terminate pregnancy.
First line
 Ampicillin, 2gm IV QID for 48 hours followed by 500mg P.O., QID or 7-10 days.
PLUS
 Gentamicin, 80mg intravenously TID

OR
 Chloramphenicol, 500-1000mg intravenously QID
3. Term PROM with no evidence of chorioamnionitis
 Admit to the labor ward and follow for evidence of infection
 If labour does not start spontaneously after the latency period, induce labour with
oxytocin.
4. Prolonged PROM:
 Ampicillin, 2gm I.V. QID during labor until she delivers, then 500 mg QID for 7 days.
22.1.6. Preterm Labour

General description
 Preterm labor can be defined as regular uterine contractions that cause progressive
dilatation of the cervix after 28th weeks of gestation and before 37 completed weeks.
 Approximately 8-10% of all pre-pregnancies end in preterm labour.
 Prematurity is one of the major causes of perinatal mortality and morbidity.

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Causes
 The etiology of preterm labor is multi-factorial, including;
o Multiple gestation
o Infection like UTI, febrile illness, abdominal surgery
o Uterine anomalies, APH (placenta previa and abruptio placentae)
o PROM
o Low socioeconomic status

Clinical features
 Pushing down sensation in the mother and if the clinician detects regular rhythmic uterine
contraction of four in 20 minutes or eight in 60 minutes that leads to progressive cervical
dilatation and effacement.
 Cervical dilatation greater than 2 cm
 Cervical effacement of 80 percent or greater

Investigation
 CBC
 FBS
 Transvaginal ultrasound can show cervical dilatation and effacement
 Fibronectin in vaginal secretion

Treatment
 When the diagnosis of preterm labour is made, the medical team should attempt to
determine the cause and whether further continuation of the pregnancy will be
beneficial or harmful to the mother and fetus.
 The choice of treatment depends on the answer to these questions and maturity of the
fetus.
 Once foetal maturity is assured there is no benefit to conservative management and
pregnancy should be terminated through the safest route.
 But if the fetus is premature, conservative management should be attempted.

Objectives
 Prevent or detect early intrauterine infection
 Prolonged pregnancy until foetal maturity is achieved
 Promote foetal lung maturity by administering corticosteroids
 Treat any underlying causes e.g., UTI, malaria, pyelonephritis etc.

Non pharmacologic
 Bed rest
 Oral hydration, especially with nutritive calories, such as fruits juices, milk etc.

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  Circlage

Pharmacologic
 Use of a tocolytic medicine is not associated with a clear reduction in perinatal or
neonatal mortality or neonatal morbidity.
 The main effect of tocolytic medicines when used for women in preterm labour is to
reduce the numbers who deliver within 48 hours or within 7 days after the medicine
administration.
 Data on long-term outcome are sparse.
 It remains plausible that, for selected women, such as those who require transfer for
neonatal care or time to complete a course of corticosteroids, there may be benefits
associated with tocolysis.
 However, the benefits have not been formally evaluated in randomized trials.
o N.B. There is no benefit from maintenance tocolytic therapy.
 Nifedipine, initial 20mg orally, followed by 10-20mg three to four times daily, adjusted
according to uterine activity for up to 48 hours; a total dose of 60mg appears to
associated with 3-4-fold in adverse events such as headache and hypotension.

PLUS
 Steroid therapy for stimulation of surfactant production to be given 28-34weeks of
gestation

First line
 Betamethasone, two doses of 12mg IM 24 hours apart. After 48 hours from the first
dose, the full effect on maturing the surfactant has been obtained.
o If patient does not deliver within one week, the treatment should be repeated if the
fetus is less than 34 weeks of gestation.

Alternative
 Dexamethasone, 6mg P.O./IM for two doses six hours apart for two doses.
o Note: Use of corticosteroids in the presence of infection is contraindicated
 Sympathomimetics: Ritodrine and salbutamol are associated with significant;
potentially life-threatening maternal side effects (particularly if given in combination
with corticosteroids) which include fluid overload, pulmonary edema, myocardial
ischemia, hyper or hypoglycemia, hence, these combinations should be abandoned
totally in the management of preterm labour.

22.1.7. Prolonged Pregnancy

Brief description

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  The terms ―Prolonged, post-date and Post-term pregnancy‖ which are synonymously
used, to define pregnancy that exceeds 42 weeks (294 days), from the day since the
last menstrual period.
 The incidence of post-term pregnancy averages 4-5%.
 Post-term pregnancy may be complicated by foetal post maturity, macrosomia,
oligohydramnios, meconium aspiration syndrome and placental insufficiency due to
placenta ageing.
 Management of post pregnancy can take two forms; either expectant management with
foetal surveillance, or elective induction of labour.
 Induction of labour is any attempt to initiate uterine contractions before the
spontaneous onset of labour to facilitate the expulsion of conceptus product.

Clinical features
 Prolonged pregnancy is diagnosed from the last menstrual period or ultrasonography
done in early pregnancy.
 Prolonged pregnancy may manifest with foetal macrosomia or IUGR, decrease foetal
movement, decrease amniotic fluid.

Investigations
 Ultrasonography
 Cardiotography
 Biophysical profile
 Foetal movement
 Non-stress test (NST) and Stress Test

Treatment
Objectives
 Prevent maternal birth trauma and operative deliveries
 Prevent perinatal morbidity and mortality
 Assess risk factors before any intervention
 Asses the inducibility of the cervix

Induction of labour
 This is one option of treatment of prolonged pregnancy, but before induction is
attempted the cervix must be favourable, the bladder must be empty and the
following risk factors should not be present in the pregnant woman:
o Previous scar on the uterus (C/S, myomectomy etc.)
o Cephalopelvic disproportion (CPD)
o Malpresentation or malposition
o Non re-assuring FHB pattern

1092
 o Placenta previa

Non pharmacologic induction of labour

 Breast stimulation:
 Amniotomy (artificial rupture of membrane)
 Stripping of membrane (digital separation of the membranes from the lower uterine
segment)
 Mechanical methods: iinsertion of Laminaria or Foley catheter into the cervical canal.

Pharmacologic induction of labour

 Oxytocin
o It is administered intravenously in different ways ranging from simple manually
adjusted, gravity-fed systems, through mechanically or electronically controlled
infusion pump, to fully automated closed-loop feedback systems.

Dosage schedule
 Low dose regimen
o For primigravida, 5 units in 1000ml N/S to run at 20drops/min (2mU/min), double
the drop every 20 minutes until adequate contraction is achieved to maximum of 80
drops/minute, if adequate contraction could not be achieved with the maximum
dose add 5 units to the same bag and start the drop from 40/minute, if there is no
adequate contraction with this dose add 5 units more to the same bag to a maximum
dosage of 64mU/min.
 For Multigravida: Use half of the dose for primigravida women.
 High dose regimen
o Start with 6mU/min and increase the dosage by 6mU/min every 15 minutes until
adequate contraction is achieved to maximum of 64mU/min for primigravida and
32mU/min for multigravida.
 Prostaglandins
o Vaginal or cervical applications of PGs (E2, F2α and E1) are widely used for cervical
ripening. They are administered intra-vaginally and intra-cervically.
o Dosage: PGE2 3mg into the posterior fornix six hours apart for 2 doses followed by
administration of oxytocin 12 hours later

Advantages of administration of PGE2 for cervical ripening

 Enhances cervical inducibility
 Decreased need for oxytocin for induction
 Decrease oxytocin induction time and dosage
 Decreased C/S rate related to failed induction

1093
22.1.8. Prolonged Labour

Brief description
 The labor is said to be prolonged when the combined duration of the first and second
stage is more than the arbitrary time limit of 18 hours.
 The causes of prolonged labour could be cephalopelvic disproportion (CPD) or
insufficient uterine contraction in terms of frequency, duration and strength.
 The treatment of prolonged labour depends on the cause.
 If prolonged labour is due to inefficient uterine action the treatment is augmentation
of labour using oxytocics.

Pharmacologic Augmentation
 Is any attempt to stimulate uterine contractions during the course of labour to facilitate
the expulsion of the fetus. But cephalopelvic disproportion should be excluded before
augmentation. Dose half of that of Induction.

Clinical features
 The frequency of uterine contraction is less than three in 10 minutes, duration is less than
30 seconds and weak contractions.
 This can be assessed clinically by palpating the uterus or using an intrauterine that
measures the intrauterine pressure.

Investigations
 Ultrasound
 CTG
 Doppler

Treatment
Objectives
 Prevent uterine rupture
 Prevent foetal distress and IUFD
 Carefully assess for side effects of oxytocin

Pharmacologic
 The only pharmacologic agent available thus far is oxytocin
22.2 Common Medical Disorders in Pregnancy
22.2.1 Anemia in Pregnancy

Brief description
 Anemia secondary to iron deficiency is the commonest medical disorder in pregnant

1094
 women, particularly in the developing countries.
 Anemia is one of the major indirect causes of maternal death.
 Anemia in pregnancy is defined as when the Hemoglobin (Hgb) level is below
11gm/dl in the first and third trimesters and below 10.5gm/dl in the second trimester of
gestation. The causes of anemia are the same as in non-pregnant period. Iron demand
is increased by a factor of 4-5times during pregnancy.

Classes
 Mild anemia: when the hemoglobin level is 8-11gm/dl
 Severe anemia: when the hemoglobin level is < 7gm%

Clinical features
 Nonspecific symptoms like weakness, dizziness, palpitation, shortness of breath.
 Physical examination may reveal significant pallor of the conjunctiva and other parts
of the body.

Investigations
 CBC, Hgb/Hematocrit
 Peripheral RBC morphology
 Bone marrow aspiration
 Stool examination for hookworm infestation
 Blood film for malaria
 RFT, LFT

Treatment
 Treatment depends on the severity of anemia and the underlying medical and obstetric
condition of the mother.

Objectives
 Correct the anemia as urgently as possible before the patient goes to labour.
 Identify the cause of anemia like hookworm infestation, malaria etc.
A. Mild to moderate anemia

Non pharmacologic
 Iron-rich diet
 Minimize hemorrhage during pregnancy and childbirth

Pharmacologic

First line

1095
  Ferrous sulphate, 325 mg PO TID with food.
PLUS
Folic acid, 5 mg Po daily

B. Severe anemia: Requires admission and blood transfusion in the presence of

complications.
Refer: if the anemia is severe (Hgb <7gm/dl) refer patient for further investigation and fast
correction of the anemia.
22.2.2 Jaundice in Pregnancy

Brief description
 Jaundice occurring in pregnancy may be a sign or symptom of a severe disease and
should be considered seriously.
Causes

Obstetric
 Severe pre-eclampsia/eclampsia/HELLP Syndrome (Hemolysis, Elevated Liver enzymes,
Low Platelets syndrome)
 Severe hyperemesis gravidarum
 Intrahepatic cholestatic of pregnancy
 Acute fatty liver of pregnancy

Non-obstetric
 Viral hepatitis (E, B and C)
 Hemolytic jaundice due to malaria, septicemia, medicines and herbal medications
 Surgical causes of jaundice; acute cholecystitis, cholelithiasis, obstructive jaundice

Clinical features
 Severe pruritis, malaise, anorexia, vomiting, jaundice, RUQ abdominal pain, fever,
headache

Investigations
 CBC, Blood film for malaria parasites and peripheral morphology
 Group and cross matching
 Renal function test, liver function tests, serum electrolytes
 Bile acid level, lipid profile, Hepatitis B surface antigen
 Abdominal ultrasound
 Abdominal CT scan

Treatment
 Treatment essentially depends on the underlying cause of jaundice.

1096
 1. Severe pre-eclampsia (HELLP) syndrome…….refer specific topic above
2. Hyperemesis gravidarum……………..refer specific topic above
3. Acute fatty liver of pregnancy (AFLP):
 It is common in obese multiparous women to experience multiple gestation in their
third trimester of pregnancy.
 This is due to defect in the mitochondrial fatty acid beta oxidation; fatty acids and
later triglycerides accumulate in the liver and impair its function.

Clinical features
 AFLP should be considered in any pregnant woman presenting with one or more of
the following:
o Epigastric pain, symptoms suggestive of reflux esophagitis, nausea, vomiting,
jaundice
o Bleeding diathesis even in the absence of hepatic encephalopathy.
o 50% patients will show signs of pre-eclampsia.

Investigations
 CBC, uric acid, bilirubin, liver function test, bile acid
 Hepatitis B and C test

Treatment

Objective
 Prevent grave complications
 Terminate pregnancy at the appropriate time

Non pharmacologic
 Bed rest
 Strict measurement of BP, blood sugar level and coagulation status and electrolyte
 If there is DIC: Transfuse fresh frozen plasma, fresh blood, platelet
 Termination of pregnancy
22.2.3 Intra-hepatic cholestasis pregnancy (IHCP)
Brief description
 IHCP occurs from late second trimester to third trimester of pregnancy.
 Common in women of advanced age, multiparous, previous personal or family
history of IHCP.
 It is diagnosed when otherwise unexplained pruritus occurs in pregnancy and abnormal
liver function tests (LFTs) and/or raised bile acids occur in the pregnancy.
 Pruritus that involves the palms and soles of the feet is particularly suggestive.
 Other causes of itching and liver dysfunction should be excluded before labeling the

1097
 woman as suffering from IHCP.
 Women with persistent pruritus and normal biochemistry should have LFTs repeated
every 1–2 weeks.
 Typically, jaundice develops 2-4 weeks after the debut of pruritus. Postnatal resolution
of the pruritus and the abnormal LFTs should be confirmed.
 It is associated with preterm labour, foetal distress and meconium staining liquor, and
still birth.
Clinical features
 Generalized pruritus which mainly affects the palm and sole and severe at night,
jaundice, pale stool and dark urine.

Investigations
 Same as AFLP

Treatment
Objectives
 Alleviate symptoms
 Differentiate the disease from other cholestasis causes: intra-hepatic (viral infections)
and extra-hepatic (e.g., cholelithiasis)

Non pharmacologic
 Termination of pregnancy alleviates the symptoms
Pharmacologic
 There is no evidence that any specific medicine treatment improves foetal or neonatal
outcome. However, the following medicines can be tried to alleviate the pruritus;
o Topical emollients: Calamine lotion
o Systemic medicines
o Chlestyramine, P.O., 20mg/day
o Anti-histamines, e.g, chlorpheniramine
o Vit. K

22.2.4 Cardiac Diseases in Pregnancy

Brief description
 The commonest causes of cardiac disease in pregnancy are secondary to rheumatic
heart disease followed by the congenital ones, in the ratio of 10:1 respectively.
 Due to the increase in cardiac output during pregnancy, patients with underlying cardiac
disease can be decompensated easily, particularly near 28 weeks of gestation, during
labour and immediate postpartum period, hence women with severe heart disease will
benefit immensely from preconception counseling.

1098
  On the other hand, due to these hemodynamic changes, normal pregnant patients may
report signs and symptoms that may mimic cardiac disease; hence, differentiation of
normal from abnormal is difficult.
 The severity of heart disease is assessed according to the classification of the New York
Heart Association (NYHA), which by and large depends on the response of the heart to
physical activities, not the extent of cardiac lesion.
o Class I: Asymptomatic at all degrees of activity: uncompromised
o Class II: Symptomatic with ordinary activities: slightly compromised
o Class III: Symptomatic minimal exertion: markedly compromised
o Class IV: Symptomatic at rest; incapacitated.

Causes
 Rheumatic heart disease
 Hypertension
 Cardiomyopathy
 Anemia
 Congenital heart diseases
 Hyperthyroidism

Clinical features
 Progressive dyspnea or orthopnea, nocturnal cough, hemoptysis, syncope, chest pain,
cyanosis, clubbing of fingers, persistent neck distension, systolic murmur grade 3/6 or
greater, diastolic murmur, cardiomegaly, persistent arrhythmia etc.

Investigations
 ECG, Echocardiography, CXR, CBC, Blood urea and electrolytes
 Thyroid function test, when indicated
 Other ante-natal investigations

Treatment
 A cardiologist, obstetrician and pediatrician should work as a team in the treatment of
these patients.

Objectives
 Avoid aggravating factors
 Treat exacerbating factors: thyrotoxicosis, anaemia, infection etc
 Prevent or detect cardiac decompensation early

Non pharmacologic
 Early diagnosis and arrange evaluation by a specialist
 Early booking and assessment for severity of the disease

1099
  Bed rest and limitation of activities
 Reduce cardiac work load: restrict fluid intake, reduce tachycardia, correct anaemia
 Avoid supine position in late pregnancy
 Apply elastic stocking to the lower leg to prevent pooling of blood
 Assist vaginal delivery by instruments to shorten the second stage of labour
 Put patient in propped up (semi-fowler‘s) position.

Pharmacologic
Antepartum
 Treatment of congestion: diuresis
o Frusemide: start with low dose and increase dose as per response; Frusemide 20 mg
Po daily and dose adjustment following response.
 Heart rate control: beta blockers
o Metoprolol 12.5 mg daily and escalate dose as per the response

Alternative
 Propranolol, 40mg P.O., TID
 Digoxin: indicated with reservation (same dose as that of non-pregnant women)
o To control the heart rate in atrial fibrillation
o To suppress some other supra-ventricular tachcardias
o To increase the force of contraction

Anti-coagulants for
 Valvular heart disease with fibrillation
 Prosthetic heart valves
First trimester
 Unfractionated heparin, IV, 5000 units as bolus, followed by 17,500 IU SC BID (If
perfussor is available: run 1000 IU per hour)
 Unfractionated heparin, SC, 10,000-15000 units 12hourly. The dose must be adjusted
to achieve mid-target a PTT at 2-3x of the control

Second trimester
 Warfarin, 5mg daily. Control with INR to keep within the therapeutic range of 2.5–3.5.

After 36 weeks until delivery

 Unfractionated heparin, IV, 5000 units as bolus, followed by 17,500 IU SC BID (If
perfussor is available: run 1000 IU per hour)
OR
 Unfractionated heparin, SC, 10-15,000 units 12hourly. Adjust dosage to keep the aPTT
2-3 times of the control.
 During labour

1100
 oCheck BP, PR and RR half-hourly.
oKeep the woman in a sitting or lateral position.
oDo relevant cardiac examination at least 4 hourly.
oStrict fluid balance chart should be used.
oContinuous electronic FHB monitoring is recommended.
oAdvice mother not to push and allow descent only by contractions
oVaginal delivery should be in propped up position
oOxygen (5-6L/min) with face mask should be provided if needed (e.g. Cyanosis, PAH,
MI).
o Invasive hemodynamic monitoring and pulse oximetry - if indicated
o Vaginal delivery is the preferred route.
o Reduce labour pain by giving epidural anesthesia or pethidine 50-100mg, IM/IV with
promethazine 25-50mg, IM
o Oxygen, 5-6L/min, through nasal catheter
o Broad spectrum antibiotics to prevent SBE: Gentamicin, 80mg IM/IV TID and
Ampicillin 1g, IV/IM TID at the onset or induction labour.
o Stop heparin on the morning of elective caesarean section or when there is an
established labour, restart heparin 6hours after vaginal delivery or 12 hours after
caesarean section
 Post-partum
o The first one hour is critical because of the remobilization of the fluid into the
vascular bed.
o Ergometrine should be avoided especially if the lesion is tight mitral stenosis or
an Atrio- Ventricular (AV) shunt, because it may precipitate pulmonary edema.
o Post-partum hemorrhage, anemia, infection and thromboembolism can precipitate
Heart Failure and should be managed accordingly.
o Hospital stay at least 48 hrs. after delivery.
22.2.5 Deep Vein Thrombosis/Thromboembolism (DVT/PTE) In Pregnancy

Brief description
 The adaptation of the maternal hemostatic system to pregnancy predisposes women to
an increased risk of venous thromboembolism.
 Pregnancy produces the components of Virchow‘s triad, including an increase in
vascular stasis, changes in the coagulation system, and vascular injury.
 That is why pregnancy is said to be thrombogenic.
 It is not surprising that venous TE is a potential risk of complication of pregnancy and
puerperium, because the incidence of TE is five times higher than non-pregnant patients.
 Venous thrombo-embolism (VTE) can manifest in three forms: Superficial
thrombophlebitis which can be treated with analgesics, elastic support and rest, deep

1101
 vein thrombosis (DVT) and pulmonary thrombo- embolism (PTE).
 These forms represent spectrum of diseases, as one form may progress to the next.

Clinical features
 Superficial thrombophlebitis: hot, red and tender area in relation to a superficial
vein.
 DVT: Clinical presentation vary, from severe pain and edematous white leg (phlegmasia
alba dolens) to being asymptomatic, manifesting with pulmonary thrombo-embolism
only.
 Pulmonary thrombo-embolism (PTE): Acute chest pain, breathlessness, cyanosis, and
hemoptysis may be accompanied by hypotension and collapse.

Investigations
 Compressional ultrasound of peripheral veins
 Doppler ultrasound

Treatment
Objectives
 Liquefaction of the already formed thrombus
 Prevent further propagation of thrombus
 Prevent PTE
 Prevent recurrence of thrombosis
 Prevent long term complications, including venous insufficiency, pulmonary
hypertension, right sided Heart Failure, post-thrombotic syndrome

Non pharmacologic
 Elevation of legs
 Apply a graduated elastic compression stocking to reduce leg edema
 Encourage ambulation while graduated compression stocking applied

Pharmacologic
 Heparin, IV, in the order of 5,000-10,000IU, followed by17,500 IU SC BID (if
available:1000-1200IU/hour, and should be administered in saline through an infusion
pump.
Followed by
 Warfarin, 2.5-5mg/day, excluding the first trimester up to the 36weeks of pregnancy.

Postpartum:
 Therapeutic anticoagulants should continue for at least 6 weeks.
 Warfarin should be avoided until the third day or longer in women at increased risk of
PPH.

1102
22.2.6 Diabetes Mellitus Complicating Pregnancy

Brief description
 Diabetes is one of the most common medical problems that complicate pregnancy.
 Diabetes in pregnancy can be gestational or pre-gestational.
 Women with pre-gestational diabetes need to have preconception counseling to achieve
good glycemic control at the time of conception and organogenesis to avoid congenital
abnormality.
 Women with gestational diabetes mellitus become normoglycemic immediately, but a
significant number of them can become diabetic if followed for long period of time.
 Diabetes in pregnancy, if not well controlled, may cause many obstetric and non-
obstetric complications that include; macrosomia, polyhydramnios, congenital anomalies,
maternal hyper or hypoglacemia depending on the gestational age, UTI, hypertension,
exacerbation of retinopathy etc.
 Types of diabetes in pregnancy:
o Gestational Diabetes Mellitus
o Pre-existing type I and II Diabetes mellitus
 Gestational Diabetes Mellitus (GDM) is a carbohydrate intolerance of variable severity
with onset or first recognized during pregnancy.

Clinical features
 Usually it is asymptomatic and identifications of the risk factors is important.

Investigations
 Screening; by administering 50gm glucose load and determine the blood glucose
level one hour later.
 If the value is more than 140mg/dl, the woman needs Oral Glucose Tolerance Test
(OGTT) using 100gm anhydrous glucose which is a confirmatory test.
 According to the American Association of Diabetes women with the following risk
factors should be screened for GDM between the gestational age of 24-28 weeks.
 Family history of DM in the first sibling (mother, father, sister or brother)
 Obese (BMI >27)
 Mothers above the age of 35 years
 Race (being black)
 Previously, in addition to the above-mentioned risk factors, the following were
included as a screening criterion; previous delivery of macrosomic fetus (>4kg),
previous pregnancy complicated by GDM, unexplained foetal losses, persistent
glucosuria, but if the screening is based on these criteria, 50% of pregnant women prone
to being diabetic can be missed.

1103
Table: 22.1. Upper limit for normal glucose level (mg/dl) in OGTT
Sample Fasting 1st hour 2nd hour 3rd hour
Whole blood 90 165 145 125
Plasma 105 190 165 145

Additional investigations
 Ultrasound: between 16-22 weeks for congenital anomalies, at 32 weeks for foetal size
 CBC
 Urinalysis, urine culture and sensitivity
 Vaginal swab for candidiasis
 Renal function tests and electrolytes
 Liver function tests
 FBS and 2 hours post-prandial every 2-4 weeks
 HgbA1c every 2-3months

Treatment
Objectives
 Maintain good glycemic control, i.e, the fasting plasma glucose level to be < 105mg/dl
and the two hours post-prandial <120mg/dl.
 Prevent maternal and foetal complications.
 Prevent neonatal morbidity
 Minimize long term complication of diabetes

Non pharmacologic
 Diet: most women with GDM can be managed with diet alone.
o Three meals and 3-4 snacks/day
o Diet with 40-50% carbohydrate, 20% protein and 30-40% fat content.
o 10% of calorie at breakfast, 30% at lunch and dinner and 30% with snack.
o Heavy meals must be avoided
 Exercise
o Walking or exercise using the upper part of the body is recommended.
o Mild to moderate exercise, preferably non-weight bearing, at least 3 times/week is
recommended.
o Avoid exercise in the supine position after the first trimester
o Exercise is contraindicated in the presence of the following conditions:
- Pregnancy induced hypertension
- Rupture of membrane
- Preterm labour
- Cervical incompetence

1104
 - Vaginal bleeding
- Intrauterine growth restriction (IUGR)

Pharmacologic
 Insulin, 0.5 units/kg in the first half of pregnancy and increase the dosage to
0.7units/kg in the second half. This is the average dosage otherwise the dose
requirement may vary from individual to individual.
 By splitting injection to 2/3 in the morning (as 2/3 long-acting and 1/3 short-acting)
and 1/3 in the evening (as 1/2 long-acting and 1/2 short-acting) good blood glucose
control should be achieved.
 Combination of 1/3 short and 2/3 intermediate acting insulin is used to maintain the
FBS to 60-90mg/dl 1-hour post-prandial values at<120mg/dl.

Follow up
 Fasting blood glucose and 1 hour postprandial every 2-3 weeks
 HgbA1c every 2-3months
 There is no place for urine glucose determination in the management of diabetes in
pregnancy except for screening.

Delivery
 Unless there are other obstetric contraindications, induction of labour and vaginal
delivery is the preferred route of delivery.
 If the blood glucose control is satisfactory with diet and exercise, follow the pregnancy
until term with close foetal surveillance until spontaneous onset of labor. But if the blood
glucose control is unsatisfactory, plan delivery after ascertaining the lung maturity using
shake test, laminar bodies count etc.

Intra-partum/Intra-operative Glycemic management:

 Withhold the AM insulin injection for planned delivery
 Start IV infusion with 5% D/W at 100ml/hour
 Start Insulin infusion with regular insulin at 0.5units/hour
 Monitor maternal glucose levels hourly and adjust insulin infusion accordingly
 Closely follow the foetal heartbeat

Post-partum management:
 The need for insulin declines in post-partum period, therefore adjust the dose based on
sliding scale. Insulin may not be required the first 24-48 hours for gestational and type II
diabetes patients. For type I diabetes check the blood glucose every 2 hours and follow
the scalding scale.
 If the blood glucose level becomes normal, OGTT should be done at the 6th post- partum
week.

1105
  Newborn should be assessed for the following risks:
o Hypoglycaemia: This can be prevented by initiating immediate breast feeding, or, by
giving Dextrose 10%, IV, 4ml/kg body weight as bolus, followed by maintenance of
60ml/kg body weight in 24 hours.
o Respiratory distress syndrome
o Hyperbilirubinemia
o Congenital abnormalities.
 Breast feeding should be encouraged.
 Encourage contraception with progestins or surgical sterilization.
22.2.7 Type I and II Diabetes
Mellitus

Brief description
 Many serious problems can ensue in women with type I and II diabetes during
pregnancy.
 These complications are dependent on the presence of vascular problems which in turn
are dependent on the duration of the diabetes.
 Based on this concept the White‘s classification (classes A-F) is used to predict
outcome, though, the predictive value of this classification is less precise in modern
management.
 All women with type II on oral hypoglycemic agents in the pre-pregnancy period must
be shifted to insulin.
 If hypertension combines with diabetes, it is an ominous sign.
 Therefore, the BP should be closely monitored.

Clinical features
 The same as those for GDM
Treatment
Objectives
 Same as those of GDM
Non pharmacologic
 Same as that of GDM
Pharmacologic
 The pharmacologic treatment is the same as that of gestational diabetes mellitus.

1106
  However, insulin requirement should be adjusted according to gestational age.
 Maternal hypoglycemia may occur in the first half of the pregnancy.
 Hence, the insulin should be slightly decreased from the pre-pregnancy dosage.
 Whereas on the second half of pregnancy the insulin resistance increases, typically
between the gestational age of 20-30weeks, hence, the dosage of insulin should be
adjusted accordingly.
 Sometimes, a decrease need to insulin may arise towards late pregnancy which implies
that the placenta is failing to function which implies the insulin resistance is
disappearing.
 This is an ominous sign for the fetus.

22.2.8 Thyroid Diseases In Pregnancy

Brief description
 The thyroid gland produces T4 and T3 hormones in the ratio of 5:1. T3 is produced by
peripheral conversion of T4 in a larger proportion.
 To produce this hormone the thyroid gland requires enough iodine.
 More than 95% of these hormones are found attached to thyroid binding globulin
(TBG) in the circulation.
 The production of these hormones is controlled by TSH which is secreted by the
anterior pituitary and this in turn is controlled by the negative feedback and TRH from
the hypothalamus.
 The main function of the thyroid hormones (T3 and T4) are: energy production,
stimulation of protein synthesis and facilitate growth in children.
 During pregnancy there is moderate enlargement of the thyroid gland due to its hyper-
function.

 The TBG is markedly increases, almost doubles by the 12th week, proportionally, the
T4 and T3 level also increases and the concentration of free hormone in the circulation
is changed.
 There are different types of thyroid disorders in pregnancy:

1107
Hypothyroidism

Clinical features
 Fatigue, hair loss, dry skin, excessive weight gain despite poor appetite, cold
intolerance, muscle ache, stiffness, pain or tingling in the median nerve distribution due
to carpal tunnel syndromes, low pulse rate, etc.

Investigations
 T4, T3 and TSH determination, ultrasound

Treatment
Pharmacologic
 Thyroxin (T4) 0.1mg every morning for one week and adjust the replacement dose to
2µg/Kg. Breast feeding is not contraindicated. Dosage should be reduced in the
postpartum period.
22.2.8.1 Hyperthyroidis
m
Brief description
 Hyperthyroidism also causes anovulation and amenorrhea.
 In 95% of the cases thyrotoxicosis is due to Grave‘s disease but few could be due to
solitary toxic adenoma or multinodular goiter or associated with obstetric conditions
such gestational trophoblastic neoplasia.
 Foetal hyperthyroidism is one of the complications which may lead to neonatal
hyperthyroidism, IUGR, intrauterine death etc.

Clinical features
 Family history of autoimmune thyroid disease, failure to gain weight despite good
appetite, presence of exophthalmos or lid lag, persistent tachycardia, heat intolerance
etc.

Investigations
 T4, T3, TSH and FTI. It is preferable to determine free T4 and T3,
 Fine needle aspiration
 Ultrasound
 Doppler ultrasound

1108
Treatment
Objectives
 Identify the cause of hyperthyroidism
 Assess the severity of hyperthyroidism
 Prevent complications
 Manage appropriately to bring down to euthyroid level

Pharmacologic
First line
 Propylthiouracil, 150mg PO TID for 4-5 weeks. The dose is then progressively lowered
to maintenance dose of 150 mg per day.

Alternative
 Carbimazole, 15mg TID for 4-5 weeks. The dose is then progressively lowered to
maintenance dose of 15mg per day.

Thyroid crisis (storm)

 Thyroid crisis is a rapid worsening of thyrotoxicosis brought about by stress such as
infection, labour and surgery. This scenario is common in women whose thyrotoxicosis
is not well controlled, but it can occur also in well treated women.

Clinical features
 Fever, tachycardia, extreme nervousness, restlessness and psychosis, eventually may
lapse into coma.

Investigations
 Free T3, T4,
 Ultrasound

Treatment
Non pharmacologic
 Reduce fever by tepid sponging or covering in wet sheet or turning on electric fan.
 Prevent aspiration

Pharmacologic

First line
 Propylthiouracil, 1000 mg orally initially, followed by 200mg QID.
o Note: Administration of either of the antityroid medicines is followed by
administration of sodium or potassium iodide, 500mg TID by infusion or orally
QID to inhibit the release of thyroid hormone and Dexamethasone 2mg every QID
for the first day to decrease the peripheral conversion of T4 to T3.

1109
  If the patient develops Heart Failure; Metoprolol 0.5mg IV initial dose followed as
orally in a dose of 2 5 mg three times per day. The alternative is Propranolol 80 mg PO
TID.
o Follow heart rate and symptom control.
 Chlorpromazine, 25-50mg orally or intravenously 6-8hourly is administered to reduce
fever.
Note: Aspirin should not be used to reduce fever as it displaces thyroid hormones from
TBG and thus increases the free hormones in the circulation, hence the condition could be
worsened.

22.2.8.2 Postpartum thyroiditis

Brief description
 It is a well-recognized that 10-20 % of women develop some form of thyroid
dysfunction in the postpartum period due to autoimmune diseases.
 Three quarters develop hyperthyroidism and the rest hypothyroidism in the 1–3-month
postpartum period.
 Most of those who develop hyperthyroidism go into remission within 2-3 months but
30% will enter hypothyroid phase.

Clinical features
 Fatigue and palpitation, 50% will have goiter.

Investigations
 Fine needle aspiration-lymphocytic thyroiditis is the common finding.

Treatment
 Hyperthyroid phase: Anti-thyroid medicines are not indicated.
 Hypothyroid phase: Most of the time, it is self- limiting, but if symptoms are severe
and prolonged, treatment with T4 is warranted.

22.2.9 HIV/AIDS IN PREGNANCY

Brief description
 In the last 20-25 years HIV/AIDS has become a major indirect cause of maternal
mortality.
 The majority of HIV positive women (77%) lives in Sub-Saharan Africa, and
constitutes 57% of the global adult HIV positive population.
 Pregnancy by itself does not affect the course of the disease, but HIV may increase the
risk of premature deliveries, small for date uterus and the rate of still birth.

1110
  Factors that influence MTCT include: maternal viral load, nutritional status of the
mother, presence of concomitant parasitic infection like malaria, severe
immunodeficiency, advanced HIV/AIDS stage, presence of PROM and injury to the
fetus and birth canal during labour and delivery.
 To reduce the rate of MTCT of HIV/AIDS, the Ethiopian government has adopted the
four-pronged approaches in its PMTCT strategies, namely: primary prevention,
prevention of unintended pregnancy, prevention of HIV transmission from infected
women to their infants, and treatment, care & support of HIV infected women, their
infants and their families.

Clinical features
 Symptoms suggestive of opportunistic infections/malignancies or direct effects of HIV.
History of seropositivity, history of HAART and other HIV/AIDS related illnesses,
duration of illness, status of partner, WHO staging, any medication given for HIV-
related illnesses since the beginning of pregnancy.

Investigations
 Serologic test for HIV after counseling. If she is HIV positive, carry out CD4 count, viral
load, baseline tests such as CBC, RFT, LFT.
 Test for syphilis (VDRL), Hgb
 Test for opportunistic infections like TB

Prevention
 HIV positive women who intend to get pregnant: The following general health
measures should be taken:
o Adequate nutrition that includes: high calorie and food staff rich in iron,
micronutrient supplementation such as iron, zinc and folic acid at least for three
months prior to getting pregnant.
o Prevention of malaria infection.
o Prevention and treatment of STIs.
o Prophylaxis and treatment of opportunistic infections.
o Avoid pregnancy for at least six months following recovery from TB and other
opportunistic infections.
o Administer ART, if not already on treatment
 During antenatal care (ANC)
o Advocate the benefits of VCT and persuade every pregnant woman to be tested.
o If the pregnant woman turns out to be positive apply the primary preventive
measures that include; early and appropriate treatment of STI, education about
safer sex practice during pregnancy and lactation.
 Intrapartum care: Labour and delivery: These include avoiding invasive procedures,

1111
 application of infection prevention and performing elective C/S on selected patients.
 Post-partum care: Avoiding breast feeding or exclusive breast feeding.

PMTCT clinical scenarios and ARV regimens: Refer the national guideline
Note: Link the patient to PMTCT program and follow the updated national guideline.

22.2.10 Urinary Tract Infection In Pregnancy

Brief description
 Urinary tract infections (UTIs) are one of the most common medical complications of
pregnancy. It is estimated that one in three women of childbearing age will have a
UTI.
 Because of the normal physiologic changes induced by pregnancy, pregnant women are
especially susceptible to UTIs, including asymptomatic bacteriuria, (no it is one risk
factor not a clinical condition) we aim to treat asymptomatic bacteriuria for this particular
reason cystitis and pyelonephritis. Urinary tract infection is common in women with
diabetes.

Causative organisms
 E.coli (most common, 75-90%), klebsiella, proteus, coagulase negative staphylococci,
and pseudomonas

Classes
 Asymptomatic bacteruria
 Symptomatic UTI:
o Lower UTI: Cystitis, urethritis
o Upper UTI: Pyelonephritis

Clinical features
 Lower UTI (cystitis and uretheritis) will have supra-pubic tenderness, abdominal
discomfort, hematuria, urgency, frequency, dysuria.
 Upper UTI: Flank pain (unilateral or bilateral) and abdominal pain, anorexia, nausea,
vomiting, fever, chillness headache, dehydration, tachypnea

Investigations
 Urine analysis
 Urine culture: Growth of bacteria 105 organisms/ml of urine
 Blood culture when needed
 CBC
 BUN, creatinine

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  Ultrasound

Treatment for asymptomatic bacteriuria

Objectives
 Prevent pyelonephritis
 Identify the predisposing factors, if there is any, usually there is.
 Eradicate the infection and prevent recurrence

Non pharmacologic
 Take a lot of fluid and encourage frequent voiding.

Pharmacologic
 The treatment would be more rational if the choice of antibiotics is based on culture
and sensitivity results.

First line
 Amoxicillin 500mg PO TID for one 7 days

Alternatives
 Cephalexin PO 500mg BID for 7days

Symptomatic lower urinary tract infections

 Lower UTI (cystitis and urethritis)
o The symptoms are often difficult to distinguish from those due to the pregnancy itself.
o Features that may indicate true infection include hematuria, dysuria, urethral
discharge and supra-pubic discomfort.

Treatment
 Treatment is the same as asymptomatic bacteriuria.
 Upper UTI (pyelonephritis)
o Acute pyelonephritis is a serious medical problem in pregnancy which requires
admission and aggressive management.
o Acute pyelonephritis could lead to complications like miscarriage, preterm rupture of
the membranes, IUGR, preterm labour, intrauterine foetal death and sepsis.
o The incidence increases with gestational age; 90% of the cases occur in the second
and third trimesters of pregnancy and 20-40% follows asymptomatic bacteriuria.

Treatment
 Women with pyelonephritis require admission for parenteral medication.

Objectives
 Prevent foetal complications which include preterm labour, low birth weight, IUGR,

1113
 PROM.
 Prevent maternal complication from, overwhelming urogenic sepsis, perinephric abscess,
pre-eclampsia, acute renal failure.
 Identify the predisposing factors, including renal stone, congenital anomalies, diabetes
mellitus.
 Prevent recurrence of UTI

Non pharmacologic
 Adequate nutrition and hydration
 Tepid sponging to lower fever

Pharmacologic
 The choice of antibiotics would be more rational, if it is based on culture and sensitivity.
 Antipyretics and analgesics, if tepid sponge is not effective in reducing fever.

First line
 Ampicillin, 2gm IV QID until 48 hours after the fever subsided and then 500mg P.O.,
for 10-14 days.
PLUS
 Gentamicin, 80mg IV TID until 48 hours after the fever subsided and then IM for
10-14 days.

Alternatives
 Cephotaxime, 500mg-1gm IV BID until 48 hours after the fever subsided and then
continue IM BID for 7days
OR
 Ceftriaxone, IV, 1gm, BID, until 48hours after the fever subsided and then continue
IM for 7 days.
OR
 Cefuroxime, IV, 750-1500mg, TID, until 48hours after the fever subsided and then
continue P.O., BID for 7days.
22.2.11 Syphilis in Pregnancy
Brief description

 Syphilis is a common sexually transmitted disease, which can cause significant

intrauterine infection leading to abortion, pre-term birth, perinatal death and congenital
anomalies.
 It is caused by a spirochete bacterium called Treponema pallidum.
 Routine screening is done at booking and at the third trimester of pregnancy, because it

1114
 can infect the fetus at any point during gestation.

Clinical features
 Most mothers are asymptomatic.

Investigations
 Microscopy: by dark field examination or direct immuno-fluorescent Microscopy.
Serology
 Specific treponemal tests such as TPHA or FTA-Ab
 Nonspecific treponemal tests
o Venereal Disease Research Laboratory (VRDL) test
o The Rapid Plasma Reagent (RPR) test

Treatment
Objective
 Prevent long term and short term complications
 Prevent mother to child transmission

Pharmacologic:
First line
 Pregnant women with syphilis must be treated with penicillin, since no other
medication effectively crosses the placenta to treat the fetus, even if allergic to penicillin
must be desensitized and treated.
 Benzathine penicillin 2.4 Mil IU IM (1.2 Mil in each buttock) weekly for three
consecutive weeks. Treat the partner similarly

Alternatives
 Ceftriaxone 1gm IM daily for 10 to 14 days
o Note: Patients treated for syphilis in the second half of pregnancy can develop
Jarisch- Herxheimer reaction, which can precipitate premature labor and foetal
distress.
22.2.12 Pelvic Inflammatory Diseases (PID)
Brief description
 Pelvic inflammatory disease (PID) is usually the result of infection ascending from the
endocervix causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian
abscess and/or pelvic peritonitis.
 Sexually transmitted infections (STIs) are the main causative agents but anaerobes and
other organisms from the lower genital and gastrointestinal tracts may also be
implicated.
 PID could be post-sexually transmitted infection, post-partal and post- operative.

1115
  It is caused by polymicrobial organisms such as gonoccocus, chlamydia trachomatis,
mycoplasma hominis and genitalium, other intestinal and vaginal normal flora.

Clinical features
 The following clinical features are suggestive of a diagnosis of PID:
Major criteria
 Bilateral lower abdominal pain (sometimes radiating to the legs)
 Cervical motion/ excitation tenderness on bimanual vaginal examination
 Bilateral Adnexal tenderness on bimanual vaginal examination (with or without a
palpable mass)
Minor criteria
 Fever (greater than 38°C)
 Abnormal vaginal bleeding (intermenstrual, post-coital or ‗breakthrough‘)
 Deep dyspareunia
 Abnormal cervical or vaginal mucopurulent discharge
 Presence of abundant numbers of white blood cells (WBCs) on saline microscopy of
vaginal secretions
 Elevated erythrocyte sedimentation rate
 Elevated C-reactive protein

Investigations
 WBC with differential count, ESR
 Culture and sensitivity of blood, pus, or vaginal discharge
 Vaginal Swab: excess WBC in wet mount smear may indicate PID
 RFT, LFT, electrolytes
 Ultrasonography
 Laparascopy for visualization of hyperemic tubes, purulent discharge (Gold standard): if
feasible arrange referral or consult specialist

Treatment
Objectives
 Determine whether the patient can be treated as outpatient or requires hospitalization.
 Treat the acute infection: to eradicate the offending organism and prevent further
dissemination of the infection.
 Prevent the damage of the fallopian tube which may lead to recurrent infection,
infertility, chance of ectopic pregnancy, chronic pelvic pain

Non pharmacologic
 Patient should refrain from sexual activities or douching.
 Consider removal of IUD if the woman is not improving with medication.

1116
  Surgical management indicated if there is tuboovarian abscess(TOA) includes,
laparatomy and drainage of abscess, salpingo- oopherectomy, colpotomy, hysterectomy
with or without salpingo-oopherectomy

Pharmacologic
 Outpatient treatment
First line
 Ceftriaxone, 250mg IM single dose
PLUS
 Doxycycline, 100mg P.O., BID.
PLUS
 Metronidazole, 500mg P.O., BID for two weeks.
 Inpatient treatment
 Inpatient antibiotic treatment should be based on intravenous therapy which should be
continued until 48 hours after clinical improvement and followed by oral therapy.
Admission to hospital would be appropriate in the following circumstances:
o If the diagnosis is uncertain
o Clinically severe disease
o Tubo-ovarian abscess
o PID with pregnancy
o PID in HIV positive women
o Lack of response to oral therapy
o Intolerance to oral therapy
o Poor compliance

First line
 Ampicillin, 500 – 1000mg IV, QID, followed by 500mg P.O., QID
PLUS
 Gentamicin, 80mg, IV, TID followed by IM injection of similar dose
PLUS
 Clindamycin, IV, 900mg, TID

OR
 Metronidazole, 500mg IV TID followed by 500mg P.O.,TID

Alternative
 Ceftriaxone, IV, 2gm/day, BID
PLUS

1117
  Gentamicin, IV, 80mg, TID
PLUS
 Metronidazole, IV, 500mg TID Followed by either Clindamycin 300mg P.O., QID OR
 Doxycycline, 100mg P.O., BID
PLUS
 Metronidazole, 500mg P.O., TID for 14 days
o Note: In the outpatient setting, review of patient condition at 72 hours after
initiation of medication is recommended, particularly for those with a moderate or
severe clinical presentation
 In patients who have been on IV medication should continue oral treatment for 14 days
after clinically being improved.
 In pregnancy, the physician should refrain from using Doxycline.
 Patients with PID wearing IUD: Consideration should be given to removing the IUD,
especially if symptoms have not resolved within 72 hours.
 Women on hormonal contraception presenting with breakthrough bleeding should be
screened for genital tract infection, especially for C. trachomatis.
 When a sexually transmitted infection is either proven or likely to be the cause of PID,
the current sexual partner(s) should be traced and offered health advice and screening for
gonorrhoea and chlamydia.

22.2.13 Puerperal Mastitis

Brief description
 Puerperal mastitis is breast inflammation that develops during the first month after
delivery.
 Puerperal mastitis is a commonly encountered infection, hence early diagnosis and
prompt management minimizes the impact on the mother and infant.
 Despite appropriate management, abscess formation occurs in 4-10% of cases. It is
commonly caused by Staph. aureus and in some cases Staph. epidemidis.

Clinical features
 Fever, chills, flu like symptoms, breast pain with warm, erythromatous, indurated,
engorged and tender breast (one or both breasts) and axillary lymphadenopathy.
Fluctuating breast mass.

1118
Investigations
 CBC
 Fine needle aspiration and Gram stain from the pus culture and medicine sensitivity from
the breast abscess if any

Treatment
Non Pharmacologic
 Suctioning of the breast
 Breast-feeding with only the healthy breast
 Drainage of breast abscess
 Using supporting brassieres

Pharmacologic
 Cloxacillin, 500mg PO QID for 7-10 days. If there is evidence of sepsis, the patient
requires hospitalization
 Cloxacillin, 500mg IV QID until the fever and clinical symptoms subside, and
continue with oral Cloxacillin for 7-10 days.
o Note: Do not wait until fluctuation; if there is induration, tap and confirm the
diagnosis.

22.2.14 Vaginal Discharge Syndromes

22.2.14.1 BACTERIAL VAGINOSIS
(BV)
Brief description
 Bacterial vaginosis (BV) is a clinical syndrome characterised by the presence of
malodorous vaginal discharge, with or without vaginal pruritus.
 Usually there is no external genital irritation or dysuria.
 The discharge is generally a homogeneous, non-viscous, milky white fluid which
smoothly coats the vaginal mucosa and cervix.
 Imbalance of the normal vaginal flora is thought to play a role in the aetiology of BV,
resulting in overgrowth of gardnerella, anaerobes, or genital Mycoplasmas.
 The absence of Hydrogen peroxide-producing Lactobacillus (maintain vaginal acidic PH)
in the vagina appears to correlate with development of this disease.
 BV may cause adverse pregnancy outcomes like PROM, chorioamnionitis, preterm
labour, premature birth, post-partum endometritis, and post-caesarean wound infection.

Clinical features
 Vaginal secretions characterized by at least three of the following: Amsel criteria for
diagnosis of BV (at least three criteria must be present)

1119
 o Amine (―fishy‖) odor before or after addition of 10% KOH solution.
o PH ≥ 4.5 (unreliable if contaminated by menstrual bleeding or seminal secretions
o Homogeneous, smooth, non-inflammatory discharge
o Presence of clue cells (epithelial cells coated with bacteria) on microscopic
examination.

Treatment
Objectives
 Alleviate symptoms
 Prevent adverse pregnancy outcomes following infection
 Avoid precipitating factors

Non pharmacologic:
 Avoid frequent douching

Pharmacologic
First line
 Metronidazole, 500mg P.O., BID for 7 days or 2g P.O., single dose

Alternative
 Metronidazole, 0.75% gel 5gm intra-vaginally QD for 5 days
OR
 Clindamycin 2% cream 5gm intra-vaginally, OR 300mg P.O., BID for 7 days OR
100mg intra-vaginally QHS for 3 days

In Pregnancy
 Metronidazole, 250mg P.O., TID for 7 days;
OR
 Clindamycin, 300mg P.O., BID for 7 days.
 Sex Partners: Routine treatment of male partners(s) with metronidazole does not
prevent recurrence of Bacterial Vaginosis. For recurrent BV without evidence of other
STD, use of condoms and avoiding douching is encouraged.
22.2.14.2 Mucopurulent Cervicitis

Brief description
 Mucopurulent cervicitis (MPC) has been called the female counter part of urethritis in
males.
 It can be caused by sexually transmitted organisms n a m e l y N. gonorrhoeae or C.
trachomatis, although in most cases tests are negative for both gonorrhea and
chlamydia.
 The syndrome is characterized by muco- purulent cervical discharge and a cervical

1120
 inflammatory response (friability, edema, ectopy, increased numbers of
polymorphonuclear leukocytes (PMNs).
 However, presence of IUCD, Cervical ectropion (histologic diagnosis), oral
contraceptives and menses may be associated with PMNs in endocervical smears
without MPC.
 Patients with MPC may note vaginal discharge, dyspareunia, post-coital or inter-
menstrual bleeding, or other non-specific symptoms.

Causes
 Gonorrhea or Chlamydial infections
 Herpes cervicitis
 Trichomoniasis (ectocervicitis)

Clinical features
 MPC is diagnosed by the presence of criterion (a) below and at least one other criterion
(b, c or d).
a. Endocervical gram-stained smear with a monolayer of ≥ 15 PMNs/1000 X (oil
immersion) field, (in a specimen obtained from the endocervix with a swab to wipe
the cervix free of vaginal epithelial cells or menstrual blood, and in the absence of
primary herpes, trichomoniasis, or candidiasis)
b. Purulent endocervical discharge; or positive ―swab test‖ (yellow or green color on
endocervical swab).
c. Hypertrophic or edematous cervical ectopy.
d. Endocervical bleeding induced by gentle swabbing (post coital)
Investigations
 CBC
 Wet smear
 KOH mount
 Gram stain from vaginal swab for gonorrhea
 Culture and medicine sensitivity of gonorrhea and chlamydia
 Ultrasound

Treatment
Objective
 Alleviate symptoms
 Treat aggressively to prevent short and long term complications
 Identify and treat the partner and halt further transmission of infection

Pharmacologic
First line

1121
  Doxycycline, 100mg P.O., BID for 7 days

Alternatives
 Erythromycin base, 500mg P.O., QID for 7 days
OR
 Azithromycin, 1.0gm P.O., single dose
o Note: If Gonococcal infection is likely on clinical or epidemiological grounds,
proceed treatment with a single dose gonorrhea regimen.

Sex Partners
 All current sex partners should receive full STD evaluation. It is probably most important
to evaluate those partners within the past 30 days of diagnosis or onset of symptoms.
 If Non-Gonococcal Urethritis (NGU) or gonorrhea present; treat accordingly.
 If no urethritis is documented in the partners, it is generally safe to defer treatment
pending results of tests for gonorrhea and Chlamydia. However, empiric therapy at the
time of initial examination may be indicated if follow-up cannot be assured.
22.2.14.3 Trichomonal Vaginitis
Brief description
 Trichomoniasis is a parasitic infection caused by Trichomonas vaginalis.
 Trichocomonal vaginitis is characterized by the development of profuse, purulent
malodorous vaginal discharge (occasionally foamy).
 Cervical petechiae are commonly seen (―strawberry cervix‖).
 External dysuria and genital irritation are sometimes present.
 As in BV, the vaginal PH in trichomoniasis is generally above 4.5.
 Trichomonas vaginalis may be linked to adverse pregnancy outcomes such as PROM,
premature birth, and low birth weight.

Clinical features
 Frothy, greenish and profuse vaginal discharge associated with itching.

Investigations
 Demonstration of motile trichomonads on saline wet mount of vaginal exudates

Treatment
Objectives
 Alleviate symptoms.
 Prevent adverse pregnancy outcomes including PROM, premature labour, low birth
weight.
 Halt further transmission of the infection by identifying and treating the partner/s.
First line

1122
  Metronidazole, 500mg P.O., BID for 7 days OR 2gm P.O., single dose

Alternative
 Tinidazole, 2gm P.O., stat

In Pregnancy
 Metronidazole, 2gm P.O., single dose regimen.
 Advice on abstinence from sexual intercourse until symptoms improve and partner(s) is
treated.
 Avoid alcohol during treatment with oral metronidazole and for 24 hours thereafter, due
to possible reaction.
 Treatment failure (persistence or recurrence despite sexual abstention, or after intercourse
only with a treated partner), metronidazole 500mg P.O bid for 7 days.
 Repeated treatment failure: metronidazole 2.0gm P.O. QD for 3 to 5 days.
 Metronidazole gel is not effective for the treatment of T-vaginalis.
 Consider metronidazole resistance if patient is persistently infested after multiple
treatment courses.
 Tinidazole appears to be effective against metronidazole resistant T. Vaginalis: dose is 2
gm once P.O

Sex Partners
 Routine examination for sexually transmitted disease is required.
 Metronidazole 2.0 gm P.O, single dose for all partners.
 Abstain from sexual contact until 7 days after therapy is initiated.
22.2.14.4 Vulvo-Vaginal Candidiasis

Brief description
 Vulvo vaginal candidiasis is a common cause of pruritic vaginal discharge which is
commonly caused by one of the 3 species of candida called Candida albicans. Although
other species are incriminated rarely

Clinical features
 The main manifestations include pruritus vulvae, whitish curd like vaginal discharge,
vulvar irritation, dyspareunia, and splash (external) dysuria.

Investigations
 KOH test, to see fungal hyphae, Culture

Treatment
Objective
 Alleviate symptoms.

1123
  Identify the underlying cause and manage accordingly including diabetes mellitus,
excessive use of board spectrum antibiotics, other causes that can jeopardize the immune
status of the patient

Non pharmacologic
 Avoid frequent douching using detergents

Pharmacologic
First line
 Nystatin, 100,000 IU per vaginum, QD for 14 days

Alternative
 Clotrimazole, 100mg BID to be inserted in the vagina for three days OR 200 mg/day
for 03 days. OR 100mg/day for 6 days OR 1% cream 5gm 10-14 days.
OR
 Miconazole, 200mg/day to be inserted in the vagina for three days OR 100mg/day for
7 days.
OR
 Miconazole 2% cream 5gm intra-vaginal for 7 days.

Recurrent Vulvo-vaginal Candidiasis

 Usually associated with underlying immunecompromising state (Diabetes, HIV,
Chemotherapy, age etc…)
First line
 Ketoconazole, 400mg /day OR 200 mg BID for 5-10 days. Then 100 mg /day for 6
months as prophylaxis.

Alternative
 The optimal therapy for recurrent vulvovaginal candidiasis in nonpregnant women
consists of initial induction therapy with fluconazole 150 mg every 72 hours for three
doses, followed by maintenance fluconazole therapy once per week for six months

Sex Partners
 Examination and treatment of the partner usually is not necessary.
 However, if the partner has penile candidiasis or there is recurrent infection, treatment
with an imidazole cream (e.g, miconazole, clotrimazole) may be indicated.
22.2.14.5 Abortion
Brief description
 Abortion is defined as the initiation or expulsion of the fetus and other products of
conception before the 28th week of pregnancy.
 It may be spontaneous (threatened, inevitable, incomplete, complete or missed) or

1124
 induced.

Causes
 Infections e.g. malaria, HIV, UTI, bacterial vaginosis etc.
 Foetal abnormalities
 Incompetent cervix and other congenital anomalies of the uterus
 Chronic illness e.g. diabetes, thyroid disorders, HIV etc.
 Intentional interference with the pregnancy with medications or instrumentation
 Trauma

Threatened Abortion
 This is bleeding from the uterus before 28 weeks of gestation without cervical
dilatation.

Clinical features
 This variety of abortion usually manifests with scanty to moderate painless vaginal
bleeding without cervical dilatation and effacement.
 There may be mild discomfort. Usually, the uterine size corresponds with the stated
gestational age.

Investigations
 CBC
 Blood film for malaria and other hemoparasites
 VDRL
 FBS
 HIV test
 Ultrasound scan (confirms viable fetus in utero with closed cervix)

Treatment
Objectives
 Maintain a viable pregnancy to term if possible

Non pharmacologic
 Explain the condition to the patient
 Strict bed rest at home or hospital
 Abstain from sexual intercourse
 Report if bleeding or pain increases

Pharmacologic
 In case of early pregnancy (before 9 weeks) there is a place for progesterone 10 mg po/Im
for at least 10 days.

1125
  This is to support the luteal phase until the placenta function takes over the production of
progesterone

Inevitable Abortion
 Inevitable abortion is bleeding from the uterus before 28 weeks of gestation leading to
cervical dilatation with the membranes bulging or leakage of fluid.

Clinical features
 There is lower abdominal pain associated with heavy bleeding, cervical dilatation and
effacement. There may also be painless loss of amniotic fluid.
 If the bleeding continues for more than one week, it can be considered as inevitable
abortion, even if the cervix is closed.
 The uterine size is compatible with the gestational age.
 Depending on the amount of blood loss, there may be signs of shock (pallor, collapsed
peripheral vessels, rising pulse with reducing volume, falling BP and cold clammy
skin).

Investigations
 CBC
 Blood grouping and cross matching
 Ultrasound scan to see the viability of the fetus, for assessment the cervix, to also look for
possible cause and amniotic fluid volume

Treatment
Objectives
 Resuscitate patient
 Relieve pain
 Facilitate conditions that the process of abortion to be accomplished in aseptic condition
within short period of time.
 Evacuate the retained products of conception from the uterus.
 Identify cause of abortion if possible.
 Prevent infection with antibiotic prophylaxis.
 Provide Anti D injection (50-300 mcg IM stat) in case of an RH negative status

Non pharmacologic
 Keep the patient NPO
 Blood transfusion, if required, Use uterotonics such as ergometrin or misoprostol in case
of intractable bleeding

Pharmacologic

1126
  If the uterine size larger than 14 weeks, IV fluids as necessary.
 Pethidine, IM, 75-100mg stat. Followed by 50-100mg 8 hourly promethazine
hydrochloride, IM, 25mg stat
 Oxytocin, IV, 10-20 units/litre of Normal saline
OR
 Misoprostol, per vaginum or rectum, 600-800micrograms, two doses 4 hours apart
 Post abortion antibiotic prophylaxis is also recommended (Doxycline 100 mg po BID
for 7 days)
 Provide comprehensive abortion care.

Incomplete abortion
 In this clinical scenario part of the conceptus material is expelled and some is
remaining in the uterine cavity or cervical canal.

Clinical features
 The patient may complain of the passage of large clots and/or the fetus and some
products of conceptus material per vaginum.
 Depending on the extent of bleeding patient may manifest with shock (collapsed
peripheral vessels, fast pulse, falling BP and cold clammy skin).
 Usually the uterine size is smaller than the stated gestational age.
 Cervix is dilated and part of the conception material may be in the cervical canal.

Investigations
 CBC
 Blood grouping and cross matching
 Ultrasound scan
 RFT, LFT
 Erect plain film of the abdomen, if perforation is suspected (when MVA is

Treatment
Objectives
 Resuscitate patient
 Evacuate the retained products of conception from the uterus
 Prevent infection with antibiotic prophylaxis
 Identify the cause of abortion, if possible
 Prevent risk of Rh isoimmunization

Non pharmacologic
 Digital curettage during the time of vaginal examination to decrease blood loss.
 Arrange for surgical evacuation of the retained products of conception by manual vacuum

1127
 aspiration (MVA) or metallic evacuation and curettage (E&C).
 Abstain from sexual intercourse for at least 2 weeks.
 Counseling and psychological support of the patient.
 Blood transfusion when needed

Pharmacologic
 IV fluids as necessary.
 Ergometrine, IM/IV,0.2-0.4mg stat
 Oxytocin, IV, 20 units into 1 Lt of N/S and infuse at 30-60 drops per minute
OR
 Misoprostol, rectal, 600-800micrograms two doses 4hours apart. If the woman is RH
negative and husband is RH positive: Anti D Rh Immune Globulin 250-300 Units
(150mg), IM, stat within 72 hours.
 Amoxicillin, 1gm PO 6 hourly for 7days

Complete Abortion
 Cessation or reduction of vaginal bleeding following heavy bleeding with passage of
clots and/or the fetus and placenta.

Clinical features
 Usually the patient has no pain.
 The uterus is smaller than the gestational age.
 The cervix is closed and firm.
Investigations
 CBC
 Blood grouping and cross matching
 Ultrasound scan: to confirm empty uterine cavity

Treatment
Objectives
 Assess for and manage anaemia if present.
 Investigate for the cause of abortion if possible

Non pharmacologic
 Counseling and psychological support of the mother

Pharmacologic
 Resuscitate patient if necessary
 Treat anaemia if present
 Follow up

1128
22.2.15 Septic Abortion

Brief description

 This is a life-threatening complication of abortion.

 Most often the patient gives history of interference with pregnancy under septic
technique or incomplete abortion which stayed for some time without being evacuated.
 If not managed appropriately, this may lead to further complications such as septic
shock, uterine damage, peritonitis, haemorrhage, disseminated intravascular
coagulation (DIC), acute renal failure, adult respiratory distress syndrome, tetanus or gas
gangrene.

Clinical features
 Severe lower abdominal pain, fever, vomiting, headache, offensive and bloody vaginal
discharge, tachycardia, sign of peritonitis.
 If conditions worsen, patient may manifest with septic shock.

Investigations
 CBC
 Coagulation profile
 Blood grouping and cross matching
 Blood culture and sensitivity
 Urine culture and sensitivity
 Endo-cervical swab for culture and sensitivity
 Blood urea and electrolytes
 Chest and abdominal X-ray (to exclude foreign body, gas under the diaphragm
suggesting uterine perforation)
 Abdomino-pelvic ultrasonography (for intra-abdominal and pelvic abscesses, peritonitis
and gas in the pelvis)
Treatment
Objectives
 Resuscitate patient
 Treat infection
 Evacuate uterus and prevent further infection or organ damage
 Provide counseling

Non pharmacologic
 Evacuate the retained products of conception. Careful evacuation of the uterus must be
done as risk of uterine perforation is high.
 Do gentle digital curettage followed by the instrumental curettage under general

1129
 anaesthesia within 6 hours of initiation of antibiotic therapy. Extreme care is needed in
order not to perforate the uterus (if it has not been perforated already).
 If there is sign of peritonitis or uterine perforation, laparotomy may be required.
 Psychological support and family planning counseling.
 Blood transfusion when required

Pharmacologic

 IV fluids as necessary.
 If the gestational age is above 14 weeks and the fetus is not aborted yet, Oxytocin, IV,
20units in 1Lt of N/S to run 50-60drops/min
 Ampicillin, IV,1-2 g 6 hourly for 24-72 hours
PLUS

 Gentamicin, IV, 80 mg 8 hourly for 24-72 hours

PLUS

 Metronidazole, IV,500 mg 8 hourly for 24-72 hours

 Switch over from IV to oral therapy when appropriate. Continue with gentamicin, IM
or IV, 80 mg for at least 7 days. (The culture and sensitivity test results will direct
the antibiotic therapy)
 Pethidine, IM, 100 mg 4-6 hourly with Promethazine, IM, 25 mg 8-12 hourly
 Tetanus prophylaxis, if there is interference with pregnancy under septic condition.

Missed Abortion
 This refers to foetal death in-utero before 28 weeks gestation which does not show
any sign of expulsion.

Clinical features
 There is reversal of the symptoms of pregnancy with recurrent bloody vaginal discharge.
 The mother fails to perceive the foetal movements (if quickening has already occurred).
 The uterus is smaller than the stated gestational age. The foetal heart beat is absent.

Investigations
 CBC
 Blood grouping and cross matching,
 Blood film for malaria parasites if the clinical features suggest acute febrile illness
 Blood clotting profile
 Pregnancy test
 Ultrasound scan
 Fasting Blood Sugar

1130
  VDRL

Treatment
Objectives
 Prepare the patient for uterine evacuation
 Ensure safe uterine evacuation
 Ensure there is no DIC before attempting to evacuate the uterus
 Establish cause of foetal death if possible

Non pharmacologic
 First trimester (<12 weeks): Evacuation of the uterus can be accomplished by suction
curettage (manual or with machine) or using the metallic curettes (E&C).
 Hysterotomy may be indicated where induction fails or is contraindicated.
 Blood transfusion when the need arises

Pharmacologic
 IV fluids as necessary
 Misoprostol, oral or vaginal, 400micrograms stat, at least 3 hours prior to suction
curettage. This will facilitate curettage and prevent damage to the cervix by metallic
dilatation. Misoprostol can also be used to both ripen the cervix and facilitate
evacuation of the uterus. If there is previous uterine scar decrease the dose by half and
use mechanical means such as cervical catheter and laminaria dilators if available.

If 12–24-week gestation:
 Misoprostol, 200micrograms, vaginal, 12 hourly until expulsion or 400micrograms,
oral, 4 hourly until expulsion.
If 4–12-week gestation:
 Misoprostol, 800micrograms, vaginal or sublingual, every 24 hours for two days
 Intrauterine foetal death (>24 weeks) with previous caesarean section consider;
o 13-17 weeks: 200microgram 6hourly
o 18-26 weeks: 100microgram 6hourly
o 27-42 weeks: 25-50microgram 4hourly
o Induction of labour (live fetus >24 weeks): 25-50microgram vaginally 4 hourly

Induced Abortion
Brief description
 This refers to the deliberate termination of pregnancy.
 Termination of pregnancy is requested for and done for reasons permissible by law
either through a surgical procedure or by pharmacological means.
 The Ethiopian law permits to terminate pregnancy under the following conditions:
o In case of rape, defilement or incest

1131
 o Threat to physical and mental health of the mother
o Presence of foetal abnormality
o Mental retardation of the mother
o Minors aged under 18
o Any medical condition that endangers the life of the mother if pregnancy continues

Treatment
Objectives
 Ensure that legal requirements for termination are met
 Ensure the termination is performed safely
 Provide family planning counseling after the procedure
o If pregnancy is following rape, management should follow the guide on providing
care for survivors of sexual assault

Non pharmacologic
 Pre-abortion Counseling
o Advise on the other possible options before deciding on termination.
o Explore the reasons for the abortion request to ensure that it meets the legal and
medical requirements.
o Provide information of other care options and on the available methods of abortion.
 4-12 weeks gestation: Manual Vacuum Aspiration; Dilatation and curettage
 12 weeks gestation: Cervical ripening with misoprostol or prostaglanding E2, followed
by dilatation and evacuation/ extraction

Pharmacologic
 4-12 weeks of gestation:
o Mifepristone, 200mg P.O., stat followed by after 24 hours misoprostol 800
microgram, then the same dose 4 hours.
 12-24 weeks gestation:
o Misoprostol, 400 micrograms PO 4 hourly until expulsion
OR

o Mifepristone, 200mg P.O., stat, followed by Misoprostol 200microgram P.O., after

24 hours

22.2. Gynecological Disorders

22.2.1. Abnormal Uterine Bleeding (AUB)

Brief description
 Menstruation is considered normal:
o If the cycle comes every 21 to 35 days,
o The duration of bleeding is 1 to 7 days

1132
 o The amount is less than 80ml and
o It is not associated with any pain.
 Anything other than this is considered abnormal.
 Abnormal uterine bleeding includes dysfunctional uterine bleeding (DUB), i.e., uterine
bleeding with no organic cause and bleeding from structural causes.
 Dysfunctional bleeding can be ovulatory or anovulatory.
 The Anovulatory variety is the commonest type (greater than 80%), usually occurring in
post- menarche and premenopausal periods.
 It is characteristically acyclic, unpredictable as to the onset of bleeding, and variable in the
duration and amount of bleeding.
 Ovulatory DUB is usually associated with premenstrual symptoms such as breast
tenderness, dysmenorrhea, and weight gain and regular periodicity but heavy in amount
(heavy menstrual bleeding).
 Usually, it is caused by organic lesions, although a dysfunction of the corpus luteum or
atrophic endometrium may be the causes.
 Structural causes include fibroids, polyps, endometrial carcinoma, and pregnancy
complications.

Dysfunctional Uterine Bleeding (DUB)

Causes
 Hypothalamic dysfunction (physiologic)
 Premature ovarian failure
 Polycystic Ovarian Syndrome
 Hypo or Hyper-thyriodism
 Coagulation disorders

Clinical features
 The diagnosis is made by excluding all other obvious causes of abnormal uterine
bleedings.

Investigations
 CBC, coagulation profile, pregnancy test, ultrasound, Saline Infusion Sonography,
hysterosalpingography, endometrial sample
 TSH, T3, T 4
 Differentiate between ovulatory and anovulatory causes : serum progesterone on day ,
endometrial biopsy, Basal Body Temperature (BBT).
 If anovulatory: Prolactin, FSH, LH, free testosterone, 17-hydroxprogesterone
 For advanced chronic diseases: LFT and RFT

Anovulatory DUB

1133
Treatment
The treatment depends on the age of the patient, her desire for contraception or fertility, and
the severity and chronicity of the bleeding.

Objectives
 Control active bleeding
 Prevent recurrences, restoration of normal cycle
 Induce ovulation in patients desiring to conceive.

Non pharmacologic
If the haemoglobin level is low (less than 7gm/dl), transfuse 2 units of blood.

Pharmacologic
Control of active bleeding:
First line
 Norethisterone, 5mg QID P.O. for 2-3 days followed by 5mg P.O. QD for ten days
with or without
 Medoxyprogesterone, 10-25mg QID, P.O. until bleeding stops
Alternative
 High dose of combined oral contraceptive pill (COP) 1tablet QID, for 4 days,
followed by 1tablet, TID for 3days, then followed 1tab BID for 2 days until the bleeding
is controlled and then the standard dose of the COP one tablet/day for 21 days.
 If there is vomiting while taking the high dose COP, promethazine 25mg, PO or IM
should be given.
Note: If bleeding failed to stop despite high dose of Combined oral contraceptive pill,
Dilation and Curettage may be required.

Restoration of the cycle

 Combined oral contraceptive pills 1 tablet/day for 21 days for 3-4 consecutive
months.
 Norethisterone 5mg/day from day 14-24 each month for three months.
If fertility is desired, ovulation induction using clomiphene citrate is one modality of
treatment.

Ovulatory DUB
 This is commonly diagnosed by the presence of clinical evidence of ovulation and is
confirmed by hormone analysis and/or endometrial biopsy, Basal Body Temperature
(BBT) and stretching of cervical mucus.
 It is usually due to follicular or luteal phase defect.

Treatment
Objectives
 Identify the underlying cause
 Prevent recurrence

1134
Non pharmacologic
If there is any clinical suspicion of endometrial pathology, either of the following measures is
appropriate:
 Manual (electrical) Vacuum Aspiration or using pippet for endometrial biopsy
 Dilatation & curettage
 Endometrial ablation
 Hysterectomy

Pharmacologic: Before embarking on treatment, organic causes should be ruled out beyond
shadow of doubt.
First line
 Prostaglandin inhibitors or NSAID medicines are given few days before the bleeding
starts and the first three days of the bleeding.
o Ibuprofen, 400mg 3 times /day or Indomethacin, 25-50mg P.O., TID
Alternative
o Danazol, 200-400mg P.O., daily for 12 weeks
 Structural causes: The treatment depends on the underlying cause.
Note: Minor variations of normal bleeding pattern may not require evaluation, particularly in the
first 2 years of menarche
22.2.2. Dysmenorrhoea

Brief discussion

 Dysmenorrhoea is excessive pain during menses.

 It occurs in about 50% of menstruating women.
 It may be primary or secondary.
 Primary dysmenorrhoea is believed to be due to increased endometrial prostaglandin
production, whereas
 Secondary dysmenorhoea is due to outflow obstruction, pelvic tumours, infections,
endometriosis etc.
 Dysmenorrhea in the first few years following menarche is usually primary but the
secondary characteristically occurs many years after menarche.

Clinical features
 The pain of primary dysmenorrheal usually begins a few hours prior to or just after the
onset of menstrual flow and may last as long as 48-72 hours.
 Thorough pelvic assessment is important to rule out organic causes.

Investigations
 CBC, vaginal smear, ultrasound

Treatment
Objectives

1135
 Alleviate pain
 Treat underlying cause

Primary dysmenorrhea
Non pharmacologic:
 Reassurance
Pharmacologic
First line
 Prostaglandin inhibitors (NSAID): Ibuprofen, 400 mg, P.O., TID
OR
 Mefenamic acid, 500mg, P.O, TID.

Note: The medicines have to be administered prior to the onset of menses or at the onset of
pain every 6 to 8 hours for the first few days of menses. This modality of treatment should
continue for 4-6 months before declaring treatment failure.
Alternative
Monophasic Combined oral contraceptive pills; if contraception is also needed

Secondary dysmenorrhea
 It is cyclic pain in association with underlying pelvic pathology.
 The pain often begins 1-2 weeks prior to the onset of menses and persists until a few days
after cessation of bleeding.
Treatment
Unlike primary dysmenorrhea, Non-steroidal anti-inflammatory medicines (NSAID) and oral
contraceptive have limited roles. The underlying cause should be treated. The most common
cause is endometriosis.
22.2.3. Infertility (Male and Female)

 Infertility is defined as one year of unprotected intercourse without pregnancy.

 It could be primary or secondary.
 The major causes of infertility in female could be fallopian tube occlusion or anovulation.
 In males, it could be pre-testicular, testicular or post-testicular affecting the semen
quality in terms of volume, sperm count, morphology, concentration, and motility.
 In sub-Saharan Africa it is estimated that 11-20% couples have difficulty conceiving.
 The effect may be amplified for those living in the infertility belt of Africa which stretches
from Tanzania in the east to Gabon in the west.

Causes
 Infection:
o STI (chlamydial, gonorrhea, syphilis etc.)
o Infectious and parasitic diseases: mumps, TB, schistosomiasis

1136
 o Post-partum/abortal
 Exposure to toxic substances: arsenic, aflatoxins, pesticides, caffeine, tobacco, alcohol, heat
 Anovulation: the main cause being polycystic ovarian syndrome (PCOS) in 75%of
cases
 Surgery, trauma

Clinical features
 History of STD, features of endocrinopathies,
 History of contraception usage,
 surgical history (ovarian cyst, appendectomy, pelvic abscess, ochidopexy, repair of
inguinal hernia),
 medicine intake, diet (smoking, excessive alcohol and caffeine consumption),
 Galactorrhea,
 menstrual pattern, dysmenorrea,
 current illness,
 occupation (male)

Investigations
 CBC
 FBS
 Vaginal smear
 Hormone profile:
o To evaluate ovarian reserve (serum FSH and LH in 1-3rd day of the menstrual cycle),
o For ovulation evaluation: Serum progesterone, 7 days before the expected menses
o If menstruation is irregular: TSH, T3, T4, Testosterone, DHEA, DHEAS, prolactin
 Hysterosalpingography (HSG)
 Ultrasound: ovarian volume, counting ovarian follicles
 Laparoscopy: to look for endometriosis and tubal patency
 For male: Sperm analysis, vasography, testicular biopsy, trans-rectal ultrasound, hormone
assay (FSH, LH, prolactin, thyroid function tests, testosterone), post-ejaculatory urine
examination for male with an ejaculatory volume < 1ml.

Treatment
Objectives
 Identify the exact cause of infertility and manage it accordingly
Give couples a realistic prognosis of treatment.
 Provide information, support and counseling to the couples to cope with the stress of
treatment and possible failure
Non pharmacologic

1137
 Overweight or underweight should be normalized
 Stress should be alleviated.
 Avoid smoking, excessive alcohol and caffeine consumption
Pharmacologic
Female
 Clomiphene citrate, starting dose 50mg/day PO for five days starting from the 5th day of
the menstrual cycle, and
 if no ovulation increases the dosage by 50mg/day up to 200mg/day over three to four
treatment cycles.
 If possible, check mid-luteal phase progesterone in each cycle for ovulation
 HCG 5000-10,000IU IM 5days after the last clomiphene tablets may enhance ovulation
OR
 Metformin: Recently metformin has been used to induce ovulation,
o If the cause of anovulation is PCOS Starting dose: 500mg/day for one week,
o if tolerated, double the dose for another one week, then
o 1500mg daily, gradually increase the dose to reach maximum, 2500mg/day.
o The treatment can continue for six months.

Note: There is no need of increasing the dose if the menstrual cycle becomes regular.
OR
 Clomiphene and metformin combined: Women with PCOS, 90% will ovulate
OR
 Tamoxifen, P.O., 20-40mg/day, from day 3 of the menstrual cycle for 5 day
OR
 Gonadotrophins: Human menopausal gonadotrophins (HMG), (for women resistant to
above mentioned medicines), IM, 75IUday for 14days in step-up manner.

Male:
Non pharmacologic
 Avoid smoking, excessive alcohol and caffeine consumption
 Avoid exposure to environmental toxic substances (arsenics, aflatoxins) and heat
 Surgical: Varicocele repair, vassal reconstructions, Intracytoplasmic sperm injection (ICSI)
Pharmacologic
 None except in retrograde ejaculation, sympathomimetics such as imipramine and
pseudoephedrine, can be tried.

1138
22.2.4. Menopause and Perimenopausal Hormone Syndrome

Brief description
 Menopause refers to the point in time when permanent cessation of menstruation occurs
usually due to loss of ovarian function.
 A woman is considered to be menopausal if there is no menstruation for a period of at
least 12 months in the absence of pregnancy or lactation.
 Menopause is associated with physical, emotional and psychological upheaval of varying
intensity in the affected individual.
 Sixty percent of menopausal women may be asymptomatic.
 To alleviate symptoms and prevent osteoporosis and other cardiovascular problems,
Hormone Replacement Therapy (HRT) used to be recommended for every post-
menopausal woman.
 However, following the release of Women Health Initiative (WHI) study result in 2002,
many societies and health organizations consider HRT as dangerous and the routine use
of HRT was disrupted.
 Recently, several high ranking Obs/Gyn specialists and the International Menopausal
Society (IMS) re-affirmed and re-legitimized the use of HRT for at least 5years in healthy
post-menopausal women less than 60 years of age.

Causes
 Natural onset due to the age of the individual
 Due to surgical removal of the ovaries (bilateral oophorectomy)
 Pelvic irradiation
 Premature ovarian failure due infection and other causes
 Pituitary damage from primary post-partum haemorrhage (PPH) (Sheehan's syndrome
 Cytotoxic (anticancer) therapy

Clinical features
 Hot flushes (heat or burning in the face, neck and chest with resultant sweating).
 The flushes may be associated with palpitations, faintness, dizziness, fatigue, weakness,
emotional and psychological problems which include: mood changes, depression, anxiety,
nervousness, irritability, loss of libido.
 Atrophic changes in the genital tract may give rise to the following: increased frequency
of micturition and dysuria, vaginal dryness and dyspareunia.

Investigations
 Hormone tests if available (serum LH, FSH, estradiol).
 Routine investigations e.g. CBC, blood glucose, lipid profile.
 X-ray to evaluate bone density.

1139
 Investigation to exclude pregnancy

Treatment
Objectives
 Control symptoms e.g. severe hot flushes, atrophic vaginitis and recurrent cystitis.
 Prevent osteoporosis especially in individuals with premature menopause.
 Prevent cardiovascular morbidity and mortality

1140
Non pharmacologic
 Counseling and reassurance.
 Encourage active lifestyles, exercise and regular physical checkups for common medical
problems.
 Avoid hot weather conditions
 Light clothing, cold shower
 Balanced diet

Pharmacologic
In women with intact uterus:
 HRT can be given as sequentially opposed or continuous combined preparations.
 The continuous preparations have the advantage of less breakthrough bleeding, but should
only be commenced once the woman has been stable on sequentially opposed therapy
for a year.
 Treatment should last 5 years but should be reviewed annually.

Sequentially opposed HRT

 Conjugated equine oestrogen, 0.3-0.625mg P.O., daily for 21

days
OR
 Medroxyprogesterone acetate, MPA 5-10mg P.O., daily
OR
 Norethisterone acetate oral 1mg daily from day 11-21 followed by no therapy from
day 22-28
OR
 Estradiol valerate, oral, 1-2mg daily for 11days
PLUS
 MPA, 10mg P.O., daily from day 11-21 followed by no therapy from day 22-
28

Continuous combined therapy

First line
 Conjugated equine oestrogen, 0.3-0.625mg P.O.,
PLUS
 MPA, 2.5-5mg P.O., daily
Alternative
 Estradiol valerate, 0.5-1mg P.O.,
PLUS
 Norethisterone acetate, 0.5-1mg P.O., daily

In women with previous hysterectomy:

1141
 Conjugated oestrogens 0.625 microgram daily.
 Women with intact uteruses should never be given oestrogen alone.

Note: Start at the lowest dose of HRT to alleviate symptoms. The need to continue HRT should
be reviewed annually. If HRT is continued, it should be gradually tapered because abrupt
discontinuation of oestrogen may cause recurrence menopausal symptoms.

1142
A mammogram should be done once every two years.
Abnormal vaginal bleeding requires evaluation by a specialist to exclude endometrial cancers.

Refer
 Refer cases with osteoporosis or severe unremitting symptoms.
 Women with premature ovarian failure
 Women with post-menopausal vaginal bleeding

22.2.5. Carcinoma of The Cervix

Brief description
 Carcinoma of the cervix is the commonest form of female genital cancer in the developing
countries.
 Though common, it is preventable and curable if detected early.
 In developed countries, the incidence of this disease has fallen considerably owing to
regular screening procedures using the Pap smear.
 In the absence of an effective screening system in Ethiopia, most cases seek clinical care
very late and thus the only modality of treatment left for these patients is radiation.

Causes
 Human papilloma virus, the high oncogenic types are implicated in the causation of the
disease.
 There are more than 18 high oncogenic types.
 The other associated factors include:
o Associated risk factors
o Sexual promiscuity
o First coitus at early age, multiple child births
o Infections with Herpes Simplex Hominis type II, HIV
o Smoking
o Low socio-economic status
o Family history
o Immunosuppression

Clinical features
 Some are asymptomatic in the early stage of the disease (diagnosed on routine
screening or assessment during antenatal care, family planning etc.)
 Commonly patients present with abnormal vaginal bleeding after sexual intercourse, post-
menopausal bleeding, and increased vaginal discharge.
 In early cases there will be erosion of cervix or changes of chronic cervicitis but in
advanced cases ulcerative or fungating cervical lesion is observed on speculum
examination.

1143
Investigations
 Cervical biopsy
 CBC
 Renal function test
 Serum uric acid
 Chest radiograph
 Intravenous urography
 CT Scan and or Magnetic Resonance Imaging (to detect aortic nodes and metastases to the
lungs and liver)
 Examination Under Anaesthesia for clinical staging

Prevention
 Vaccine: Recently, a quadrivalent vaccine against 16,18,6 and 11(Gardasil) from MSD
and bivalent vaccine against 16 and 18 (Cervarix) from GSK has been developed and
made available to the market.
 These vaccines are 70-80% effective in preventive cervical cancer.

Screening:
 Pap smear, VIA, VILI and colposcopy

Treatment
Objectives
 Treat central tumor
 Treat areas of tumor spread with the aim of eradicating the disease
 Alleviate symptoms in advanced cases

Non pharmacologic
The treatment modalities for carcinoma of the cervix are:
 Surgery, the main stay treatment
 Radiotherapy: as treatment or palliation to arrest vaginal bleeding or alleviate pain
 A combination of surgery and radiotherapy
 Adequate nutrition
 Correction of anaemia
 For advanced terminal cases: provide emotional and psychological support

Early disease
Stage IA1
 Depth of stromal invasive less than 3mm with horizontal expansion of 7mm
 Simple conization of the cervix may be enough if the patient desires fertility and provided
surgical margins are free of cancer or extra fascial hysterectomy if childbearing has been
completed.

1144
 If there is lympho-vascular invasion more aggressive treatment is appropriate.
Stage IA2
 Depth of invasion 3-5mm with 7mm horizontal spread
 Requires extensive surgery (modified radical hysterectomy with pelvic lymphadenectomy).

Overt disease (Stage IB and IIA)

 Radical hysterectomy with pelvic and para-aortic lymphadenectomy.

Advanced disease (Stage IIB to IV)

 The modality of treatment is radiotherapy, with or without chemotherapy.
 Currently, in USA the standard treatment is to give weekly cisplatin 1mg/kg during
radiation therapy.

1145
Pharmacologic
Neoadjuvant chemotherapy
 Cisplatin, 1mg/kg, IV, diluted in 1L N/S over 24hours weekly for 3 weeks. If given before
surgery or radiation, patient will have better survival rate.

Palliative treatment
 Patients with end-stage cervical cancer may present with different clinical presentations
such as pain from bony metastasis, respiratory distress from lung metastasis and renal
failure secondary to tumor growth.

Palliative chemotherapy: A combination of cisplatin and paclitaxel has a better response rate
Pain management: Follow the WHO ladder approach
 Start with Non-steroidal anti- inflammatory medicines (NSAIDs) or the newer cyclo-
oxygenase-2 (COX-2) inhibitors.
 If the patient fails to respond to these agents, proceed to second line of medicines which are
opioids such morphine.

Respiratory distress: Oxygen support and withhold toxic medicines

Renal failure: Percutaneous nephrostomies

Refer
 All patients must be referred to a specialist for evaluation and decide on mode of treatment.
 The treatment of carcinoma of the cervix is best done by a specialist who has experience in
cancer management.

22.2.6. Gestational Trophoblastic Diseases (GTD)

Brief discussion
 GTD comprises a spectrum of neoplastic conditions in women derived from the placenta.
 The term GTD includes hydatidiform mole (complete mole &partial mole) invasive mole,
gestational choriocarcinoma, and placental trophoblastic tumor (PTT)
 Gestational Trophoblastic Neoplasia (GTN) refers specifically to forms with the potential for
tissue invasion and metastasis which includes invasive mole, choriocarcinoma, PTT and
post molar trophoblastic diseases.
 GTN is recognized today as the most curable gynecologic malignancies.

Classes
 Hydatidform mole (Complete mole and Partial mole)
 Invasive mole
 Choriocarcinoma.
 Placental Trophoblastic Tumour (PTT)

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Clinical features
 The classic presentation includes irregular vaginal bleeding, hyperemesis, execessive
uterine enlargement, expulsion of vesicles and failed early pregnancy.
 Rarer presentations include hyperthyroidism, early onset pre-eclampsia or abdominal
distension due to theca lutein cysts.
 Very rarely, women can present with acute respiratory failure or neurological symptoms
such as seizures; these are likely to be due to metastatic disease.

Investigations
 Ultrasound: snow-storm appearance is observed in complete mole and in partial mole
there will be cystic spaces in the placenta and transverse to antro-posterior diameter of
gestational sac is greater than 1.5.
 Serum or urine HCG.
 Histological examination of the tissue removed.
 Thyroid function tests (TSH, T3,T4).
 Coagulation profile (PT,PTT, INR)
 CBC
 Renal function test (urea, creatinine)
 Liver function test
 Blood group and cross-match

Treatment
Objective
 Resuscitate and stabilize the patient.
 Early detection of persistent mole and manage appropriately.
 Institute chemotherapy using the FIGO 2000 risk scoring system
Non pharmacologic
 If there is heavy bleeding resuscitate the patient
 Surgical evacuation of the uterus (suction curettage is the preferred method)
 Hysterectomy, if the woman has completed her family. This may eliminate local invasion
but not distant metastasis.
 If there is sign of pulmonary insufficiency: Oxygen and cardiopulmonary support

Pharmacologic
 If there is sign of hyperthyroidism, it is important to administer a beta-adrenergic
antagonist before the induction of anesthesia for surgical evacuation because of the risk of
precipitated thyroid storm.
 Proporanolol, IV, 40mg BID

Post-molar surveillance

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 After evacuation of the molar tissue or hysterectomy with mole in situ, weekly
determinations of βhCG until the results are within normal limit for 3 consecutive weeks,
then at monthly intervals for 6 months.
 FIGO criteria for the diagnosis of post-molar GTD
o Four values or more of hCG documenting plateau (10%of hCG value) over at least
3 weeks: days 1, 7, 14, 21
o A rise of hCG of 10% or greater for 3 values or longer over at least 2 weeks: days
1, 7, 14
o The presence of histologic choriocarcinoma
o Persistence of hCG 6 months after molar evacuation

Risk for post-molar gestational trophoblastic neoplasia

 Increase serum hCG level
 Uterine size larger than the expected by date
 Theca-lutein cysts
 Increasing maternal age

Chemotherapy

 The need for chemotherapy following complete mole is 15% and 0.5% for partial mole.
 Women are assessed before chemotherapy is initiated using the FIGO 2000 risk scoring
system.
 Women with score ≤6 are at low risk category and treated with a single agent:
 Metotrixate, 1mg.kg IM/P.O. days 1, 3, 5, 7 alternating with Folinic acid 0.1mg/kg days 2,
4,6, 8 (repeated every 14days)
 Women with score ≥7 are at high risk category and treated with multiple agent
chemotherapeutic agents that include: (see table 22.2 below)

Table 22.2: EMA-CO regimen for high risk malignant GTD

Day Agent Dose and route
1 Etoposide 100mg/m2 IV infusion over 30minutes
Methotrexate, 100mg/m2 IV bolus
D actinomycin 350mg/m2 IV bolus
2 Etoposide 100mg/m2 IV infusion over 30minutes
D actinomycin 350mg/m2 IV bolus
Folinic acid 15mg, Po/IM Q 12hourly 4doses,24 hours

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 after methoterixate bolus
8 Cyclophosphamide 600mg/m2, IV infusion over 30minutes
Vincristine, 1 mg/m2, IV bolus
15 Begin next cycle

 Treatment should continue, in all cases, until the hCG level has returned to normal and
then for a further six consecutive weeks.

Table: 22.3. FIGO scoring system

FIGO scoring 0 1 2 3
Age <40 >40
Antecedent pregnancy Mole Abortion Term
Interval from end index
pregnancy to treatment (months) <4 4-<7 7->13 ≥13
Pre-treatment serum hCG <103 03-<104 104-<105 ≥105
Largest tumour size, including
uterus(cm)
<3 3-<5 ≥5
Site of metastasis Lung Spleen, Kidneys Gastrointestinal Liver, Brain
Number of metastasis - 1-4 5-8 ≥8
Previous failed chemotherapy - - Single 2 or more

Note:
 Histological examination of all failed product of conception is recommended to exclude
GTN.
 A urinary pregnancy test should be performed in all cases of persistent or irregular vaginal
bleeding after pregnancy events.
 Women who undergo chemotherapy are advised not to conceive for one year after
completion of treatment.
 Women with GTD should be advised to use barrier methods of contraception until hCG
level normalizes. Once hCG is normalized, Combined oral contraceptive pill can be used.
 IUCD should not be used until hCG levels are normal to reduce the risk of uterine
perforation.
 Anti-D prophylaxis: Because of the poor vascularization of the chorionic villi and absence

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 of the anti-D antigen in complete mole, anti-D gammaglobulin is not required after
evacuation of complete mole but should be given following partial mole.
 Women who receive chemotherapy for GTN are likely to have an earlier menopause.

22.2.7. Hormonal Contraceptives

 Contraceptives include different kinds of methods used to prevent the occurrence of

pregnancy.
 The variety of contraceptive methods includes, natural methods, barrier methods,
intrauterine contraceptive devices, hormonal and permanent surgical methods.
 Hormonal contraceptives are one of the most effective methods that are prescribed to a
client based on informed choice.

Combined Oral Contraceptives (COC)

 A group of contraceptive medications composed of synthetic oestrogens and progesterone
in different doses; 20mcg, 30mcg or 50mcg of oestrogen and 0.15-1mg of progesterone in
each tablet.
 They act primarily by inhibiting ovulation, and also by making the cervical mucus less
favorable to sperm penetration and rendering the endometrium more atrophic.
First line
 Levonorgesterol+ethnylestradiol and iron, in starting from the first day of menses.
Alternative
 Norethindrone + Ethnylestradiol, 0.5mg + 0.035mg /day starting from the first day of
menses
OR
 Norethindrone + Mestranol, 1mg + 0.05mg /day starting from the first day of menses

Progesterone Only Contraceptives (POP)

 This is indicated whenever there is contraindication for oestrogen as in lactating
mothers, Diabetics and Hypertensive patients.
 However, it is less effective compared with COC.
Orals
 Lynestrenol, 0.5 mg/day
Injectables
 Medroxyprogesterone acetate, 150 mg deep IM injection within the first 5 days of the
cycle to be repeated every three months.
Implants
Levonorgesterel in six silastic capsules implanted in the left upper arm under local anesthesia,
effective up to five years.

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Emergency contraception (EC)
 Contraception aimed at preventing pregnancy after unplanned sexual exposure in a
woman who is not on regular contraception. EC cannot be used as a regular method of
contraception.
First line
 Levonorgesterol, two 0.75mg tablets to be taken 12 hours apart within 72 hours
unplanned sexual exposure
OR
 Combined oral contraceptive pill (COC) with 50 microgram of oestrogen, 2 tabs BID
within 72hours of unplanned sexual exposure for 2doses.
OR
 Combined oral contraceptive pill (COC) with 35microgram of oestrogen, 4 tabs BID
within 72 hours unplanned sexual exposure for two doses
Alternative
 IUD: This would be effective if inserted within five days of unplanned exposure, after
ruling out the existence of infection.

22.2.8. Sexual Assault

 Sexual assault is defined as any sexual act performed on another person without consent.
 Physician evaluating the victim of sexual assault should aim at providing adequate
medical care and collect evidence. Rape is the most common reported sexual assault.

Investigations
 History and physical examination
 Identification of spermatozoa from specimen over the genitalia or high vaginal swab.
 Tests for chlamydia and gonorrhea.
 Wet mount for trichomonas.
 The wet mount can also be examined for evidence of bacterial vaginosis and candidiasis.
 Serum testing for HIV infection, hepatitis, and syphilis.
 Pregnancy testing should be done for women of childbearing age

Treatment
Objectives
 Medical or surgical treatment of acute injury.
 Screen for STI, HIV, Hepatitis virus B infection and pregnancy at initial visit, repeat
screening for HIV, HbsAg at three and six months.
 Prevention of STI.

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 Prevention of pregnancy
 Rehabilitation
 Medical recording should be meticulous and management approach should be
multidisciplinary

Non pharmacologic
 Rehabilitation: counseling and psychological support.
 Surgical repair of physically injured parts of the body

Pharmacologic
 Treatment of infection such as gonococcal, trichomonas and chlamydial Ceftriaxone, 250
mg IM in single dose
PLUS
 Metronidazole, 2gm orally in single dose,
PLUS
 Doxycycline, 100mg P.O., BID for 7 days

In Child Abuse
 Ceftriaxone, 125-250mg IM
OR
 Erythromycin, 250mg P.O., TID seven days

Prevention of Pregnancy: provide emergency contraception, within 72 hours after exposure

 Levonorgesterol two 0.75mg tablets to be taken 12 hours apart.
 Combined oral contraceptive pills with 50-mcg oestrogen, two tabs 12 hours apart for
two doses.
 Combined oral contraceptive pills with 30-mcg oestrogen, four tabs 12 hours apart for
two doses.
 IUD insertion up to 5 days following exposure. Screen for infection and pregnancy before
inserting IUD
 Post Exposure Prophylaxis (PEP) for prevention of HIV infection: refer guideline

22.2.9. Neonatal resuscitation

Most episodes of birth asphyxia can be anticipated based on high risk antepartum and
intrapartum factors. For effective resuscitation, it is important to anticipate the need for
resuscitation and prepare equipment and personnel.
Antepartum factors that call attention to prepare for resuscitation include:
 Maternal diabetes
 Pregnancy induced hypertension
 Maternal chronic illness

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 Previous Rh-sensitization
 Polyhydramnios or oligohydramnios
 Maternal infection
 Poor obstetric history including difficult or operative delivery, abortion, still births, low
birth weight babies, developmental defects etc.
 Multiple gestation and post-term gestation
 Maternal medicine treatment like reserpine, lithium carbonate, diazepam etc.
 Maternal under-nutrition (height < 145cm, weight < 40kg)
 Maternal anemia, Hgb < 8gm%
 Maternal age (<20 years or > 35 years).

The intrapartum factors include:

 Elective or emergency caesarian section
 Abnormal presentation
 Premature labor and precipitous labor
 Rupture of membrane more than 24 hours prior to delivery
 Foul smelling amniotic fluid
 Prolonged labor greater than 24 hours or prolonged 2nd stage of labour greater than 2
hours
 Foetal distress of whatever cause
 Use of general anesthesia
 Narcotics administered to the mother within 4 hours of delivery
 Meconium stained amniotic fluid
 Prolapsed cord
 Antepartum haemorrhage

Preparation for resuscitation:

For normal term deliveries, a trained person, such as a midwife or nurse, should be capable of
at least providing Bag and Mask ventilation. A radiant warmer or simple room heater,
preheated mattress, dry clothes should be ready for use. All resuscitation equipment should
also be immediately available and in working order. When asphyxia is anticipated, trained
health workers capable of intubating the baby (e.g. pediatrician) should attend the delivery. If
pediatrician is not available, an obstetrician or a general practitioner who is trained to intubate
the newborn baby should attend the delivery. All equipment should be ready for use.
Equipment and medicines that need to be ready include:
 Radiant warmer, sterile sheets
 Suction catheters
 Suction machine
 Infant resuscitation bag

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 Appropriate size face-masks
 Laryngoscope with blade
 Endotracheal tube (2.5, 3.0, 3.5, and 4.0)
 Scissors, adhesive tape, gloves and stethoscope
 Syringes of different sizes
 Needles
 Alcohol and iodine
 Umbilical catheters of 5F to 8F
 Feeding tubes
 IV cannula (24G) and 3-way connectors, if available
Other equipment/medicines may be needed based on the specific condition and situation of
the newborn.

Initial steps of neonatal resuscitation

For most normal deliveries, all that is required is Essential Newborn Care (ENC); drying,
warming, cord care, eye care and initiation of breast milk within the 1st one hour of life.
Note: In every case of neonatal resuscitation, remember that a delay or ineffective
resuscitation can lead to an increased chance of brain damage and make resuscitation more
difficult.

Procedures of Initial steps of resuscitation: Open airway:

 Place on back in horizontal position with neck slightly extended (may use shoulder roll).
Both hyperextension and under-extension of the neck can compromise air entry.

Figure: 22.1. Hyperextended slightly extended flexed

 Suction mouth, then nose

 Start bag and mask ventilation

Bag and Mask ventilation

Indications

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 No spontaneous breathing at all
 Gasping respiration
 Recurrent apnea or irregular breathing

Contraindication to bag and mask ventilation

 Diaphragmatic hernia
 Baby born with thick meconium stained liquor

Cautions:
 Select the proper size mask, which should cover from the tip of the chin to the nose in an
air tight manner.
 Ensure neck is slightly extended and there are no secretions.
 If bag and mask ventilation is given for > 2 minutes, insert and oro-gastric tube
 If HR>100bpm and respiratory efforts are good, stop ventilation and provide free flow
oxygen. Continue monitoring HR, respiration and color.
 If HR is 60-100bpm and increasing, continue ventilation.
 If HR is 60-100 and not increasing, continue ventilation and start chest compression.
 If HR < 60bpm, continue ventilation and start chest compression

Adrenaline
Indication:
 Heart rate < 80bpm after 30 seconds of chest compression along with positive pressure
ventilation with 100% oxygen
 If heart rate is zero
o Dose: 0.1 – 0.3ml/kg of 1:10,000 solutions

Route: Intravenous or intra-tracheal. Give as rapid as possible. After 30 seconds of giving

adrenaline, check the heart rate. If the heart rate is still <100bpm, consider repeating adrenaline.

22.2.10. Recommended immunization schedule

Table: 22.4. Recommended schedule for immunization according to EPI program

Age Vaccination
Birth BCG OPV-0
6 weeks OPV-1 , DPT1-HBV1-Hib1 (Pentavalent)
10 weeks OPV-2, DPT2-HBV2-Hib2 (Pentavalent)
14 weeks OPV-3, DPT3-HBV3-Hib3 (Pentavalent)
9 months Measles

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Table: 22.5. Recommended schedule of immunization for children attending clinic at later
age but before 5 years

Age Vaccination
BCG if Mantoux test is negative
OPV-1
First visit DPT1-HBV1-Hib1 (Pentavalent)
OPV2
Second visit (after one month)
DPT2-HBV2-Hib2 (Pentavalent)
OPV-3
Third visit (after one month)
DPT3-HBV3-Hib3 (Pentavalent) Measles

Table: 22.6. Hepatitis B vaccine doses

Route of Adverse reaction
Vaccine Type of vaccine administratio
n
BCG Life attenuated Intradermal BC Gioma
DPT-HBV-Hib Toxoid (DT) Inactivated bacteria (P) IM Fever, anaphylaxis,
(Pentavalent) Protein conjugated polysaccharide (Hib) crying, & shock
Recombinant product (HBV)
OPV Life attenuated virus Oral Paralysis
Measles Life attenuated virus Subcutaneous Fever

Engrix B 10 microgram is also available and three doses are recommended (at birth, at one
month and at six months of age). Booster dose is given after 10 years.

22.2.11. Feeding Problems

Feeding of normal baby:

The mother should be instructed to start feeding the baby within one to two hours after
delivery. The first feed should be the breast milk and there is no need for any test feed with
water or dextrose. The first few feeds should be supervised and records of feeds should be
documented.

Feeding of a preterm, small for date (SGA) and infants of diabetic mothers (IDM):
Infants less than 1500 grams should receive all the fluids and calories intravenously for the
first 24 hours. SGA and IDM babies should be started feeding by one hour of age, First few
feeds may be given by NG tube and they should be fed at least two hourly if sucking is poor.
Once sucking is well established and blood sugar is normal these babies should be given to
the mother for supervised breast feeding.

Feeding of term asphyxiated infants:

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Mildly asphyxiated infants should feed like any healthy baby but must be closely supervised
for the first 12 hours. Babies with severe asphyxia should be started with 2/3 maintenance IV
fluids and strict intake records should be maintained routinely.

Evidence for adequate nutrition

Weight gain should be 20–30g/kg/day for premature infants and 10g/kg/day for full term
infants.

Adequate growth requires:

 100-120kcal/kg/day in term infants
 115-130kcal/kg/day for preterm infants
 150kcal/kg/day for very low birth weight infants

22.2.12. Fluid and electrolyte

Normal maintenance requirements (volume of fluid/kg/day)
 Day 1: 60 m1/kg/day
 Day 2: 80 m1/kg/day
 Day 3: 100 m1/kg/day
 Day 4: 120 m1/kg/day
 Day 5: 140 m1/kg/day
 Day 6 & above: 150 m1/kg/day

Additional allowance:
 Increase insensible water loss:
 Radiant warmer: 20 m1 /kg /day
 Photo therapy: 20 m1 /kg /day
 Increase body temperature: 10-20 m1 /kg/day

Increase loss of water from other routes:

Example: neonatal entrocolitis, GI aspirates diarrhoea. The loss in the above conditions are
variable, they should be replaced volume for volume.

Stomach contents should be replaced with half saline with KCL loss. Small intestinal contents
should be replaced with Normal saline and KCL.

22.2.13. Kangaroo mother care

Kangaroo Mother Care (KMC) is defined as early, prolonged and continuous skin to skin
contact between a mother and her low birth weight infants (LBWI), both in hospital and after
early discharge until at least the 40th week of postnatal gestational age. KMC does not need
sophisticated equipment, and for its simplicity it can be applied almost everywhere including
peripheral hospitals. Kangaroo Mother Care also contributes to the humanization of neonatal

1157
care and the containment of cost, for which reason it may also be attractive for neonatal units
in high-income countries.
Kangaroo care a program of skin-to-skin contact between mothers (or any family
member) and a LBWI is part of the revolution in the care of premature infants.
The benefits of Kangaroo Mother Care: Many studies showed that Kangaroo Mother Care
offers the preterm infants many physical and emotional benefits, which includes:
 A stable heart rate
 More regular breathing
 Improve dispersion of oxygen throughout the body
 Prevention of cold stress and also warming babies who are already in cold stress,
Kangaroo transportation where transport incubators are not there to keep the warm chain.
 Longer period of sleep (during which the brain matures).
 More rapid weight gain and earlier discharge from hospital.
 Reduction of purposeless activity which simply burns calories at the expense of infant‘s
growth and health.
 Decreased crying.
 Opportunities to breast feed and enjoy all the healthful benefits of breast milk.
 Earlier bonding

The KMC works so beautifully because of three factors affecting the infant:
 It creates conditions similar to those with which the infant had become familiar in utero,
such as the proximity of the mother‘s heart beat sounds and her voice coupled with the
gentle rhythmic rocking of her breathing
 It provides containment and allows for flexion and prevents heat loss and provides
heat from skin to skin contact.
 Protects the infant and offers a reprieve from the stressful elements of NICU.

When to Discharge from Kangaroo position:

The decision of discharging from Kangaroo position is made by the baby itself (at about the
40th week (gestational age + postnatal age) and weight of about 2000 grams. When the baby is
restless and the mother can no longer maintain the Kangaroo position, it is time to take the baby
out of the kangaroo ―pouch‖.

Further reading
Management protocol for selected Obstetrics conditions, FMOH, 2014
Standardized Treatment Guideline for Ethiopia, FMOH, 2014

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