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ALGORITHMS
President’s Message
Dear Colleagues,
It is a matter of pride and honor for me to present to you this ‘Times of Gynaecology – Decision
Tree’. It started as a thought in my mind, to put together a concise, clear and systematic algorithm
on important subjects in obstetrics and gynecology. This has germinated and bloomed into a
wonderful publication on eleven different topics being presented to you in a simple systematic
format.
75 expert gynecologists from across the length and breadth of India got together for two days and
brain stormed in groups and together - to bring out this decision tree. Two days of intense debate,
discussions, disagreements and consensus, at the end of which these algorithms were put
together. They were further modified and then are being brought to you. These of course are only
opinions of our experts and not recommendations or guidelines and are only meant to give you all
a systematic flow chart to follow, using your own expertise to make final judgements.
I would like to thank Abbott and Science Integra for felicitating these discussions and helping
integrate the entire decision tree.
I hope you enjoy reading this decision tree, as much as we enjoyed putting it together.
“The key to pursuing excellence is to embrace an organic, long-term learning
process, and not to live in a shell of static, safe mediocrity. Usually, growth comes
at the expense
of previous comfort or safety.” — Josh Waitzkin
Best wishes!
INFERTILITY ................................................................................................. 4
Menopause .................................................................................................. 17
Vaccination .................................................................................................. 35
Hypertensive Disorders
in Pregnancy ............................................................................................... 38
This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and image s of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for a ny errors, omissions or
© 2017
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, National Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
1 Luteal phase Support In Intrauterine Insemination
Preface
Intrauterine insemination (IUI) enhances the probability of pregnancy in
sub fertile couples. The success of IUI depends on various factors
including quality of the luteal phase; and deficiency in this phase is
associated with insufficient production of progesterone that is essential for
embryo implantation and maintenance of early pregnancy. The clinical
conditions that manifest as luteal phase deficiency (LPD) status are stress,
polycystic ovary syndrome (PCOS), aging, ovulation stimulation, ovulation
induction with or without gonadotropin releasing hormone (GnRH)
agonists, and assistant reproductive technologies (ART).
The medication to support luteal phase include progesterones, estrogens,
and human chorionic gonadotrophin (hCG). There is an on going debate on
optimal luteal phase support with many physicians favoring the use of hCG,
despite the risk of ovarian hyper-stimulation syndrome (OHSS).
The aim is of the FOGSI team is to uncover a protocol which is simple,
effective, and acceptable to the patients.
2 Luteal phase Support In Intrauterine Insemination
Duration
• IUI – positive
pregnancy test
to 10–12 weeks
of gestation
• IVF – 10–12
weeks of gestation
A B
IUI IVF (LPS needed
in all ART cycles)
See next
CC/ letrozole CC/ letrozole
Gonadotropin page
(not needed) + gonadotropin
MODES
Progesterone
(All routes similarly effective,
most preferred is oral)
Oral – dydrogesterone 10 mg TDS
Vaginal – MVP 200 mg TDS,
Vaginal gel 90 mg OD
3 Luteal phase Support In Intrauterine Insemination
B
IVF (LPS needed
in all ART cycles)
MODES
• HCG +
• HCG along progesterone
• Not • No beneficial
recommended effect
• Beneficial in
cycles with GnRH
agonist triggers
ART: assisted reproductive technology; CC: clomiphene citrate; GnRH: gonadotropin-releasing hormone; HCG: human chronic
gonadotropin; FET: frozen embryo transfer; IM: intramuscular; IUI: intrauterine insemination; IVF: in-vitro fertilization; LPS: luteal
phase support; MVP: micronized vaginal progesterone; OD: once daily; OPU: ovum pick-up; SC: subcutaneous; TDS: trice daily
dosing; IUI: intrauterine insemination; IVF: in-vitro fertilization.
Dusterberg B et al. All pharmacokinetics and biotransformation of Estradiol Valerate in Ovariectomized women.
*
INFERTILITY
Moderators : Dr. Rishma Pai, Dr. Sudha Tandon
Panel Members : Dr. Hrishikesh Pai , Dr. Nikita Lad, Dr.
Meenu Handa, Dr. Sarita Sukhija, Dr.
Kedar Padte
Preface
Infertility is the inability to achieve pregnancy after 12 months of regular,
unprotected intercourse. Infertility is estimated to affect one in seven to one
in eight couples of reproductive age, with male infertility being responsible
for 20% of the cases.
Preliminary Assessment
• Age of both partners
• Duration of infertility: duration of infertility and contraceptive use
• Lifestyle: timing of sexual intercourse, alcohol, smoking, drugs,
occupation, and stress
• Menstrual/medical/surgical/sexual history and physical examination of
both partners
• Obesity/ low body weight
Preliminary Health
• Folate
• Rubella: if negative , vaccinate the female and wait for 1 month (RCOG)
• Thyroid
• Prolactin
• Thalassemia test of either one of the partner.
• AMH and AFC are recommended and HIV, HBsAg, and Anti-HCV
are compulsory for all
A5
*NICE
6 INFERTILITY
WHO Group I WHO Group II (PCOS), normal WHO Group III (Ovarian
Low FSH & E2 FSH, Normal/high LH & E2 Failure) High FSH, Low E2
• Lifestyle changes
Gonadotropins Offer genetic testing (KT)
• Weight reduction (BMI <29)/ and
MI & DCI (optional)
• CC or Letrozole (3–6 cycles)
• If no ovulation after 3 cycles
»» Offer metformin + Consider donor oocyte
CC/Letrozole with/without IUI
IUI / IVF/ICSI »» Gonadotropins /ovarian drilling
• USG monitoring
• Offer Bariatric surgery, if BMI >35
ICSI
AMH: anti-Mullerian hormone; AFC: antral follicular count; BMI: body mass index; CC: clomiphene citrate; E2: estradiol; FSH: follicle-stimulating
hormone; LH: luteinizing hormone; MI & DCI: Myo-inositol & D-chiro-inositol; PCOS: polycystic ovary syndrome; HBsAg: hepatitis B surface
antigen; HCV: hepatitis C virus; HIV: human immunodeficiency virus; ICSI: intracytoplasmic sperm injection; RCOG: Royal College of Obstetricians
and Gynaecologists; USG:ultrasonography; WHO: World Health Organization.
7 INFERTILITY
• HSG/HyCoSy
• Hystero/laparoscopy – suspected
tubal pathology/ if no conception
after 3-4 cycles COS with/without IUI
Normal Abnormal
Timed intercourse
If corrected Corrective tubal surgery
IUI – 3-4 cycles
Not corrected
IVF/ICSI
Uterine Factors
Surgical correction of
pathology
TIC IVF
IUI Surrogacy
8 INFERTILITY
Unexplained Infertility
COS: controlled ovarian stimulation; HyCoSy: hystero salpingo contrast sonography; HSG: hysterosalpingogram;
ICSI: intracytoplasmic sperm injection; IUI: intrauterine insemination; IVF: in-vitro fertilization; TIC: timed intercourse.
Preliminary Health
• Folate
• Rubella: If negative , vaccinate the female and wait for 1 month (RCOG)
• Thyroid
• Prolactin
• Thalassemia test of either one of the partner
• AMH and AFC are recommended and HIV, HBsAg and Anti HCV
are compulsory for all
*NICE
9 INFERTILITY
Semen analysis
• The results of semen analysis conducted as part of
an initial assessment should be compared to WHO
2010 reference value in the recommendations
• If the results of the first semen analysis is
abnormal, a repeat confirmatory test should
be offered ideally after 3 months or earlier, if
there is a gross abnormality in semen report
Normal Abnormal
Antioxidants + CC
+DNA fragmentation FSH – Low FSH – High
Testosterone – Low Testosterone – Low
Testicular volume – Low Testicular volume – Low
See
next page
10 INFERTILITY
Congenital HH Adult HH
ICSI
Post-ejaculatory Positive
Obstructive urinalysis
ICSI
Negative
Infective CBAVD
If azoospermia TESE
TRUS versus Vasography
PESA, TESA Offer CFTR mutation if planning
TESE testing to female reconstructive surgery
IF female+CFTR
ICSI
test male
Palpable
Varicocele**
AMH: anti-Mullerian hormone; AFC: antral follicular count; CAVD: congenital absence of the vas deferens; CC: clomiphene citrate;
CT: computed tomography; CFTR: cystic fibrosis transmembrane conductance regulator; DNA: deoxyribonucleic acid; FSH: follicle-stimulating
hormone; HBsAg: hepatitis B surface antigen; HCV: hepatitis C virus; HCG: human chronic gonadotropin; HIV: human immunodeficiency virus;
ICSI: intracytoplasmic sperm injection; IUI: intrauterine insemination; MRI: magnetic resonance imaging; PESA: Percutaneous epididymal
sperm aspiration; RCOG: Royal College of Obstetricians and Gynaecologists; TRUS: transrectal ultrasound; TESE: testicular sperm extraction;
TESA: testicular / epididymal sperm aspiration; TSH: Thyroid-stimulating hormone; WHO: World Health Organization.
12
SCREENING IN PREGNANCY
Moderators : Dr. Narendra Malhotra, Dr. Mala Arora
Panel Members : Dr. Ranjana Khanna, Dr. Pragya Mishra,
Dr. Abha Rani Sinha, Dr. Navneet Magon,
Dr. Ganpat Sawant
Preface
Pregnancy is a normal physiological process and any intervention that is
offered to the pregnant or expectant mother should have known benefits and
should be acceptable to the woman. Screening in pregnancy is the process of
surveying a population of women with markers and defined screening cut-off
levels, to identify those at higher risk for a particular disorder. All pregnant
women, regardless of age, should be offered, through an informed counselling
process, the option of a prenatal screening test for the most common clinically
significant fetal aneuploidies in addition to a second trimester ultrasound for
dating, assessment of fetal anatomy, and detection of multiples.
During the entire antenatal period, clinician should remain alert to risk factors,
signs or symptoms of conditions that may affect the health of a pregnant
woman such as pre-eclampsia and diabetes. Screening tests assess the
degree of risk, or chance, of a fetus that may potentially have certain common
birth defects, but there is no certainty that the baby born will actually have the
problem. If a pregnant women has a positive screening result, she should
have genetic counseling and undergo one of two invasive diagnostic tests,
that have greater accuracy and reliability than genetic screening alone.
The FOGSI protocol has been arrived at after careful consideration of
evidences to achieve best practice for screening of women of all
pregnancies and provides information for decision making about
appropriate treatment in specific circumstances.
13 SCREENING IN PREGNANCY
SCREENING IN PREGNANCY
(Recommended three antenatal visits, [preferable 5])
At booking general physical exam heart/lungs/breast/abdomen
In all trimesters
• Maternal weight/BMI
• Blood pressure/mean arterial pressure
• Urine dipstick (albumin, sugar)
Antenatal Screening
Confirm pregnancy
(Clinically/β HCG/
UPT/Ultrasound
Viability Test
(Fetal heart rate)
(Clinical/Fetal Monitor/USG)
Pregnancy
First -trimester
Blood group
Wt, BP, Hb and Rh (Both Urine — R/M, VDRL, HpB, HIV, TSH; DIPSI
Intermediate risk
High risk <1:100 Low risk > 1:1000
1:101 – 1: 999
BP: blood pressure; CBC: complete blood count; Hb: hemoglobin; HCV: hepatitis C virus; Second trimester
HPLC: high performance liquid chromatography; MSU: midstream urine; NT: nuchal anomaly scan
translucency; R/M: routine microscopy; OGTT: oral glucose tolerance test; TSH: thyroid
stimulating hormone; UPT: uterine pregnancy test; USG: ultrasonography; Wt: weight.
ANTENATAL CHECKLIST
Weight BMI
Blood pressure Mean arterial pressure
Hemoglobin Complete blood count/
Peripheral smear/Hb
Electrophoresis/ HPLC
Blood group ABO & Rh
(both partners)
Urine routine MSU + culture
VDRL/ Hep B / HIV HCV / Rubella IgG
TSH Thyroid function test / thyroid
antibodies
Vitamin D
DIPSI test 75 gms 2 hours blood HbA1C / OGTT/ 6 point blood
sugar sugar test
Dating scan + NT Cervical length
Double marker (free HCG + Uterine artery Doppler
PAPP A1 ) NIPT
(Contingent Screen2) Placental Growth Factor1 (PLGF)
Per speculum exam Pap smear, bacterial vaginosis
and chlamydia screen
1Low levels predict pre ecclampsia
2 Low risk no further test (1 : 1000)
Intermediate risk (101 : 999) to proceed to second trimester screening vs NIPT
High risk (1 : 100) to go for NIPT / CVS
15 SCREENING IN PREGNANCY
SECOND TRIMESTER
Pregnancy
Second-trimester
(18-24 weeks)
Recommended Preferable
Repeat blood tests NIPT
Hemoglobin Uterine artery Doppler
TSH 2D-4D scan
Urine dipstick Fetal echocardiography
DPISI
Quadruple/triple marker
Anomaly scan
Cervical length
DIPSI: Diabetes in Pregnancy Study Group India; HbA1c: hemoglobin A1c; NIPT: non-invasive prenatal tests; TSH: Thyroid-stimulating hormone.
16 SCREENING IN PREGNANCY
THIRD TRIMESTER
Pregnancy
Third-trimester
24 weeks onwards
Recommended Preferable
Repeat blood tests DIPSI
Hb Color Doppler
TSH CTG (NST)
Urine dipstick Modified biophysical
DPISI profile
Quadruple/triple marker Doppler velocimetry
Anomaly scan
Cervical length
BP: blood pressure; BMI: body mass index; CBC: complete blood count;, CTG (NST): ; CVS: ; DIPSI: ; GCT: Glucose Challenge Test;
Hb: hemoglobin, HbA1C: hemoglobin A1C, Hep B: hepatitis B virus, HCV: hepatitis C virus; HIV: human Immune deficiency virus;
HPLC: high performance liquid chromatography; HbA1C: hemoglobin A1C, R/M: Routine microscopy, MAP: , MSU: midstream urine;
NT Scan: nuchal translucency scan; NIPT: Non invasive prenatal testing; OGTT: Oral glucose tolerance test; PAPP A: pregnancy-
associated plasma protein A; PlGF: placental growth factor; TSH: thyroid stimulating hormone; VDRL: Venereal Diseases Research
Laboratory Test; Wt: weight.
17
Menopause
Moderators : Dr. Maninder Ahuja / Madhuri Patel
Panel Members : Dr. Niranjan Chavan, Dr. Mandakini Megh,
Dr. Vineet Mishra, Dr. Rajnikant Contractor
Preface
Menopause is a biological stage in a woman’s life marked by cessation of
menstruation and associated with infertility. A woman not menstruating for
one year after her last period is termed as being postmenopausal. Reduced
estrogen levels associated with menopause affects the body by causing
vasomotor, musculoskeletal, urogenital, and psychological symptoms. It
also has a profound effect on the bone and the cardiovascular system,
which can significantly affect a woman’s quality of life. Therefore, women
need to know about the available therapeutic options, their risks and
benefits in order to make an informed decision for effective treatment. The
following flowchart helps in the diagnosis and guides the process of the
management and treatment of menopause symptoms.
18 Menopause
MENOPAUSE
• Define menopause
• Types of menopause
• Diagnosis of menopause
• Initial assessment at menopause
• Classifying women to plan management
• MHT
Menopause
Presentation of patient.
Symptoms in woman
AMH: anti-Mullerian hormone; CHD: coronary heart disease; FSH: follicle-stimulating hormone; H/T: hypertension; LH: luteinizing hormone;
MHT: menopausal hormone therapy; MS: metabolic syndrome; POF: premature ovarian failure.
19 Menopause
Menopause definition
Hormonal changes
• FSH ↑
• LH ↑
• Antimullerian hormone (AMH) ↑
• Inhibin↑
• Estradiol↓
• Estrogen becomes main hormone
• Ovaries go on producing androgens – androstenedione till 65 years↓
Presentation
Management of symptoms
Early symptoms
Vasomotor: Hot flashes, night sweats mood disturbances, and irritability
Menstrual: Irregular cycles, first short and then long AUB
Intermediate symptoms
Musculoskeletal
Aches and pains, arthralgia
Urogenital atrophy, itching of vagina, dryness, frequency of urine,
dyspareunia, and low libido
Late symptoms
Osteoporosis, metabolic syndrome, CHD, cancers, and Alzheimer’s disease
Personal history:
• Last menstrual period, age of menarche
• PCOD, OH, hypertension, PIH, diabetes , CHD,
fracture, thromoboembolic, cancer
• Diet and physical activity,
• Sleep, sexual diseases, CKD or liver disease,
• Gall bladder or pancreas problem
• OCP use or MHT use or OCT,
• Alcohol or drug use,
• Eye or hearing problem
Universal assessment
General
Loose clothing, dress in layers, cool air, and avoid hot spicy food
Menopausal hormone therapy
Within 10 years of menopause or before 60 years of age
After counseling and assessment for risk of MHT, stroke, DVT or any
other co-morbidity where MHT is contraindicated.
Co-morbidities
Call for re-evaluation every year and loss of height is very important
23 Menopause
MHT
If indicated
• For hot flushes , night sweats, irritability, insomnia because of hot
flushes
• For urogenital syndrome vaginal route
• For prevention of osteoporosis
Types of MHT
Routes of administrations
How MHT
Estrogens salts
Natural estrogens
• 17 β-estradiol tab (17 b-estradiol has minimal liver load as compared to
estradiol valerate and CEE)
• Estradiol valerate tab
• Estrone cream
• Estriol
• CEE tablets and vaginal cream
Synthetic estrogens
• Ethinyl estradiol is 750–1,000 times more potent than natural estrogens
• Enhances hepatic effects that increases synthesis of clotting factors,
angiotensin, and SHBG
Progesterone
Progesterone
Duration of therapy
Premature menopause
• Up to natural age of menopause
• Further continuation of therapy according to the indication and need
Natural menopause
• Safety data of EPT therapy with CEE+MPA is 3–5 years, with ET
safety data for use is 7 years of treatment with 4 years follow up
• 17-b estradiol and dydrogesterone can be given 3–5 years
Contraindications to MHT
Non-hormonal treatments
Dosage of MHT
Choice of
• Ultra low dosage
• Low dosage
• Normal dosage
Dosage
Progesterone
• Dydrogesterone
• MPA
• Micronised progesterone
• Norethisterone
• Cyproterone acetate
• Dienogest
• Select dydrogesterone or micronized progesterone, early reports of
neutral effect on breast cancer
• Metabolically friendly
Androgenic progesterone
• Blunt positive effect of estrogens on lipids, implicated in breast cancer,
and CVD
• Used for hemostatic control in DUB
29 Menopause
• During perimenopause
• Contraception
• Control of bleeding: AUB
• Women with side effects for oral progestogens
Dose of progesterone
• A drug that acts like estrogen on some tissues but blocks the effect of
estrogen on other tissues
• Used in osteoporosis, positive effect on bone
30 Menopause
Estrogen-androgen combination
Endometrial surveillance
Check list
Risk of DVT
Risk of Alzheimer
Bibliography
AUB: abnormal uterine bleeding, CEE: conjugated equine estrogen CHD: coronary heart disease, CKD: chronic kidney disease,
CVD: cardiovascular disease, DUB: dysfunctional uterine bleeding, DVT: deep vein thrombosis EPT: estrogen and progesterone
therapy Hb: hemoglobin, HbA1c : Hemoglobin A1c; HPE: histopathological evaluation IUD: Intrauterine devic KFTs: Kidney
functions tests, LFTs: liver function tests, MHT: menopausal hormone therapy, OCP: Oral contraceptive pill, OPD: outpatient
department; PAP/LBC: Pap smear and liquid-based cytology; PCOD: Polycystic ovary syndrome, PIH: pregnancy-induced
hypertension, POF: premature ovarian failure; SHBG: Sex hormone–binding globulin TSEC: Tissue-selective estrogen complex
TSH: Thyroid-stimulating hormone TVS: Transvaginal sonography; VIA: visual inspection with acetic acid; VMS: vasomotor
symptoms.
35
Vaccination
Moderators : Dr. Sarita Bhalerao, Dr. Neerja Bhatla
Panel Members : Dr. Kawita Bapat, Dr. Arun Nayak, Dr.
M C Patel, Dr. Krishnendu Gupta
Preface
Immunization of a pregnant woman enables a number of important health
benefits for both mother and the baby. Vaccine-preventable diseases have
been shown to cause significant morbidity and mortality among maternal,
neonatal, and young infant. Furthermore, some of these infections can be
serious enough to waste pregnancy, or affect the infant post delivery.
Vaccination of the pregnant women has been shown to strengthen her
immune systems to fight off serious infectious diseases. It helps in
protecting the mother from infections and this immunity passes to her infant
during pregnancy, keeping the child safe during the first few months of life.
The fear that fetus can be at risk after vaccination of the mother during
pregnancy has no scientific bases. There have been no study to show if there
is risk for fetus after maternal vaccination with inactivated vaccines or
bacterial vaccines or toxoids. Since live vaccine poses a theoretical risk to a
developing fetus, all live vaccines should be avoided during pregnancy.
Vaccination in Adult
Women
HPV
Pregnancy
Tdap
• Can replace TT (wherever available)
• Single dose replaces both doses of TT: Administered 28–36 weeks, if previously immunized
• If not immunized: 2 doses of TT and 1 dose of Tdap.
37 Vaccination
Older women
Influenza vaccine
CounselLing
• The lady must be counseled properly clearly explaining the benefits and
side-effects of the concerned vaccine; consent must be obtained.
• AEFI (Adverse Events Following Immunization) reporting: Risk
of anaphylaxis must be explained.
HPV: human papillomavirus; IgG: immunoglobulin G; MMR: Measles, mumps, and rubell.
Documentation must be made regarding that the “patient and accompanying relatives, if present, were properly counseled
about the potential benefits and risks of the vaccine prior to administration”.
38
Hypertensive Disorders in
Pregnancy
Moderators : Dr. Suchitra Pandit / Dr. Pratima Mittal
Panel Members : Dr. Ashis Mukhopadhyay, Dr. Atul Munshi,
Dr. Sudhir Shah, Dr. Nita Thakre,
Dr. Alpesh Gandhi
Preface
Hypertensive disorders during pregnancy (HDP) are a major cause of
maternal morbidity and mortality and are known to complicate about 3-10% of
all pregnancies. About 10-15% of all maternal deaths are contributed by
hypertensive disorders of pregnancy especially in the developing world.
Preeclampsia and eclampsia has been seen to occur, most often after 20
weeks of gestation.
A noteworthy feature is that the prevalence of hypertension during
pregnancy has been seen to be significantly higher in women with
previous history of cesarean section (17.6 vs 6.5%) as compared to
women with no history of cesarean section. A significantly higher rate of
prior cesarean section were recorded in women with chronic
hypertension as compared to normotensive women.
The complications of HDP which are responsible for maternal morbidity and
mortality include cerebro-vascular accidents, acute renal failure and pulmonary
edema, all of which are potentially preventable. So, the need of the hour is
to enable an effective screening strategy to diagnose hypertension
during pregnancy and also to device a comprehensive protocol for
management of such cases.
39 Hypertensive Disorders in Pregnancy (HDP)
Non-Severe Severe
Management
Monitoring
Non-Severe Severe
Maternal Fetal
• Severe disease • Severe FGR
• Imminent • Poor NST
eclampsia • Fetal
• HELLP syndrome compromise
• Abruptio
Non-Severe Severe
NOTE :
• No sublingual Nifedipine
• No Frusemide
• Avoid drastic and sudden lowering of BP.
• Can use Nifedipine + Magnesium sulphate, but with caution
• Prior to transfer to tertiary care start IV line and give Inj magnesium
sulphate
APLS: antiphospholipid antibodies; BP: blood pressure; CBC: complete blood count; CRP: C-reactive protein; CKD: chronic kidney
disease; DBP: diastolic blood pressure; FGR: fetal growth restriction; HDP: hypertensive disorders of pregnancy; HELLP: Hemolysis,
elevated liver enzymes, low platelet count syndrome; LDH: lactate dehydrogenase; LFT: liver function tests; LSCS: lower (uterine)
segment Caesarean section; NST: Non-Stress test; RFT: renal function tests; RUQ: right upper quadrant; SGPT: serum glutamic
pyruvic transaminase; USG: ultrasonography.
43 Hypertensive Disorders in Pregnancy (HDP)
• Monitor vital sign (pulse, BP & respiration > 16/min), patellar reflexes and
urinary output > 30ml/hr
• Maintain strict fluid balance chart to prevent fluid overload.
• Provide maintenance dose of anti-convulsive and anti- hypertensive drugs
• Auscultate lung base hourly for rales ( indication of pulmonary edema)
• Plan delivery, Monitor progress of labour, LSCS for obstetric indication
44
Postpartum hemorrhage
Moderators : Dr. Vanita Raut, Dr. S. Shanthakumari
Panel Members : Dr. M G Hiremath, Dr. Saraogi,
Dr. Mahesh Gupta, Dr. Dipak Bhagde,
Dr. M. Krishna Kumari
Preface
Postpartum hemorrhage is generally considered as ≥500 ml of blood loss
within 24 hours after birth, while severe PPH is blood loss ≥1000 ml within
24 hours. It is the most common cause of maternal death worldwide. Most
cases of PPH associated morbidity and mortality occur in the first 24 hours
following delivery, whereas other few cases of PPH also occur due to
abnormal or excessive bleeding from the birth canal between 24 hours and
12 weeks postnatally. Blood loss post-delivery is rarely measured in clinical
practice, hence there is lack of clarity. Measuring blood loss may improve
the care and outcome for women. Grand multiparity and multiple gestations
are known risk factors for PPH. Moreover, it may occur in women without
identifiable clinical or historical risk factors. Therefore, it is recommended
that active management of the third stage of labor should be offered to all
women during childbirth. Preventing delays in the diagnosis and treatment
improves the chances of survival. The following demonstrates the “care
pathway” for management of PPH, as a practical guide for clinicians.
45 Postpartum hemorrhage (PPH)
Definition
Any bleeding after the delivery of a baby that may affect the hemodynamic
status/vital parameters of the mother.
Blood loss: Vaginal delivery >500 ml; caesarean section >1000 ml
Types
• Early
• Late (primary/secondary)
Prevention of PPH
Prevention of PPH
• Uterine massage
• Bimanual uterine compression-AORTIC Compressium
• Drugs
• Uterotonics
»» Oxytocin
»» 10U IM / 5U IV followed by 20–40U IV in 500–1000ml at
125mL/hr »» Ergometrine every 5 mins, 5 doses, 0.25–0.5mg
IV/mcg IM »» Misoprostol 400–800 mcg rectal
»» Carboprost 0.25 mg IM every 15 mins, max 8 doses
• Tranexamic acid 1g IV
• Surgical intervention
»» Removal of retained placenta
»» Repair of tears
»» Uterine packing
aPPT: activated partial
thromboplastin time; BP: blood
»» Balloon tamponade
pressure; CBC: complete blood »» Brace sutures
count; FFP: fresh frozen plasma; »» Step in devascularisation
ICU: intensive care unit; OT: »» Arterial embolization
operation theater; PT-INR: • Hysterectomy
prothrombin time-and
international normalized ratio.
47
Polycystic ovary
syndrome
Moderators : Dr. Jaideep Malhotra, Dr. Kuldeep Jain
Panel Members : Dr. Vinita Singh, Dr. H. P. Pattnaik,
Dr. A. Charmila, Dr. Seema Pandey,
Dr. Sushma Pandey
Preface
Polycystic ovary syndrome (PCOS) is one of the most common endocrine
disorders in women of reproductive age with prevalence estimates ranging from
2.2% to as high as 26%. This syndrome is a common disorder complicated by
hyperandrogenism and chronic anovulatory infertility associated with clinical
manifestations of oligomenorrhoea, hirsutism, and acne.
Women having PCOS are generally obese, exhibit an adverse cardiovascular
risk profile, and have a higher prevalence of impaired glucose tolerance, type
II diabetes, and sleep apnoea. These patients are also prone to high incidence of
cardiometabolic syndrome involving hypertension, dyslipidaemia, visceral obesity,
insulin resistance, and hyperinsulinaemia. Gynaecologists are observed to
frequently diagnose PCOS; therefore in order to offer a holistic approach
to the disorder, it is essential to have a good understanding of the long-term
implications of the PCOS diagnosis. The healthcare professionals need to educate
the women with PCOS regarding the possible long-term health risks and positive
effects of lifestyle modifications. Those with PCOS before pregnancy should be
diagnosed for gestational diabetes. The algorithm provided in
this chapter guides through the process of diagnosis, investigations and
management of adolescents, women and postmenopausal women with PCOS.
48 Polycystic ovary syndrome
PCOS
• Commonest endocrinopathy of
reproductive age group
• Worldwide prevalence of 5–15%.
• Four phenotypes
• Major symptoms related to-
hyperandrogenism, ovulatory
dysfunction, and polycystic
ovarian morphology
• Perimenopausal
Adolescent PCOS Adult PCOS • Menopausal
• PCOS
• Diagnosis
• Investigations
• Management
• Long-term
consequences
• Follow up
49 Polycystic ovary syndrome
Adolescent PCOS
Adult PCOS
Diagnosis
• Rotterdam’s criteria-2/3
• FSH, LH, TSH, E2 and prolactin to rule
out other causes
• Biochemical determination of Not seeking fertility
testosterone. Grade , Evidence level 4
• AMH Grade B, Evidence level 4
• 17 hydroxy progesterone in obese
and hirsute
Lifestyle modification by
• Progesterone withdrawal bleeding
diet and exercise (like in
Grade B, evidence level 4
adolescents)
Identification of metabolic
syndrome markers and
treat them properly.
Menstrual irregularities
also to be treated similarly
as adolescents.
Ovulation induction
Ovulation Induction
LOD (surgical
Medical management
management)
• Clomiphene citrate (CC)- • Letrozole/ AI- 2.5- 5 mg/ • Not a first line management
first line option for OI. day for 3-6 cycles • Recommended mode in
dosage 50-150 mg x 3-6 • Best response in non- women with CC resistance
cycles, with per cycle obese PCOS and hyper LH PCOS, before
increment of 50 mg. • And hyper LH PCOS. gonadotropin stimulation.
• Ultrasound monitoring • CC failure • Number of punctures
with CC recommended according to the size of
• Gonadotropin failure
to see the response and ovaries but not to exceed
reduce the chances of • Very soon may replace
4-6 holes/ovary. Grade B,
multiple gestation and CC as first-line
Evidence level 4
hyper-stimulation. management of OI?
• No other factor
• In unavailability of contributing to infertility
USG, LH kit monitoring CC failure / CC resistance /
should be present.
recommended. no conception
Peri-menopausal/
menopausal PCOS
@
Kalra B, Kalra S, Sharma JB. The inositols and polycystic ovary syndrome. Indian J Endocr Metab. 2016;20:720-4.
*Regidor PA, Schindler AE. Myoinositol as a safe and alternative approach in the treatment of infertile PCOS women: A German Observational Study. Int J
Endocrinol. 2016;2016:9537632.
** Colazingari S, Treglia M, Najjar R, et al. The combined therapy myo-inositol plus D-chiro-inositol, rather than D-chiro-inositol, is able to improve IVF
outcomes: Results from a randomized controlled trial. Arch Gynecol Obstet. 2013;288(6):1405–411.
# Papaleo E, Unfer V, Baillargeon JP, et al. Myo-inositol in patients with polycystic ovary syndrome: A novel method for ovulation induction. Gynecol Endocrinol.
2007;23(12):700–03.
$ Minozzi M, Nordio M, Pajalich R. The Combined therapy myo-inositol plus D-Chiro-inositol, in a physiological ratio, reduces the cardiovascular risk by
improving the lipid profile in PCOS patients. Eur Rev Med Pharmacol Sci. 2013;17(4):537–40.
AI: Aromatase Inhibitor; AMH: anti-Mullerian hormone; BMI: body mass index; COCs: combined oral contraceptive; E2: estradiol;
EE: ethinylestradiol; FSH: follicle-stimulating hormone; GTT: glucose tolerance test; HPE: histopathological evaluation; IVF: in-vitro
fertilization; LH: luteinizing hormone; LOD: laparoscopic ovarian drilling; OGTT: oral glucose tolerance test; OI: Ovulation Induction;
PCOM: polycystic ovarian morphology; TSH: Thyroid-stimulating hormone; TVS: Transvaginal sonography; USG: ultrasonography.
54
Reversible
contraception practice
Moderators : Dr. Ritu Joshi, Dr. Reena Wani
Panel Members : Dr. Shyamal Sett, Dr. Archana Baser,
Dr. Tarini Taneja, Dr. Komal Chavan,
Dr. Monika Doshi
Preface
Unintended pregnancies have significant social and economic consequences.
The effectiveness of different currently available methods in preventing
pregnancy varies widely. It is generally accepted that long-acting reversible
contraceptives (LARCs), including intrauterine devices (IUDs), and progestogen
implants, are most effective apart from permanent sterilization methods such as
vasectomy and tubal ligation. LARCs are safe and highly effective for women in
reducing unintended pregnancy and abortion rates due to their long duration of
action and requirements of minimal adherence.
Ovulation occurs at a mean of 39 days post-partum in non-lactating women,
which increases the risk of unintended and short-interval pregnancy. Around
70% of pregnancies are unintended during the first year post-delivery.
Therefore, use of reversible contraceptive methods can provide several
potential benefits and help in lowering the rate of unintended pregnancy and
avoiding short-interval pregnancy.
Before selecting a post-partum reversible contraceptive method, women
should be counseled prenatally, including counseling regarding the
advantages, risks of IUD expulsion, as well as contraindications. Therefore,
LARCs are recommended as effective means of contraception without its
impact on future fertility. The algorithms provide a process for availability,
methods, and selection of modern contraceptive options.
55 Reversible contraception practice
Selection of Modern
Contraceptives
Oral Non-Oral
Short-term reversible Long-acting reversible
• Hormonal
• Combined
• Progesterone
Administered by whom?
• As back-up, EC
• Extended use-algorithm
for OCS
Medical/Paramedical/
Self
Midlevel practitioner
Vaginal ring
Limited duration Extended duration
Combined
hormonal
Injectable IUD
Progestogen only
Non hormonal
Progestogen only Copper
Transdermal DMPA • Short duration
Injectable SC Hormonal
• LNG-IUS
Implants
Combined hormonal
POP
Check MEC
Condoms Diaphragm
Intrauterine Implants Injectables
with
spermicide
Copper IUD Hormonal IUD Male Female
HCP needed
Not
available
• Categorize according to
patient need and MEC
1. Adolescents
2. Medical disorders
3. Postpartum/post aborted
4. Perimenopausal
5. Special categories
C/I: contraindicated; COCs: combined oral contraceptive; DMPA: depo-medroxyprogesterone acetate; EC:
emergency contraception; HCP: health care provider; IUD: Intrauterine device; LNG- IUS: levonorgestrel
intrauterine system; MEC: medical eligibility criteria; POP: progestin-only pills; SC: subcutaneous; STI:
sexually transmitted infections.
58
Ectopic pregnancy
Moderators : Dr. Alka Kriplani, Dr. Chaitanya Ganapule
Panel Members : Dr. Bijoy Nayak, Dr. Atul Ganatra,
Dr. Navina Singh
Preface
Ectopic pregnancy is a high-risk condition wherein a fertilized ovum gets
implanted outside the uterine cavity. This condition poses a significant
threat to women of reproductive age and is a leading cause of maternal
death during the first trimester. It is reported to affect around 1% to 2% of
all pregnancies. Risk factors for ectopic pregnancy include surgery or
infection that causes tubal damage, as well as maternal smoking and in
vitro fertilisation. However, the majority of women with an ectopic
pregnancy have no identifiable risk factor. Advances in diagnosis and
treatment of ectopic pregnancy have reduced the mortality rates by 50%.
First-trimester bleeding and abdominal pain may be indicative of common
symptoms of an unruptured ectopic pregnancy. It is essential to consider
ectopic pregnancy when a pregnant woman presents with these symptoms.
The details involving clinical history on pregnancy dating, the onset and
intensity of symptoms, and a review of risk factors can help in determining
the best diagnostic course, as well as the speed of processing the workup.
Noting the severity of symptoms is important; especially for those with more
severe bleeding, and hemodynamic instability. Surgical treatment may be
warranted in such cases. The following flowcharts may help in guiding the
diagnostic and treatment approaches for patients with ectopic pregnancy.
59 Ectopic pregnancy
PUL
Intrauterine
Adnexal mass Negative
pregnancy
Medical or
surgical treatment
Incidence 11/1,000
• Ampullary
• Isthmic
Classical triad • Cornual
• Amenorrhea • Interstitial
• Pain Ectopic pregnancy • Scar
• Bleeding • Ovarian
Risk factors • Abdominal
• Cervical
• History of PID
• Tubal surgery /ligation
• Previous ectopic pregnancy
• Infertility
• ART
• Smoking
• Maternal age >40
• Pregnancy with IUCD
60 Ectopic pregnancy
Ectopic pregnancy
Initial Assessment
• Vital signs
• UPT/β hCG (whenever possible)
Haemodynamically
Haemodynamically stable
unstable
Management
Indications
• Ready to come for follow up
• No significant pain
• β hCG <1500 mIU
Indications
• No significant pain
• Adnexal mass <35 mm
Medical
• β hCG :1500 to 5000 mIU
• No visible heart beat
• No intrauterine pregnancy
Laparoscopy
Surgical Laparotomy
(if laparoscopy not possible)
Salpingectomy Salpingotomy
Indications Indications
• Healthy contralateral tube Salpingotomy
• Contralateral tube damage
• No other fertility reducing With tubal repair
• Other fertility reducing
factor (in expert hands)
factors
• Family complete • Desires fertility
(Contralateral tubal
sterilization may be
offered)
F/U with β hCG after 7 days and
weekly thereafter till <5 mIU
If levels plateau/increasing
(persistent trophoblast) then
manage medically
Cervical pregnancy
Scar pregnancy
CBC: complete blood count; HCG: human chronic gonadotropin; PUL: pregnancy of unknown location; RFTs: Renal functions tests,
LFTs: liver function tests, POD: pouch of Douglas; PID: pelvic inflammatory disease; TAS: transabdominal scan; TVS: transvaginal
scan; IUCD: intrauterine contraceptive device; UPT: uterine pregnancy test.
63
Preface
Acute uterine bleeding (AUB) which is unrelated to pregnancy has been
described as “bleeding that is sufficient in volume as to, in the opinion of
the treating clinician, require urgent or emergent intervention”. Many
women of reproductive age experience acute bleeding when not pregnant,
but this aspect has not received much attention. Also, uterine hemorrhage
occurs secondary to pregnancy.
AUB
• History1
• Rule out pregnancy
• Examination
• Cervical cytology if appropriate
• CBC, TSH, USG (TVS±SIS)2,3
Endometrial
sampling Hysteroscopy Fibroid Adenomyosis
& proceed (AUB-L) (AUB-A)
Specimen Specimen
adequate inadequate Family not Family
complete complete
Medical
management Prefers to
UAE retain uterus
Myomectomy7 UAE/HIFU
Medical
management, Offer hysterectomy
COCP, Ulipristal, if family complete
GnRHa, Low dose & over 40 years
Mifepristone
No structural
problem; possibly
hormonal (AUB-
COEIN)
Medical management8,9
• Tranexamic acid
• Mefenamic acid
• COC pillsv
• LNG IUS
• Ormeloxfene
• Cyclical progesterone
(21/28 days)
• Inj DMPA
Succeeds Fails
Continue medical
management Offer endometria Offer hysterectomy if
ablative procedures if family complete and
family complete over 40 years
1History
Age, H/o amennorhoea, history suggestive of bleeding disorder, hormone intake (Progesterone/COCP/Danazol/Tamoxifen), h/o drug intake (antithrombotics etc),
risk factors eg DM, Hypertension, Obesity, Thyroid disorders.
2When to investigate?
Women 40 years, Intermenstrual bleeding, DM, Obesity, Hypertension, Prolonged unopposed exposure to estrogen
5Postmenopausal bleeding
Any postmenopausal bleeding needs an ultrasound assessment on Endometrial thickness (ET) preferably by TVS. Hysteroscopy with curettage is indicated if ET
4mm.
6Endometrial carcinoma
Tranexamic acid (may need parental) & high dose hormones (Progesterones/COCP,Estrogen)
Coagulopathy
9
CBC: complete blood count; COCP: Combined oral contraceptive pills; DMPA: depot medroxyprogesterone acetate;
GnRHa: Gonadotropin releasing hormone agonist; HIFU: High-Intensity Focused Ultrasound; LNG_IUS: Levonorgestrel intra-
uterine system; TSH: Thyroid-stimulating hormone; UAE: Uterine artery embolization; USG: ultrasonography.
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Bacterial vaginosis
checklist
BACTERIAL VAGINOSIS
CHECKLIST
Moderators : Dr. Nandita Palshetkar, Dr. Ameet Patki
Panel Members : Dr. Rajesh Modi, Dr. Sunita Arora, Dr.
Meenu Handa, Dr. Sarita Sukhija, Dr.
Pushpa Nagar , Dr. Dhanashri Natu
From left to right: Dr. Dhanashri Natu, Dr. Sarita Sukhija, Dr. Rajesh Modi, Dr. Nandita Palshetkar,
Dr. Ameet Patki, Dr. Sunita Arora, Dr. Meenu Handa, Dr. Pushpa Nagar
Preface
Bacterial vaginosis is the most common urogenital disease affecting about 19-24% of
the women during the reproductive age, and occurs as a result of imbalance in the
vaginal microbiota. Disruption of the normal Lactobacillus and subsequently increase in
predominantly anaerobic bacteria including Gardnerella vaginalis, Mycoplasma
hominis, Prevotella, and Peptostreptococcus have led to its occurrence.
Lactobacillus is associated with supporting full-term birth and healthy
pregnancy, and is the dominant microbe in the vagina of women. Hence, its
disruption increases the risk of potentially severe gynaecological and obstetric
complications. Bacterial vaginosis is associated with an elevation of cervico-
vaginal pro-inflammatory cytokines including interleukin-1 beta (IL-1β) and IL-8,
which initiates the cascade of inflammatory events involved in labour. Bacterial
vaginosis is associated with increased risk of pelvic inflammatory disease, tubal
factor infertility, late miscarriage, chorioamnionitis, premature rupture of
membranes, preterm birth, and postpartum endometritis.
Antibiotic therapy is the current treatment for bacterial vaginosis, but its
uncertainty in preventing preterm birth in women has been reported. Also,
antibiotics are unable to fully eradicate bacterial vaginosis vaginal biofilms-
associated bacteria, which can explain its high recurrence rates. Therefore,
probiotics have been suggested as an add-on to antibiotic therapy in restoring
vaginal lactobacilli and reversing bacterial vaginosis.
The flowchart created by FOGSI guides through the process of bacterial vaginosis in
terms of flora included, diagnosis, and management options in the affected women.
Best wishes!
This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
© 2018 Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for any errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
2 chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
Normal vaginal flora
Over 50 microbial species have been recovered from the vaginal tract and Lactobacillus is
the predominant species.
• Often seen in women of childbearing age and sometimes even menopausal women.
Bacterial vaginosis
• Depletion of lactobacilli population
Symptoms
• Offensive fishy smelling vaginal discharge
Signs
• Thin white, homogenous discharge coating the walls of the vagina
• No evidence of inflammation
3
Bacterial vaginosis Diagnosis
Clinical diagnosis
AMSEL’S Criteria: At least three of the four criteria are present for the diagnosis to
be confirmed.
• Homogeneous gray-white discharge
• Fishy smell ( using few drops of 10% KOH, positive whiff test)
• Vaginal pH >4.5
Laboratory diagnosis
Gram stained vaginal smear (Hay/Ison criteria, Nugent criteria)
Hay/Ison criteria:
• Grade 1 (Normal): Lactobacillus morphotypes are predominate
• Grade 3: Predominantly Gardnerella and/or Mobiluncus morpho types and few or absent
Lactobacilli.
• Grade 4: Predominantly Gram-positive cocci
• Intermediate: 4-6
4
Diagnostic and differential diagnosis algorithm
Vaginal discharge
White cottage-cheese
Gray thin, watery or
appearing, homogenously
yellowish-green
thick
Check pH
Saline microscopy
Positive Negative
PID No diagnosis
Negative
Normal
GC:Neisseria gonorrhoeae; NAAT: nucleic acid amplification test; physiological
PID: pelvic inflammatory disease discharge
5
Whom to screen?
AMSEL’S Criteria: At least three of the four criteria are present for the diagnosis to
be confirmed.
• All symptomatic patients
• Asymptomatic with high risk (previous adverse pregnancy outcome like recurrent
miscarriage, preterm delivery, preterm pre-labour rupture of membranes)
Screening Test
• Amsel’s Criteria
Complications
• Bacterial vaginosis is not a sexually transmitted but it may be associated with
sexually transmitted infections (STIs) and other genital infections.
• Increased risk of acquiring human immunodeficiency virus (HIV) in pregnant women.
6
Management
General advice: (Grade C)
7
Antenatal CARE
checklist
1
ANTENATAL CARE CHECKLIST
Moderators : Dr. Suchitra Pandit, Dr. HP Pattanaik
Panel Members : Dr. Sujata Dalvi, Dr. Geetha Balsarkar,
Dr. Vanita Raut, Dr. Anahita Chauhan,
Dr. Ritu Joshi
From left to right: Dr. Ritu Joshi, Dr. Sujata Dalvi, Dr. Suchitra Pandit, Dr. HP Pattanaik,
Dr. Vanita Raut, Dr. Geetha Balsarkar, Dr. Anahita Chauhan
1
Preface
Routine antenatal care should be provided to all pregnant women to
ensure the best health conditions for both pregnant mothers and their
fetuses during pregnancy. Antenatal care includes risk identification,
prevention and management of pregnancy-specific or other concomitant
condition, education, and health promotion.
Most guidelines recommends screening interventions that include screening for
syphilis, human immunovirus, anemia (hemoglobin levels) and pre-eclampsia and
routine ABO and RhD testing. Also, most commonly used interventional
screening include screening for fetal anomalies, Down syndrome, early
ultrasound (first and second trimester), and late ultrasound and/or Doppler.
By mapping the current guidelines and practices related to routine antenatal
care, a checklist for antenatal care has been created to suite Indian women.
This antenatal checklist offers recommendations on clinical care for all
pregnant women, but it does not offer information on the additional care that
will be required by some women such as those with cardiac diseases or
renal diseases etc.
Best wishes!
This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
© 2018 Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for a ny errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, N ational Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
2 chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
Confirm pregnancy and encourage
early registration
FIRST VISIT
RISK STRATIFICATION
LOW RISK
Refer to the low risk HIGH RISK
algorithm
3
LOW RISK PATIENTS
I II III
ADVICE SUPPLEMENTAION AND VACCINATIONS
MEDICATIONS
D: Desirable; TDaP: Tetanus, diphtheria, and pertussis ; Td: Booster vaccine for tetanus and
diphtheria *Reference: Beyer WE et al. Clin Drug Investig. 1998;15(1):1-12.
# Centers for Disease Control and Prevention Key Facts About Influenza (Flu) Available from:
https://www.cdc.gov/flu/keyfacts.htm ; accessed on 3rd January 2018)
4
LOW RISK PATIENTS LOW RISK PATIENTS
IV V
SCHEDULE OF VISITS MANAGEMENT PLAN
5
Cesarean-section
checklist
1
CESAREAN-SECTION
CHECKLIST
Moderators : Dr. Hrishikesh Pai, Dr. Sunita Tandulwadkar
Panel Members : Dr. Maninder Ahuja, Dr. Ameya Purandare,
Dr. Surveen Ghumman, Dr. Sheela Mane,
Dr. Adarsh Bhargava, Dr. Selvyapirya Sarvanan
From left to right: Dr. Ameya Purandare, Dr. Maninder Ahuja, Dr. Selvapirya Sarvanan, Dr. Sunita
Tandulwadkar, Dr. Surveen Ghumman, Dr. Adarsh Bhargava, Dr. Hrishikesh Pai
3
Preface
Caesarean section is a life-saving procedure that is widely used in the obstetric
practice. Due to the advances in anaesthetic services and improved surgical
techniques, the morbidity and mortality of caesarean procedure have reduced
drastically. However, it can cause a significant and sometimes permanent
complication, disability or death in settings that lack the facilities to conduct the
intervention safely. Caesarean sections should preferably be conducted when
medically necessary, as its impact on maternal and perinatal morbidity, pediatric
outcomes, and psychological or social well-being are unclear.
In a country that is under-resourced, we need interventions that will make a
difference, hence evidence-based strategies and interventions that reduce
morbidity and cost of operation can be beneficial to the patient. Also, the women
should be offered evidence based support to enable them to make informed
decision about childbirth with option of vaginal birth after caesarean section.
Due to the vastness of India and the variety in the types of hospital settings, the
checklist provided here may have to be individualized as demanded by
situations. However, minimum standards should be maintained, which include −
Information to woman, planned lower (uterine) segment Caesarean section,
procedural aspect, care of the woman. The checklist for caesarean provided is to
provide quick guidance in managing women scheduled for caesarean section.
Best wishes!
This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
© 2018 Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for any errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
4 These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
Definition
• Abdominal route of delivery
• When vaginal delivery is not possible not indicated
• For maternal or fetal indication
• To optimize outcome
• Elective/emergency Robson’s criteria
• After the period of viability 1 Nullipara, single cephalic, ≥ 37 weeks, spontaneous labour
Nullipara, single cephalic, ≥ 37 week
2 A. Induced
B. Caesarean section before labour
PATIENT DETAILS 3 Multipara, single cephalic, ≥ 37 weeks, spontaneous labour
Multipara, single cephalic, ≥ 37 weeks
• Age 4 A. Induced
B. Caesarean section before labour
• Parity Previous caesarean section, singleton cephalic, ≥ 37 weeks
A. Spontaneous labour
• Gestational age 5
B. Induced labour
C. Caesarean section before labour
• Single/multiple All nulliparous breeches
A. Spontaneous labour
• Unscarred/scarred 6 B. Induced labour
C. Caesarean section before labour
• Vertex/non-vertex All multiparous breeches (including previous caesarean section)
(a) Spontaneous labour
• Risk factors: Yes/no 7 (b) Induced labour
(c) Caesarean section before labour
All multiple pregnancies
A. Spontaneous labour
8
B. Induced labour
C. Caesarean section before labour
All abnormal lies (including previous Caesarean section but excluding breech)
A. Spontaneous labour
9 B. Induced labour
C. Caesarean section before labour
All singleton cephalic, ≤ 36 weeks (including previous Caesarean section)
A. Spontaneous labour
10
B. Induced labour
C. Caesarean section before labour
INDICATIONS
Maternal Fetal Others
To be ticked as appropriate
Indications for CS as per government of India guidelines to be mentioned clearly.
Refer to the links below:
http://nhm.gov.in/nrhm-components/rmnch-a/maternal-health/guidelines.html
http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/C-section_document_Low_Res_5th_Jan.pdf
Emergency Elective
To be ticked as appropriate
5
Counseling
• Counseling for indicated LSCS
• Counseling for on demand
CONSENT
• Mention if emergency or elective
• Clearly denote high risk, if any
• Indication for the same
• Type of anesthesia
• Draft of consent should include “all risks, complications and consequences”
Kindly refer to the Consent Form as per Government of India guidelines by visiting the following links:
http://nhm.gov.in/nrhm-components/rmnch-a/maternal-health/guidelines.html
http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/C-section_document_Low_Res_5th_Jan.pdf
6
Surgical techniques
1. Use a transverse lower abdominal incision.
2. Wear double gloves for LSCS, especially for women who are HIV-positive.
Postoperative monitoring
Postoperative monitoring
7
PostOPERATIVE care and recovery
• Clearly mention that its patient’s preference and not obstetrician’s decision.
8
Vaginal birth after cesarean (VBAC)
1. Indications*
• Singleton: One previous low transverse cesarean should be counseled and offered
TOLAC
• Individualize
• Even if patient not a good candidate but admitted to labor floor in active labor,
clinical judgement may be used
• Good candidates are those where balance of risk (low) and chance of success
(high) are acceptable to patient and provider
• Decisions surrounding TOLAC should include discussion of future pregnancies
2. Contraindication*
9
Hyperglycaemia
in Pregnancy
1
HYPERGLYCAEMIA
IN PREGNANCY
Moderators : Dr. Parag Biniwale, Dr. Suvarna Khadilkar
Panel Members : Dr. Shanthakumari, Dr. Manavita Mahajan,
Dr. Meenakshi Ahuja, Dr. Lata Rajoria
From left to right: Dr. Manavita Mahajan, Dr. Suvarna Khadilkar, Dr. Parag Biniwale,
Dr. Meenakshi Ahuja, Dr. Shanthakumari, Dr. Lata Rajoria
1
Preface
Hyperglycemia in pregnancy is the most common metabolic disorder of
pregnancy. This condition is highly associated with the risk of adverse
perinatal outcomes including cesarean section, induction of labor, large for
gestational age, macrosomia, and infant adiposity.
In addition, abnormal high blood glucose during pregnancy is associated with
an increased risk of long-term ill-health outcomes in the mother (type 2
diabetes and cardiovascular disease) and infants (obesity, neural tube
defects, and associated cardiometabolic risk).
Oral glucose tolerance test is the diagnostic test of choice that is usually
administered during 24 and 28 weeks of gestation. Risk factors that are
associated with this condition include physical inactivity, body mass index
(BMI) ≥30 kg/m2, hypertension, triglyceride level >250 mg/dL, family history of
diabetes, polycystic ovary syndrome, and maternal age ≥40 years.
As the prevalence of hyperglycemia in pregnancy and its adverse influence on
perinatal outcomes is increasing, clinicians must aim to reduce the hyperglycemia
and also the risk of adverse outcomes. Diet and lifestyle modification is highly
recommended as the first-line treatment, but additional pharmacological intervention
with oral hypoglycemic agents and insulin is required for severe cases.
Self-monitoring of glucose levels is necessary, particularly in women undergoing
pharmacological treatment. Understanding the increased risk of adverse outcomes
associated with high glucose level in pregnancy, the following protocol from FOGSI
provides an approach to achieve normal glycemia supporting pregnant women to
live healthy.
Best wishes!
This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
© 2018 Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for a ny errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
2 These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
Prevention
• Identify high risk group - e.g. obese, adolescents with polycystic ovary
syndrome (PCOS)
• Preconceptional care: Especially for high risk group (obese/PCOS/family history
of diabetes/gestational diabetes in previous pregnancy/comorbidities
• Women planning to conceive: Give folic acid and vitamin B12 supplements
Hyperclycaemia in pregnancy
Hyperclycaemia in pregnancy
Gestational diabetes
Diabetes in pregnancy
mellitus
Maternal issues
Maternal Risk
3
Diabetes in Pregnancy Study Group India (DIPSI)
In the antenatal clinic, a pregnant woman after undergoing preliminary clinical examination, has to
be given a 75 g oral glucose load, without regard to the time of the last meal. A venous blood
sample is collected at 2 hours for estimating plasma glucose.
Advantage: The pregnant women need not be fasting. Causes least disturbance in a pregnant
woman’s routine activities. Serves as both screening and diagnostic procedure.
Manage as GDM as per guidelines Repeat testing at 24-28 weeks DM: diabetes mellitus; GDM: gestational
diabetes mellitus, PG: plasma glucose.
4
Medical management
Maternal Risk
Plasma Glucose 140-199 mg/dl Medical nutrition therapy
Plasma Glucose >199 mg/dl Medical nutrition therapy + Insulin
After 1 week
Fasting Plasma Glucose target ~ 90 mg/dL
2-hr Post-Prandial Glucose target ~ 120 mg/dL
Fetal risks
Fetal risk
Spontaneous abortion Congenital malformation
Foetal monitoring
First trimester Clinical exam, dating scan, nuchal translucency
(NT) scan + biochemical screening, uterine arteries -
prediction of preeclampsia umbilical arteries, middle
cerebral artery (MCA) - for the detection and monitoring
of intrauterine growth restriction
Second trimester Clinical exam, anomaly scan 19 weeks, triple/quadruple
marker if not screened earlier, amniotic fluid index (AFI),
foetal echo 22 weeks
Third trimester Clinical exam (fundal height, abdominal girth), growth
scans 28, 32, 36 weeks, colour doppler as indicated,
AFI, non-stress test (NST) 32 weeks onward, if on
insulin
Assess EBW at 38 weeks Role of steroids: betamethasone to enhance lung
maturity
5
Glycaemic control
Medical nutrition therapy: Lifestyle management, diet,
exercise Oral antidiabetics: Metformin, glyburide Insulin
Table 1. Pragmatic use of metformin in mild GDM$ , based on biopsychosocial health model
Domain Clinical situations
Contraindications
General All contraindications to metformin use in non-pregnant individuals
Pregnancy Ketonuria
specific Any evidence of maternal distress
Any evidence of fetal distress
Indications As monotherapy
Biological GDM not responding to medical nutrition therapy
GDM detected during late third trimester
Poor compliance with the treatment plan when the treatment plan
includes insulin
Lack of skills for self-management with insulin therapy and monitoring
As combination therapy, with insulin
Uncontrolled hyperglycemia, not responding to optimized insulin regimes
Unwanted weight gain with insulin therapy
Psychological If the suggestion of insulin causes extreme psychological stress
When suggestion of insulin causes patient to reduce nutritional intake in
order to maintain glycemia
Social If the suggestion of insulin causes extreme family/social stress
Financial burden
In health-care settings where insulin is not available or accessible
In health-care settings where regular glycemic monitoring is not feasible
Precautions Regular fetal surveillance
Regular maternal surveillance
Glucose loweringObstetricinmonitoringpregnancy
Medical monitoring
$An abnormal result on an oral glucose-tolerance test but a fasting glucose level below 95 mg/dl (Ref.: Landon et al.).
GDM: Gestational diabetes mellitus.
Degree of hyperglycemia + + ++
Predominantly fasting +
hyperglycemia
Predominantly post- + +
prandial hyperglycemia
FBG <95 mg/dl & 2 hrs FBG <95 mg/dl & 2 hrs FBG 95 mg/dl & 2 hrs
PPPG <120 mg/dl PPPG 120 mg/dl PPPG 120 mg/dl
Continue same dose of Increase dose of insulin Give Inj. Insulin 2 dose pre
insuli + MNT by 2 U+MNT breakfast - by 4 U
FBG <95 mg/dl & 2 hrs FBG <95 mg/dl & 2 hrs FBG 95 mg/dl & 2 hrs
PPPG <120 mg/dl PPPG 120 mg/dl PPPG 120 mg/dl
7
38-39 weeks
Poor control
Poor complicance Yes
Previous stillbirth
Vascular disease
No
8
New born and postpartum care
New born care Postpartum care
• Be careful - traumatic delivery • Breast feeding at earliest
• Hypoglycaemia • W/F infection
• RDS • Close monitoring of BSL, if on insulin
• Hyperbilirubinaemia • BSL F / PP on D3 if on MNT / OAD
• At 6 weeks - OGCT (DIPSI)
• Counsel for lifestyle , diet, exercise
• Fastinv plasma:>126 mg/dl
• 75 g OGTT 2 hour plasma glucose
»» Normal: <140 mg/dl
»» IGT: 140-199 mg/dl
»» Diabetes: >200 mg/dl
Hyperglycemia in pregnancy
HIP
Postpartum contraception
Barrier IUD - Cu / LNG
9
MANAGEMENT OF
LABOUR
1
MANAGEMENT OF LABOUR
Moderators : Dr. Pratima Mittal, Dr. Shalini Rajaram
Panel Members : Dr. Veena Acharya, Dr. Prabha Luhadia, Dr.
Usha Shekhawat, Dr. Niranjan Chavan, Dr.
Mahesh Gupta
From left to right: Dr. Mahesh Gupta, Dr. Prabha Luhadia, Dr. Veena Acharya, Dr. Usha
Shekhawat, Dr. Pratima Mittal, Dr. Niranjan Chavan, Dr. Shalini Rajaram
1
Preface
The World Health Organization (WHO) has defined normal birth as
“spontaneous in onset, low-risk at the start of labor and remaining so
throughout labor and delivery. The infant is born spontaneously in the vertex
position between 37 and 42 completed weeks of pregnancy. After birth,
mother and infant are in good condition.”
The process of labour and delivery has been divided into three stages and
each stage carries specific risks to both mother and infant if delay is not timely
identified. Hence, it is absolutely essential that management protocols are
followed closely.
For timely identification of complications, the available management tools
must be utilized effectively and in a manner that conforms to specific criteria.
These management tools are all based on regular clinical assessment of the
pregnant woman supplemented by expected progress of labour.
This management of labor algorithm provides recommendation for
intrapartum management of women who are expected to have a normal birth.
There are a number of options available for managing these women, but
have insufficient clinical evidence for making strong recommendations for a
specific approach. Hence, our approach is based on our clinical experience,
data from observational studies, international guidelines, and expert opinions.
Best wishes!
This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
© 2018 Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for any errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
2 These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
INITIAL ASSESSMENT
Booked/unbooked
History
Calculate POG by LMP
Examination
Identify if
No Patient is for
any high
identifiable LSCS OBSERVE
risk factor
high risk absolute (not in LR)
maternal/
factor indication
fetal
3
MANAGEMENT OF 1ST STAGE OF LABOUR
1st Stage of labour: Till full dilatation of cervix
Goal: Watchful expectancy and careful monitoring
Oxytocin Watchful
Review progress after 4 hours
augmentation expectancy
No or delayed progress
4
MANAGEMENT OF 2ND STAGE OF LABOUR
2nd Stage of labour: From full dilatation to delivery of the foetus
Re evaluate
Partogram charting • Absent FHR
• Hourly pulse, BP and temperature • Abnormal FHR
• Significant MSL
• Empty bladder if full
• Maternal pyrexia
• Half hourly monitor frequency
• Fresh bleeding developing in labour
of contractions
• Raised diastolic BP >90 mmHg,
• Hourly vaginal examination systolic BP > 140 mmHg
• Every 15 mins FHS • Oxytocin augmentation
Evaluate: Contractions, Station, Rotation and FHR If not delivered by 3 hours in primi and by
Start oxytocin if uterine contractions inadequate 2 hours in multi
Delivery of head*
• Routine episiotomy not required Operative Vaginal Delivery / CS
• Maintain flexion of head by pushing
occiput downward with one hand &
other hand supports the perineum
• Encourage pushing with Valsalva manoeuvre ESSENTIAL NEWBORN CARE
• Fundal pressure should not be given
• Double set of sheets
• No suction to be done, if baby has cried
Delivery of shoulder
• Not to be hasty in delivery • Keep the baby on mother’s abdomen
• After restitution, hold the neck with
both hands, draw the head downward
• Delayed cord clamping after 60 sec
till anterior shoulder is delivered
• Next head is drawn upward to BP: blood pressure; FHR: fetal heart rate; MSL: meconium stained liquor; CS: Caesareans section.
deliver posterior shoulder *Look for loops of cord around the neck and release the cord if around the neck
5
MANAGEMENT OF 3RD STAGE OF LABOUR
6
MANAGEMENT OF 4th STAGE OF LABOUR
(One hour after placental Expulsion)
• Maternal vital monitoring (pulse/blood pressure/respiratory rate/temperature)
• Breast feeding within 1 hr of delivery
• Inspection of perineum for blood loss and swelling, if episiotomy
• Look for uterine tone
• Advice contraception
7
MALPOSITIONS
Occipito positerior position
Spontaneous or
ventouse or forceps
assisted delivery
Partial Anterior
No rotation Malrotation
Rotation
LSCS
• Ventouse can
Caesarean section
be tried Spontaneous face
Arrest in descent
• LSCS to pubis delivery
Give generous
Episiotomy
LSCS
LSCS: lower segment caesarean section.
8
PRETERM
LABOUR
PRETERM LABOUR
Moderators : Dr. Rishma Dhillon Pai, Dr. Madhuri Patel
Panel Members : Dr. Punit Bhojani, Dr. Bipin Pandit,
Dr. Muralidhar Pai, Dr. Ranjana Khanna,
Dr. Sarita Bhalerao, Dr. Sonia Malik
From left to right: Dr. Sonia Malik, Dr. Muralidhar Pai, Dr. Ranjana Khanna, Dr. Rishma Dhillon
Pai, Dr. Sarita Bhalerao, Dr. Punit Bhojani, Dr. Madhuri Patelw
1
Preface
Preterm labour is the labor that starts before 37 weeks’ of gestation. It is an
important problem in obstetrics that affects 23% of pregnancies in India. It is
considered as one of the most important risk factors for neonatal morbidity
and mortality.
Preterm labour is a multifactorial problem and it’s most common causes include
ascending infection, multiple gestations polyhydramnios, and uterine developmental
malformations. Although the improved ability of obstetric care providers to identify
pregnant women at risk for preterm delivery has increased, the overall incidence of
preterm birth has remained unchanged for the past 30 years.
Among the various risk factors such as nutritional status, chronic diseases, and
intrauterine malformation contributing to preterm labour, the strongest ones are
multiple pregnancies and previous incidence of preterm delivery. In order to identify
asymptomatic women at the risk of preterm delivery, cervical length assessment
has been recommended to be performed in the second trimester of pregnancy.
For a gynaecologist, knowledge of the molecular mechanisms responsible
for the process of preterm labour and its early diagnosis is important.
With a thorough review of the literature assessing the causes and
consequences of preterm labour, FOGSI presents the following algorithm of
diagnostic approach and possible preventive measures that provide a
framework to improve the outcomes of preterm delivery.
Best wishes!
This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for any errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
2 These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systemati c flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
Definition and Terminology
Delivery less than 37 weeks (WHO Fact sheet, Nov 2017)
Subcategory
• Extremely preterm : Less than 28 weeks
• Very preterm : 28-32 weeks
• Late preterm : 32-37 weeks
Suspected/threatened preterm labour: uterine contractions without cervical dilatation
Diagnosed preterm labour: uterine contractions with cervical changes
Established preterm labour: uterine contractions plus progressive cervical dilatation of
more than 4 cms
Review history
Medical, surgical, obstetric, social
Physical examination
• Vital signs
• Abdominal palpation
• Fetal surveillance – FHR, CTG
• Sterile speculum exam
»» Identify if ROM
»» Visualize cervix/membranes
»» High vaginal swab for culture and GBS
»» Test for Fetal fibronectin (if available)
• Cervical dilatation
»» Sterile digital vaginal exam unless
ROM, placenta praevia
• Ultrasound – if available
• Fetal growth and well-being
• TVS for cervical length
Laboratory tests
• Midstream urine for M/C and S
• CBC, RBC, CRP
CTG: cardiotocography; CBC: complete blood count; CRP: C-reactive protein; EFM: electronic fetal monitor; GBS: group B
streptococcus; M/C and S: Microscopy/ culture and sensitivity; RBC: red blood cells; TVS: transvaginal ultrasound scan;
ROM: rupture of the membrane;
3
Table 1. Common tocolytic agents
4
Neuroprotectives
Magnesium 4 g IV initially followed by Maternal: Causes Myasthenia Not very
sulfate 1 g/hour X 24 hours flushing, diaphoresis, gravis effective for
nausea, loss tocolysis but
of deep tendon has neuro-
reflexes, respiratory protective role
depression, and
cardiac arrest;
suppresses heart
rate, contractility
and left ventricular
systolic pressure
when used with
CCBs; and produces
neuromuscular
blockade when used
with CCBs
Fetal: Neonatal
depression
†Data are conflicting regarding this association. CCBs: calcium channel blockers; DCGI: Drugs Controller General of India;
PTL: preterm labour; PGSI: prostaglandin synthetase inhibitors.
Maintenance:
Indian evidence suggests that isoxsuprine is superior with regards to maternal and fetal
outcome when administered in appropriate doses.
Evidence 1
Jaju et al (Dec 2017), in a recently concluded study in Indian patients, reported that
patients receiving oral dose of isoxsuprine with a maximum daily dose of up to 40 mg
for an average of 23 days had a mean latency period of 37 days. Significant
improvement in prolongation of delivery beyond 48 hours and perinatal outcomes were
also noted amongst these patients on isoxsuprine versus other pharmacological agents.
Evidence 2
In study reported by V.K. Singh et al, isoxsuprine was initially administered intravenously,
which was followed by maintenance oral therapy till 37 weeks of gestation. In this study,
the mean latency period reported was 28 days, maximum being 70 days (Singh VK et al.,
J. Obstet and Gynecol of India).
5
In utero transfer
Aim for in-utero transfer whenever necessary after 1st dose of steroids
Initial treatment
Steroids
• Give dexamethasone/betamethasone 24–34 weeks mandatory unless active infection
• From 34–37 weeks recent data indicates reduction in respiratory morbidity
• Betamethasone 12 mg 24 hours apart (use bethamethasone propionate)
• Dexamethasone 6 mg 12 hourly 4 doses (preferred in patients with diabetes, hypertension,
PIH)
Rescue course
• If pregnancy continues beyond 7 days after primary dose and if you suspect she will
deliver within 7 days (delivery is imminent) then rescue course of betamethasone or
dexametha-sone can be given up to 34 weeks of gestation
• Repeated doses are not recommended
Tocolysis
Need to be considered in threatened and diagnosed preterm labor
• Isoxsuprine. Refer Table 1.
Antibiotics
• If established labor (or imminent risk of PTB) give intrapartum GBS prophylaxis regardless of
GBS status or membrane status
• If chorioamnionitis (membranes intact or ruptured)
»» Ampicillin (or Amoxycillin) 2 g IV initial dose, then 1 g IV every 6
hours »» Gentamicin 5 mg/kg IV daily
»» Metronidazole 500 mg IV every 12 hours
• If penicillin hypersensitivity and chorioamnionitis:
»» Clindamycin 600 mg IV every 8 hours and
»» Gentamicin 5 mg/kg IV daily and
»» Metronidazole 500 mg IV every 12 hours
• If labor does not ensue (and no evidence of chorioamnionitis) and membranes intact then
cease antibiotics
• Coamoxyclav not to be given
Neuroprotection
1. Magnesium Sulfate
• Gestational age 24–32 weeks
• Labor established or birth imminent
Loading dose: 4 g IV bolus over 20 minutes
Maintenance dose: 1 g/hour for 24 hours or until birth – whichever occurs first
2. Delayed cord clamping up to 30s not more than 3 minutes except Rh negative mother and
HIV+
GBS: group B streptococcus; HIV:human immunodeficiency virus; IVH: intraventricular hemorrhage; PIH: pregnancy induced hypertension;
PTB: preterm birth.
6
Management algorithm for preterm
premature rupture of membranes
Symptoms and/or signs
suggestive of preterm PROM
Initial management
• Admit for labor and delivery
• Confirm the diagnosis
• Exclude other diagnoses
• Confirm gestational age
• Document fetal well-being
• Administer antenatal
corticosteroids, if indicated
• Neonatal complications related broad-spectrum antibiotics
Offer elective
primarily to prematurity to prolong latency
delivery at or after
• Postpartum endometritis is • Consider tocolyis therapy
32 weeks± FLM
increased after preterm PROM in threatened and
diagnosed preterm labor
• Consider Fetal Surveillance
CBC: complete blood count; FLM: fetal lung maturity test; GBS: group B beta-hemolytic Streptococcus; MFM: maternal-fetal medicine;
PROM: premature rupture of membranes; T&S: type and screen test.
7
Prediction and prevention of preterm birth
Progesterone for the prevention of preterm birth
8
CONCLUSION
• Preterm labor is an improtant factor for neonatal morbidity and mortality.
• Antenatal corticosteroids are recomended to reduce neonatal morbidity and mortality.
• Tocolytics have been found to be useful in delaying preterm labor.
• Beta-adrenergic receptor agonists, isoxsuprine, has been approved by DCGI for use
in preterm labor in Indian women.