Obstetric Protocols (supplementary)

-Downloaded on 27-02-2009 from OG departmental website, obtained during IV

rotation OG 2008/2009
-Similar arrangement to previous version
-A Reminder from Prof. Tam: Materials included are only meant for reference, and
may be idiosyncratic and not the ideal management
-Some references and citations were re-included
-Prepared by medic 2010 Rashid Lui (I deleted all the parts that were redundant, but if
you find anything missing or you want all the original downloads, feel free to find
me.)

Table of Contents

APH...........................................................2
Preterm labour...........................................3
Maternal medicine.....................................8
Fetal medicine.........................................34
Second Trimester Sonographic Soft
Markers for Trisomy 21..........................35
Labour.....................................................38
Drugs.......................................................43
Misc.........................................................55

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APH

APH of unknown origin Updated:7/14/2008

Diagnosis and Management of Antepartum Haemorrhage of Unknown Origin

• Rule out other causes: placenta praevia, abruptio placentae, genital tract lesions
• Document the amount of bleeding by history and speculum examination.
• Perform CTG if >= 26 weeks.
• Consider induction of labour or caesarean delivery if CTG is abnormal.
• If gestation < 34 weeks of gestation:
o Perform TVS cervical length assessment, and give corticosteroid if cevical
length <15mm, or manage as a case of threatened / preterm labour when
there are uterine contractions.
• Discharge if no more vaginal bleeding or abdominal pain for 2 days.
• Remark:
o No need for routine weekly CTG assessment or induction of labour in cases
with history of APH of unknown origin.

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Preterm labour

TVS cervical length Updated:7/14/2008

Indications

• To assess the immediate risk of preterm delivery when patients present with
symptoms of threatened preterm labour
• To predict, in long term, the chance of preterm delivery in asymptomatic patients
present at antenatal clinic at 20-24 weeks of gestation

Method of assessment

• Patient must empty bladder before scan

• Use 5-MHz transvaginal transducer
• Put TVS probe 3 cm proximal to the cervix to avoid any cervical distortion of its
position or shape
• Obtain a good sagittal view of the cervix, with the echogenic endocervical mucosa
along the length of the canal
• Magnify the view as much as possible
• Measure the length of the straight line between the internal os and the external os

Interpretation of Result

• For cases present with threatened preterm labour:

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 o a positive result (cervical length <15mm) indicates indicates 37% chance of
delivery within 7 days and hence corticosteroid and tocolytic may be
indicated
o a negatiave result indicates 99% chance that delivery would not occur within
7 days and hence corticosteroid and tocolytic are not necessary

References

• Tsoi E, Akmal S, Rane S, Otigbah C, Nicolaides KH. Ultrasound assessment of

cervical length in threatened preterm labor. Ultrasound Obstet Gynecol. 2003
Jun;21(6):552-5.

Cervicovaginal fibronectin test Updated:7/14/2008

Introduction

• Fetal fibronectin (fFN) is an extracellular matrix protein found in the decidua basalis
next to the placental intervillous space. It acts like a ‘glue’ attaching the fetal
membranes to the uterine decidua.
•
• Mechanical or inflammatory mediated damage to the placenta or membranes may
result in its release into the cervico-vaginal fluid.

• Fibronectin is often found in cervico-vaginal fluid before 18 weeks’ gestation and at

the end of term pregnancy; however, it is not normally present from 22 to 37 weeks,
and hence its presence is associated with an increased risk of preterm birth.

Indication of cervico-vaginal fibronectin test

• To assess the immediate risk of preterm delivery when patients present with
symptoms of threatened preterm labour

Method of assessment

• The test must be done before any digital examination of the vagina and cervix
• After insertion of speculum into the vagina, a Dacron polyester swab is put into the
posterior vaginal fornix, and roll across to absorb fluid
• The Dacron swab is then inserted into a collection tube for bedside monoclonal
antibody assay (available in Ward 7E)
• Remark: blood and amniotic fluid in the vagina will give false positive result and
hence the test should not be done in case of APH or ROM

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 •

Interpretation of Result

• For cases present with threatened preterm labour:

o a positive result (fibronectin level >=50ng/ml) indicates 24% chance of
delivery within 7 days and hence corticosteroid and tocolytic may be
indicated
o a negatiave result indicates 98% chance that delivery would not occur within
7 days and hence corticosteroid and tocolytic are not necessary

References

• Tsoi E, Akmal S, Geerts L, Jeffery B, Nicolaides KH. Sonographic measurement of

cervical length and fetal fibronectin testing in threatened preterm labor. Ultrasound
Obstet Gynecol. 2006 Apr;27(4):368-72.

Preterm labour Updated:7/14/2008

Definition of preterm labour

• Onset of labour after 24 weeks and before 37 weeks of gestation

• Onset of labour can be diagnosed when there are the cervix started to dilate or has
totally effaced, associated with regular painful uterine contractions
• Onset of labour is suspected (threatened preterm labour) when there are uterine
contractions plus one of more of the following:
o Show of mucus
o rupture of membranes
o shortening of cervical length as measured by transvaginal scan
o cervicovaginal fibronectin test is positive

Initial assessment

• Inform on-call Medical Officer

• Ascertain gestation
• Look for causes of preterm labour eg.
o Abruptio placentae or APH
o Chorioamnionitis (check for rupture of memrbanes and take HVS)
o Urinary tract infection (check MSU)
o Polyhydramnios
o Multiple pregnancy or fetal anomalies

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 • Depending on the gestation and clinical presentation, TVS cervical length,
cervicovaginal fibronectin test result, decide the use of corticosteroid, tocolytic agent,
time and mode of delivery with Mid-1 or above

Management of threatened / preterm labour before 34 weeks

• Inform Mid-call 1, and Mid-call 2 if < 26 week

• To labour ward, NPO, X-match, iv access
• Continous fetal monitoring when gestation >= 26 week
• Invite Neonatalogists to counsel the patient
• Give corticosteroid and tocolytic agent in the following conditions:
o preterm labour (cevix is dilated or effaced)
o threatened preterm labour with cervical length <15mm, or +ve cervicovaginal
fibronectin test
• Withhold corticosteroid and tocolytic agent if the above conditions are not fulfilled.
However, when uterine contractions persist, reassess TVS cervical length to make
decision accordingly.

• If immediate delivery is required or unavoidable, decide mode of delivery according to

clinical situation

Management of preterm after 34 weeks

• Allow delivery and manage as for term pregnancy

• No need for corticosteroid or tocolytic agent,

Management of threatened / preterm labour with special conditions

Extreme prematuirty less than 26 weeks

• Discuss with patient:

o Prognosis (together with Neonatalogists)
o Different modes of fetal monitoring (continuous vs intermittent ascultation)
o Different modes of delivery (classical CS and vaginal delivery) in case of fetal
malpresentation and fetal distress

Antepartum Haemorrhage

• Rule out abruption which requires immediate delivery

• Tocolytic agents may be used to suppress labour in mild case of APH. Atosiban is the
preferred choice.

Prolonged rupture of membranes

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 • Labour that starts after prolonged ROM may be a result of evolving chorioamnionitis.
Use of tocolytic agents to suppress labour should only be considered with strong
indications (e.g. extreme prematurity, for completion of corticosteroid), and should be
decided by specialists

Drugs for the mothers

• Entonox for labour pain relief

• Pethidine for labour pain relief
• syntometrine or syntocinon iv or im injection for management in the third stage of
labour.
• Sodium citrate
o Purpose:
 premedication prior to emergency caesarean section
o Regimen:
 30ml of 0.3M po once
• Panadol
o Purpose:
 for post-delivery pain relief
o Regimen:
 500mg po QID prn
• Potassium permaganate (KMnO4), Zinc oxide, hirudoid, sitz bath
o Purpose:
 for local treatment of perineal wound
o Regimen:
 local application bd

Drugs for the newborns

• Vitamin K1 for routine prophylaxis against neonatal haemorrhagic disease.

• Naloxone (Narcan) for treatment of neonatal respiratory depression as antidote to
maternal narcotic effect.
• Hepatitis B immunoglobin (hyperhep) to reduce the risk of vertical transmission of
hepatitis B.
• Hepatitis B vaccine, polop and BCG vaccine
o Purpose:
 for routine newborn immunization
o Regimen:
 hepatitis B vaccine 0.5ml imi
 polio 0.25ml po
 BCG vaccine

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 • Zinc oxide, Drapolene cream, Penatan cream. For treatment and prevention of nappy
rash, Apply cream after every nappy change. Drapolene: contain benzalkonium
chloride 0.01% and cetrimide 0.2% in a water miscible base

Maternal medicine

Ovarian cyst Updated:11/10/2004

Antenatal management

• Perform USG to assess the size and characteristics of the cyst

• Look for any symptoms related to complications of the cysts
• Confirm gestation
• Management will depend on the nature of the cysts, presence of any symptoms and
gestation as stated below.

Simple unilocular ovarian cysts

• Before 16 weeks of gestation and size <= 6cm:

o Most likely physiological cyst that will resolve spontaneously by 16 weeks.
o Adopt conservative management during antenatal course unless the patient
develops complication.

• Before 16 weeks of gestation and size > 6cm:

o Unlikely to be physiological cyst.
o Counsel patient on the pros and cons of operation on ovarian cysts during
pregnancy.
o Surgery should be preferably performed at around 14 weeks of gestation
unless complication arises, earlier if the cyst is larger.
o Contact endoscopy team for arrangement of operation.

• Between 16 - 20 weeks of gestation:

o Unlikely to be physiological cyst.
o Counsel patient on the pros and cons of operation on ovarian cysts during
pregnancy.
o Contact endoscopy team for arrangement of operation.

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 • After 20 weeks of gestation:
o Unlikely to be physiological cyst.
o Adopt conservative management during antenatal course unless the patient
has symptoms.

Ovarian cysts with ultrasonic features of benign pathological cysts

• Before 20 weeks of gestation:

o Counsel patient on the pros and cons of operation on ovarian cysts during
pregnancy.
o Surgery should preferably be performed around 14 weeks unless
complication arises, earlier if the cyst is larger.
o Contact endoscopy team for arrangement of operation.
• After 20 weeks of gestation:
o Adopt conservative management during antenatal course unless the patient
develops complication.

Ovarian cysts with ultrasonic features suggestive of malignancy

• Contact oncology team for assessment.

Intrapartum management

• Presence of asymptomatic ovarian cysts should not be an indication for caesarean

section.
• However, operation on ovarian cysts can be performed opportunistically during
caesarean section.

Acute complications during pregnancy

• When there is clinical features suggestive of complications such as rupture, torsion or

haemorrhage, arrange surgical treatment.
• No indication of Caeserean delivery at the same time unless:
o there is other obstetric indication, or
o the gravid uterus causes surgical difficulty (should be decided by Mid-call 2).

Postnatal management

• For ovarian cysts in which conservative management is adopted during antenatal

period:
o Arrange an ultrasound examination of pelvis at radiology department to be
performed 3 months after delivery.

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 o Arrange a follow-up appointment at Pelvic Mass Clinic in the cluster at 4
months after delivery to review the report of ultrasound examination. (Need to
state the reason of the arrangement of a gynaecology follow-up on the
inpatient record)
• For patients with ovarian cysts removed at caesarean section:
o Arrange a routine follow-up appointment at general gynaecology clinic in the
cluster for review of pathology report. (Please state the reason for gynaecology
follow-up on the in-patient record).
o

Fibroid Updated:5/23/2005

Antenatal management

• Counsel the patient:

o It is a bengin lesion and would not cause any risk to the mother and the fetus
in most of the cases
o Small chance of red degeneration that may lead to abdominal pain
o May cause fetal malpresentation if the fibroid is situated at the lower pole of
the uterus
• No need to arrange serial ultrasound examination routinely throughout the antenatal
period, unless there is difficulty in monitoring fetal growth by fundal height
measurement.
• For fibroid locating at the lower pole of the uterus, arrange follow-up at 37 weeks of
gestation (+/- USG) to assess the fetal presentation and engagement and decide
mode of delivery:
• Allow vaginal delivery unless the uterine fibroid is situating at the lower segment AND
affect engagment of fetal head or cause malpresentation.

Intrapartum management

• If Caesaerean section is indicated for any reason, DO NOT perform myomectomy at

the same time.
• After delivery, no need for routine prophylactic syntocinon infusion unless the uterine
fibroid larger than 5 cm. Give syntocinon infusion (40 units in 500 ml of cystalloid
solution over 4 hours) if it is required.

Postnatal follow up

• For patients who are asymptomatic before the pregnancy (no menorrhagia or
pressure symptoms):

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 o It is not necessary to give gynaecology follow-up after delivery
o Advise patient to seek medical advice when she has symptoms
• For patients who has symptoms before the pregnancy:
o Arrange a follow-up appointment at Pelvic Mass Clinic in 6 months with
pictorial chart given to patient to document the menstrual pattern
o It may be necessary to postpone the follow-up appointment if the patient
would have long period of breast feeding and remains amenorrhoea.

Bacterial vaginosis Updated:7/14/2008

Diagnostic Test

Nugent’s method and classification of result (based on Gram stain and a scoring system):

• normal vaginal flora

• intermediate
• indicative of bacterial vaginosis

Indications of Treatment

• Treatment is only for patient with result 'indicative of BV':

o For symptomatic relief, or
o For asymptomatic pregnant woman before 20 weeks of gestation
 risk of preterm delivery significantly reduced if treated before 20
weeks but not after 20 weeks
• Routine treatment of sex partners is not necessary

Treatment regimen

• Clindamycin 300 mg bd po * 7 days; or

• Metronidazole 400 mg tds po * 7 days:
o Metronidazole can be used throughout pregnancy as multiple studies and
meta-analyses have not demonstrated an association between metronidazole
use during pregnancy and teratogenic or mutagenic effects in newborns
o Advise against drinking alcohol during metronidazole treatment and up to 24
hours afterwards

Screening

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Evidence does not support routine screening, even in high risk groups

Discussion / Justification

Risk of preterm delivery before 37 weeks significantly reduced RR 0.63 (95% CI: 0.48 – 0.84)
if patients who have bacterial vaginosis receive treatment before 20 weeks. However, studies
do not show any benefits when treatment is started after 20 weeks

Haematuria Updated:5/7/2001

Routine antenatal screening

• Urine hemostix for all NEW obstetric cases

• If positive, perform urine culture to exclude infection

If persistent haematuria (haematuria persists in two visits):

• Refer to renal physician with special referral form

• Perform
o urine cytology,
o RFT and
o 24 hour urine for protein and creatinine clearance.
• If all other investigations are normal, patient can have routine AN care.
• If the renal function is abnormal, refer to Medical OBS.

Note: #Trace# of RBC should be considered as positive

• Sample of referral letter:

o I would like to refer the above lady for your further assessment whom we
detected persistent microscopic hematuria during antenatal check-up.
o She is now _______________ weeks pregnant. Her EDC is
___________________

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Cardiac arrest Updated:5/7/2001

Cardiopulmonary resuscitation for cardiac arrest in obstetric patients

• Nursing staff start cardiopulmonary resuscitation before doctors arrive, and mark the
time of all events:

1st nurse

• Secure airway
• Apply Ambu bag with 100% O2

2nd nurse

• Call Junior obs and gynae on call M.O.s and midcall 1 using emergency code
9996/7/8/9
• Call resuscitation team 2468
• Call labour ward
• Display uterus to left side by:
o Putting the wooden board underneath the patient"s back
o wedging the board to tilt the patient to left lateral position at about 30 degrees
• Apply ECG electrodes to the chest
• Perform external cardiac massage

3rd nurse or nursing Officer

• Deploy nurses from other wards.

• Assist in resuscitation +/- Perimortem Caesarean section

Other labour ward nurses

• Inform paediatrician, NNU

• Inform house officers, midcall 2 and consultant
• Inform anaesthetist on call
• Assist MO in the perimortem Caesarean section
• Assist resuscitation of the baby
• Prepare Caesarean section set for suturing

Medical staff to decide perimortem Caesarean section and continuation of resuscitation:

1st Medical officer who arrives

• Enquire the duration of cardiac arrest from nursing staff

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 • Check the patient"s carotid pulse and ECG tracing when nurse withholds cardiac
massage
• Decide to proceed with perimortem Caesarean section if the duration of cardiac arrest
is greater than 4 minutes without response to CPR
• Instruct the nurse to stop cardiac massage during perimortem Caesarean section

2nd doctor (medical officer or intern) who arrives

• Establish IV line
• Prepare for defibrillation in case of Ventricular fibrillation (300 J from the start)

Mid-call doctors

• Assist in the CPR or the rest of the caesarean section

Decision on Perimortem Caesarean section

• Avoid undue delay

• Aim to deliver within 4 minutes of cardiac arrest which will optimise neonatal outcome
and facilitate maternal CPR
• Liaise with anaesthetist for ICU transfer if resuscitation is successful and after
completion of Perimortem Caesarean section

Perimortem CS Updated:5/7/2001

Indication

• Obstetric patients with sudden cardiac arrest

Procedure

• Put on the gloves and mask

• Skip unnecessary steps: scrubbing, draping of operation site, bladder catheterization
• Antiseptic is not required
• Midline subumbilical incision and classical Caesarean section
• Antibiotic cover with 1.2 gram IV Augmentin if patient responded to resuscitation
• Close the wound

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DM-antenatal management Updated:10/11/2007

Initial management of pre-existing IGT/DM

• In patient management is preferred

• Early admission to start diet control and h’stix monitoring
• Stop any oral hypoglycaemic drug and change to insulin
• Check HbA1c and investigate for diabetic complications
• Arrange morphology scan at second trimester
• Refer to ophthalmologist for retinal assessment

Initial management of newly diagnosed GDM

Mild (fasting glucose < 6.1mmol/l or 2nd hour < 11.1 mmol/l)

• Outpatient management is preferred for most GDM

• Refer DM education class to see dietitian for DM diet and DM education
• Start outpatient H’stix monitoring
• Follow up in Thursday medical obstetric clinic
• Routine growth scan is not necessary

Severe (fasting glucose >= 6.1mmol/l and/or 2nd hour glucose >=11.1 mmol/l)

• Early admission to start diet control and h’stix monitoring

• Check HbA1c and investigate for diabetic complications
• Fetal growth scan
• Start insulin as indicated

Diet control:

Pregnancy 1st trimester 2nd trimester

singleton 1500kcal/day 1800kcal/day
multiple 1500kcal/day 2000kcal/day

Reference for glycaemic control

H'stix Normal Borderline Abnormal

Fasting (mmol/L) <= 5 > 5 - 5.5 > 5.5

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Postprandial (mmol/L) <= 7 > 7 - 7.5 > 7.5

Subsequent Outpatient management for DM/GDM

GDM/DM on diet control

• H'stix monitoring one to two days per week (4 times/day: Fasting, PB, PL, PS)
• Check compliance and revise dietary plan if glycaemic control is borderline
• Admit to consider insulin if glycaemic control is persistently borderline or abnormal
• Uncomplicated GDM not requiring insulin can be followed up by midwives diabetic
clinic (MCDM) on Thursday morning

GDM/DM on insulin

• H'stix monitoring two to five days per week (4 times/day: Fasting, PB, PL, PS)
• Adjust insulin dosage if persistently borderline or abnormal glycaemic control
• Admit if glycaemic control is difficult
• Growth scan every 4 weeks
• CTG weekly from 36 weeks for GDM/DM on insulin

Indications for blood sugar series

• Routine blood sugar series is not necessary for all GDM cases
• Blood sugar series would be used as a reference for the commencement of insulin,
the final insulin dosage for individual cases and when the h’stix result is in doubt

Timing of delivery

• GDM on diet with good control: await spontaneous labour and induction at 41 weeks
gestation
• GDM requiring insulin or pre-existing DM/IGT with normal H'sitx: consider induction at
40 weeks
• GDM or pre-existing DM/IGT with poor glycaemic control and/or any complication:
consider induction at 38 weeks or earlier if indicated

Mode of delivery

• Discuss elective caesarean delivery if the EFW > 4 kg

• Take precaution of shoulder dystocia if mother with a macrosomic fetus (AC > 97
centile) undergoes vaginal delivery:
• Doctor standby at fetal head delivery
• Mid-call doctor assess before instrumental delivery

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Measurement of blood pressure in pregnancy

• Patient should be rested and sitting at 45-degree (or in lateral recumbent position while in

labour)

• BP cuff should be of the appropriate size [standard cuff for arms ≤ 33 cm circumference,

large cuff (15 × 33 cm bladder) for larger arms].and placed at the level of the heart

• Be aware that BP obtained using automated BP recording devices may differ significantly

from those using mercury sphygmomanometry in pregnancy

• DINAMAP can be used for BP monitoring provided that it has been cross checked with

sphygomanometer at the time of diagnosis

• Use Korotkoff sounds K1 (systolic) and K5 (diastolic) to record the blood pressure while

using mercury sphygmomanometer

References:

• Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, et al. The detection,

investigation and management of hypertension in pregnancy: executive summary. Aust N

Z J Obstet Gynaecol 2000;40(2):133-8.

• The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No.

10 A, March 2006.

Diagnostic Criteria

Diagnostic criteria for hypertension in pregnancy

• SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg on 2 occasions at ≥ 4 hours apart, or

• SBP ≥ 160 mm Hg or DBP ≥ 110 mm Hg at any occasion

Diagnostic criteria for significant proteinuria in pregnancy

• Urine protein ≥ 0.3 g/d (24-hour urine collection should always be used for the

diagnosis of significant proteinuria unless the clinical urgency dictates immediate

delivery)

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• Spot urine protein to creatinine ratio ≥ 30 mg/mmol which usually equivalent to > to 0.3 g

proteinuria / 24 hours can be used as an alternative

• Urine albustix ≥ 2 + usually suggest significant proteinuria but should always be confirmed

by 24 hour urine or spot urine protein to creatinine ratio

• Urinary tract infection should be excluded by MSU

References:

• Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, et al. The detection,

investigation and management of hypertension in pregnancy: executive summary. Aust N

Z J Obstet Gynaecol 2000;40(2):133-8.

• Roberts JM, Pearson G, Cutler J, Lindheimer M, Pregnancy NWGoRoHD. Summary of

the NHLBI Working Group on Research on Hypertension During Pregnancy.

Hypertension 2003;41(3):437-45.

• The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No.

10 A, March 2006.

Classification

Classification of hypertensive disorder in pregnancy

• Gestational hypertension

o De novo hypertension without proteinuria onset after 20 weeks gestation

• Pre-eclampsia/eclampsia

o Pre-eclampsia is de novo hypertension accompanied by new onset significant

proteinuria after 20 weeks

o If gestational hypertension is associated with headache, abdominal pain, or

abnormal laboratory tests (especially, thrombocytopenia < 100 or ALT), the

diagnosis of pre-eclampsia should be considered

o Eclampsia is diagnosed as convulsion superimposed on a case of pre-eclampsia

• Chronic hypertension

o Hypertension before pre-conception or diagnosed before 20 weeks gestation

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  Essential hypertension: hypertension without an apparent cause

 Secondary hypertension: hypertension associated with renal,

renovascular and endocrine disorders and aortic coarctation.

o Gestational hypertension that fails to normalize at 12 weeks after delivery would

be re-classified as chronic hypertension

• Pre-eclampsia superimposed on chronic hypertension

o The following clinical conditions will suggest pre-eclampsia in women with chronic

hypertension

 De novo proteinuria occurs after 20 weeks gestation

 A sudden increase in the magnitude of hypertension or sudden increase

in proteinuria in women who have proteinuria early in gestation

 Appearance of thrombocytopenia <100, and /or raised ALT

N.B. ‘White-coat’ hypertension

o It is not real hypertension and hence not under the classification of hypertensive

disorder It is a common condition in which blood pressure elevates in the presence

of a clinical attendant (e.g. in clinic) but returns normal in the normal environment

(e.g. home BP monitoring, after rest in ward, or ambulatory blood pressure

monitoring)It should replace all other terms for the diagnosis of condition

References:

• Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, et al. The detection,

investigation and management of hypertension in pregnancy: executive summary. Aust N

Z J Obstet Gynaecol 2000;40(2):133-8.

• Brown MA, Lindheimer MD, de Swiet M, Van Assche A, Moutquin JM. The classification

and diagnosis of the hypertensive disorders of pregnancy: statement from the

International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertens

Pregnancy 2001;20(1):IX-XIV.

• Roberts JM, Pearson G, Cutler J, Lindheimer M. Summary of the NHLBI Working Group

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 on Research on Hypertension During Pregnancy. Hypertension 2003;41(3):437-45.

Severe pre-eclampsia

Diagnostic criteria of severe pre-eclampsia

• Severe hypertension (SBP ≥ 170 mmHg or DBP ≥ 110mmHg on 2 or more occasions)

with significant proteinuria, or

• Moderate hypertension and significant proteinuria, with any symptom or sign of

impending eclampsia, such as

o Neurological: ankle clonus, severe headache, persistent visual disturbances,

papilloedema

o Hepatological: epigastric pain +/- vomiting, liver tenderness, impaired liver function

(ALT > 70)

o Haematological: thrombocytopenia < 100, disseminated intravascular coagulation;

haemolysis

• Other clinical features which also indicate the severity of the clinical condition and may be

an indication of earlier delivery

o Renal insufficiency – plasma creatinine ≥ 90 µmol/l or oliguria (< 500 ml/24 h)

o Fetal growth restriction or features of utero-placental insufficiency

• In case the clinical conditions warrant delivery in a case of severe pre-eclampsia, MgSO4

is indicated for the prophylaxis of eclampsia

Early onset pre-eclampsia

• Pre-eclampsia with onset ≤ 34 weeks

• Investigate for underlying cause: e.g. anticardiolipin antibody and lupus anticoagulant

• Aspirin prophylaxis (80 mg daily) is indicated in a previous early onset pre-eclampsia

resulted in preterm delivery

References:

• The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies,

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 benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled

trial. Lancet 2002;359:1877-90.

• von Dadelszen P, Magee LA, Roberts JM. Subclassification of preeclampsia. Hypertens

Pregnancy 2003;22(2):143-8.

• The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No.

10 A, March 2006.

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Peripartum management of Pre-eclampsia

General management in pre-eclampsia

• Manage patient in the labour ward

• NPO

• IV fluid: Hartmann solution at 80 ml/hr

• Use infusion pump for syntocinon infusion and adjust maintenance fluid accordingly

• Check CBP, RFT & LFT (clotting profile is not required routinely if platelet count is normal)

• Monitor BP/P every 15 minutes

• Monitor hourly urine output

• Continuous fetal heart monitoring

• Advise on epidural anaesthesia for pain relief if no contraindication

• Give slow IV syntocinon 5 units injection at third stage of labour and avoid IM syntometrine

Special management in severe pre-eclampsia

• MgSO4

o Indicated for the prophylaxis of eclampsia if the clinical conditions warrant

delivery

o Loading dose: IVI 4 g over 20 min (8 ml of 50% MgSO4 diluted with normal saline

into 20 ml)

o Maintenance dose: IVI 1 g per hour (20 ml of 50% MgSO4 diluted with normal

saline into 50 ml)

 Use a lower dose at 0.5 g per hour in case of renal impairment

o Monitoring while on MgSO4

 Hourly urine output

 Check deep tendon reflex hourly (e.g. biceps reflex if patient is /has been

on regional anaesthesia)

 Check respiratory rate hourly

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  Continuous SaO2

 Routine serum Mg level monitoring is not necessary but it should be

monitored every 6 hourly if MgSO4 is used in patient with renal

impairment

o Caution

 MgSO4 should be used with caution in patient with renal impairment,

neuromuscular disease or respiratory depression

• Antihypertensive

o Indicated when SBP ≥ 160 mmHg or DBP ≥ 100 mmHg or at a lower threshold if

there symptom and sign of impending eclampsia, or serious condition like HELLP

syndrome

o IV Labetalol

 First line for intrapartum BP control

 Bolus regimen: give iv 20 mg over 1 min; increase dose to 40 or 80 mg

every 10 min if indicated (until a maximum cumulative dose of 300 mg)

 Infusion regimen: start at 20 mg/hr (dilute 100 mg into 100 ml with normal

saline), increase by 5-10 mg/hr every 30 min, (maximum 100 mg/hr)

 Stop labetalol if maternal heart rate falls below 70/min

 Avoid in the presence of pulmonary edema, heart failure or with asthma

o IVI Hydralazine

 Second line for intrapartum BP control if labetalol fails or is

contraindicated

 Bolus regimen: give 5 mg IV over 1 min and repeat at 20 min if indicated

(maximum cumulative bolus dose: 20 mg)

 Infusion regimen: use if fail to control BP with 4 bolus doses, start at 5

mg/hr (dilute 100 mg into 100 ml with normal saline) increasing by 5

mg/hr every 30 minutes as indicated (usual dose varies between 5 to 20

mg/hr)

 Consider other alternative antihypertensive if hydrallazine fails to control

CUHK medic 2010 23

 BP or causes maternal side effects (e.g. tachycardia >120/min)

 Caution: Maternal hypotension may occur with bolus or infusion regimen

o Oral nifedipine

 Nifedipine should only be given as oral and preferably used in

postpartum

 Regimen: Nifedipine (Adalat®) 5mg orally for acute hypertension while

nifedipine slow release (Adalat®retard) starting at 20 mg bd for

maintenance in postpartum

o Oral labetalol

 Start at 200 mg bd for BP control in postpartum

• Management of oliguria (U/O < 20 ml/hr for ≥ 2 hrs)

o Fluid replacement (250 ml of Hartmann solution over 1 hour) in the absence of

fluid overload

o Stop MgSO4

o Give IV diuretics (furosemide 20-40 mg) if there is pulmonary edema

o Consult anaesthetist for CVP to guide fluid management if persistent oliguria after

fluid replacement

Management of magnesium toxicity

• Slurred speech, double vision, absent deep tendon reflexes and respiratory depression

may be symptoms and signs of toxicity

• Absence of deep tendon reflexes

o Stop MgSO4

o Check for respiratory depression

o Continue cardiac monitoring

o Check urgent serum Mg level

o Give IV 1 gram (10 ml of 10%) Calcium gluconate over 10 min

• Respiratory depression (respiratory rate < 10/min)

o Stop MgSO4

o Give O2 via mask to maintain SaO2 > 95%

CUHK medic 2010 24

 o Continue cardiac monitoring

o Check urgent serum Mg level

o Give IV 1 gram (10 ml of 10%) Calcium gluconate over 10 min

o Consult anaesthetist for the need of respiratory support

• Serum Mg level and toxcity

Serum level (mmol/l)

Normal pregnancy 1
Therapeutic 2-4
Loss of patellar reflex 5
Prolonged AV conduction 6
Respiratory failure 7.5
Cardiac arrest 12

References

• The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No.

10 A, March 2006.

• Sidhu H. Pre-eclampsia and Eclampsia. In: Johanson R, Cox C, Grady K, Howqell C, ed.

Managing Obstetric Emergencies and Trauma: The MOET Course Manual. London:

RCOG Press; 2003 p.133-147.

Management for eclampsia

• General measure

o Call for help

o Lie patient in left lateral position

o Maintain airway and give 100% O2

o Documentation of the event and duration of convulsion

• Anti-convulsant

o Diazepam is used to terminate any ongoing convulsion

 Regimen: 5-10 mg slow IV bolus (given over about 1 minute)

o MgSO4 is used to prevent further recurrent convulsion

 If eclampsia occurs before commencement of MgSO4, start loading dose

infusion over 5 min

 If eclampsia occurs during initial loading dose, complete the loading dose

CUHK medic 2010 25

 over 5 min

 If eclampsia occurs during MgSO4 maintenance infusion, additional 2

gram bolus of MgSO4 (4 ml of 50% MgSO4 diluted with normal saline

into 10 ml) given over 5 minutes

o Recurrent eclampsia can be managed with a further 2 gram bolus of MgSO4 but

alternative anti-convulsant or intubation should be considered if a total 10 gram of

bolus has been given

• A consultant or specialist in maternal medicine should be involved in case of eclampsia

Reference

The Management of Severe Pre-eclampsia/Eclampsia. RCOG Green top guideline No. 10 A,

March 2006.

CUHK medic 2010 26

Postpartum management for pre-eclampsia

• Investigate for underlying cause if the case is an early onset pre-eclampsia

• Oral antihypertensive can be used as to control BP if indicated

o Use Adalat®retard: 20 mg - 40 mg bd and/or labetalol 200 mg bd - 400 mg tid

o Avoid methyldopa as it may increase the risk of postpartum depression

o Consult physician for refractory case

• At discharge from postnatal ward, antihypertensive drugs can be tailed off gradually over

2-4 weeks with dose revision at weekly to biweekly interval with BP monitored at ward

follow up.

• Postnatal follow up in General clinic at 6 to 8 weeks to review blood pressure and

proteinuria by urine albustix

o Renal function and 24 hour urine collection are not required routinely except renal

impairment at the diagnosis of pre-eclampsia or persistent positive albustix at

postnatal follow up

o CBP and LFT at 1 week before follow up as indicated in case of HELLP

syndrome

• Refer patient to physician if hypertension or proteinuria still persists after puerperium

Flow chart for management of eclampsia

CUHK medic 2010 27

Antibiotic for heart diseases Updated: 2007

CUHK medic 2010 28

Intrapartum antibiotic prophylaxis is indicated in:

• Prosthetic cardiac valve

• Previous infective endocarditis
• Congenital heart disease (CHD) limited to the following conditions:
o Unrepaired cyanotic CHD, including palliative shunts and conduits
o Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the
first 6 months after the procedure
o Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibit endothelialization)
• Cardiac transplantation recipients who develop cardiac valvulopathy

Antibiotic Regimen

No allergy Allergy to ampicillin

At onset of labour/ rupture of Ampicillin 2.0g ivi Vancomycin 1.0g iv infusion
membranes
Intrapartum Ampicillin 500mg ivi Q6H Vancomycin 1.0g iv infusion Q12H

Postpartum Not required Not required

Remarks

• Risk of infective endocarditis under an ordinary elective or pre-labour caesarean

section is very low so that antibiotic cover is not indicated for the above cardiac
conditions
• Vancomycin infusion guideline
o reconstitute in 20 ml water, and dilute with 200 ml NS
o infuse over at least 100 min
• Consult physician
o for the vancomycin dosage in case of severe renal impairment
o for opinion if patient allergic to both ampicillin and vancomycin

Discussion / Justification AHA has reviewed the topic and updated the guideline on antibiotic
prophylaxis in May 2007. Reference: AHA Prevention of Infective Endocarditis. A guideline
from the American Heart Association Rheumatic fever, endocarditis, and Kawasaki disease
committee, council on cardiovascular disease in the young, and the council on clinical
cardiology, council on cardiovascular surgery and anesthesia, and the quality of care and
outcomes research interdisciplinary working group. Circulation. published online, Apr 19,
2007.

CUHK medic 2010 29

Management of acute VTE

General management

VTE should be suspected in women at risk

ECG abnormalities are frequently transient and the commonest abnormality is sinus
tachycardia

Start anticoagulant once the clinical diagnosis of VTE is made in women at risk

Clinical assessment of deep vein thrombosis (DVT) and pulmonary embolism

(PE) could be unreliable

Perform USG Doppler lower limbs in suspected DVT

Perform spiral CT in suspected PE

Perform USG Doppler lower limbs if PE confirmed

Spiral CT has higher sensitivity & specificity and lower radiation to the fetus than
V/Q scan, but it increases the life time risk of breast cancer

V/Q scan can be performed if spiral CT is inconclusive

D-dimer should not be used for the diagnosis in pregnancy or puerperium

D-dimer is raised during pregnancy, especially in pre-eclampsia

A positive test is not useful in the diagnosis, only a negative test can make the
diagnosis of VTE less likely

Thrombophilia screening

Anticardiolipin antibody (AC) and lupus anticoagulant (LA) at the time of

diagnosis while Protein C, protein S, antithrombin III when anticoagulant has
been stopped for at least 2 wk and at least 6 weeks postpartum

Initial treatment of DVT

Both above knee or below knee DVT require anticoagulant treatment

Encourage mobilisation with graduated elastic compression stockings

Elevate the affected leg at rest in the first few days in order to reduce leg oedema

CUHK medic 2010 30

Start therapeutic dose of LMWH

SC enoxaparin (1mg/kg early pregnancy weight) Q12 hour

Use the nearest dose as charted:

Early pregnancy weight Initial dose of SC enoxaparin

< 50 kg 40 mg Q12 hr
50 - 69 kg 60 mg Q12 hr
70 - 89 kg 80 mg Q12 hr
≥ 90 kg 100 mg Q12 hr
Routine anti-Xa level and platelet count monitoring while on LMWH treatment is not required
except in

patient is at the extreme weight (< 50 kg or ≥ 90 kg)

renal impairment

recurrence on treatment

For antenatal above knee DVT

Arrange USG Doppler of lower limbs at 2-4 weeks after the initial treatment to
assess interval changes and repeat later if indicated

Initial treatment of PE

Mild PE Therapeutic dose of LMWH as for DVT

Severe PE Consult physician or cardiologist for the need of IVI heparin
Massive PE Consult ICU and cardiothoracic surgeon for the need of embolectomy

Anticoagulant regimen and duration

Antenatal VTE

Anticoagulation should be continued throughout pregnancy till at least 6 weeks

postpartum and the total period should last for 3 months at minimum

Postnatal VTE

Start warfarin 2 days after delivery if there is no excessive bleeding and stop
enoxaparin when INR reach the target range

CUHK medic 2010 31

Severe/ massive PE

Regimen as decided by physician or cardiologist

Intrapartum management

Spontaneous labour or ROM

Advise patient to withhold next dose at onset of labour or rupture of membranes

and admit for assessment

Withhold enoxaparin during labour till delivery

Elective induction

Stop enoxaparin 1 day prior to induction

Elective CS

Stop enoxaparin 1 day prior to CS and resume prophylactic dose (enoxaparin 40

mg SC QD) at least 3 hours postoperatively if no excessive bleeding

Anaesthetic plan & regional analgesia/anaesthesia

Consult anaesthetist regarding to regional analgesia or anaesthesia during labour and

caesarean section

Regional techniques should be avoided for at least 24 hours after the last therapeutic dose of
enoxaparin

Epidural cannula should not be removed within 12 hours of the last injection

Enoxaparin should not be given for at least 4 hours after the epidural catheter has been
removed (or at least 6 hours if procedure has been traumatic)

Postpartum management

Vaginal delivery

Resume therapeutic enoxaparin after delivery if there is no excessive bleeding

Early mobilisation with graduated elastic compression stockings

CUHK medic 2010 32

CS

Resume prophylactic enoxaparin at least 3 hour post-operation if there is no

excessive bleeding

Resume to full therapeutic enoxaparin by 12 hours later

Start warfarin 2 days after delivery and stop enoxaparin when INR is at the therapeutic range
Duration of anticoagulant:

Below knee DVT: continue till 6 weeks postnatal

Above knee DVT or PE: continue for at least 6 weeks postnatal and until at least
3 months of anticoagulant therapy has been completed

Work up for hereditary thrombophilia after completion of anticoagulant (protein C, protein S

and anti-thrombin III) at least 6 weeks postpartum and when anticoagulant has been
stopped for at least 4 wk
All patients with above knee DVT or PE should be referred to physician for long term follow up
Breast feeding is not contraindicated for either warfarin or LMWH use
Patient should be counseled to avoid COC pills

Reference

RCOG. Thromboembolic disease in pregnancy and the puerperium: acute management.

Guideline No. 28 (2nd ed) 2007.

CUHK medic 2010 33

Fetal medicine

Choroid plexus cyst Updated:11/20/2008

Definition

• Cyst in choroid plexus >=5mm in diameter

Clinical significance

• Present in 1 – 3 % of normal fetuses

• Usually resolve by 24 weeks
• Although it is regarded as one of the soft markers for fetal aneuploidies, isolated
choroid plexus cyst does not increase the risk of fetal aneuploidies

Clinical management

• If other structural abnormality is not detected and morphology scan is complete and
normal, no need to report
• If other structural abnormality is not detected but morphology scan is incomplete,
arrange repeat scan in 1 – 2 weeks to complete morphology scan (USGP or USGM)
• If other structural abnormality is detected : refer patient to Fetal Medicine Team for
further management (USG9 appointment in W7EA session)

References

• LS Chitty, P Chudleigh, E Wright, S Campbell, M Pembrey. The significance of

choroid plexus cysts in an unselected population: results of a multicenter study.
Ultrasound Obstet Gynaecol 1998; 12: 391-7.
• RC Reinsch. Choroid plexus cysts-association with trisomy: Prospective review of
16,059 patients. AJOG 1997; 176: 1381-3.
• JK Gupta, M Cave, RJ Lilford, TA Farrell, HC Irving, G Mason, CM Hau. Clinical
significance of fetal choroid plexus cyst. Lancet 1995; 346: 724-9.

CUHK medic 2010 34

Soft marker - provisional Updated:11/20/2008

Second Trimester Sonographic Soft Markers for Trisomy 21

Strong markers

Nasal hypoplasia

• Measure nasal bone in mid sagittal plane of facial profile

• =< 2.5 mm

Nuchal edema

• Measure nuchal fold in an angled transverse plane including cavum septum

pellucidum, cerebral peduncles and cerbellar hemisphere, from outer skin line to
outer occipital bone line
• >= 6 mm

Echogenic bowel

• Echogenicity of bowel as echogenic as adjacent iliac crest bone and does not fade
out before the adjacent iliac crest bone upon reducing the gain

Weak markers

Short humerus

• Humerus length < 2.5th percentile (-2SD)

Short femur

• Femur length < 2.5th percentile (-2SD)

Markers with disputed association with aneuploidies

Echogenic intracardiac focus

• Echogenic spot in ventricle as echogenic as adjacent rib bone and does not fade out
before the adjacent rib bone upon reducing the gain

CUHK medic 2010 35

Pyelectasis

• Measure anteroposterior width of renal pelvis in transverse plane from inner margin to
inner margin of the pelvis
• >= 4 mm

Markers that need to be dealt with in their own right

Nuchal edema
Pyelectasis
Echogenic bowel
Short humerus
Short femur

Management of soft markers on mid trimester scan

Isolated strong marker (Nasal hypoplasia, Nuchal edema, Echogenic bowel)

• If any one of the strong markers is detected, refer patient to Fetal Medicine Team for
further management (USG9 appointment in W7EA session)

Isolated weak marker or isolated marker with disputed association with aneuploidy
(Short humerus, Short femur, Echogenic intracardiac focus, Pyelectasis)

• If strong marker is not detected and morphology scan is complete and normal, no
need to report the presence of a soft marker. But if the marker needs to be dealt with
in its own right, manage according to the individual marker concerned as stipulated in
3.
• If strong marker is not detected but morphology scan is incomplete, arrange repeat
scan in 1 – 2 weeks to complete morphology scan (USGP or USGM)
• If any one of the strong markers is detected, refer patient to Fetal Medicine Team for
further management (USG9 appointment in W7EA session)

Markers that need to be dealt with in their own right

Pyelectasis

• Mild pyelectasis (AP width 4 – 7 mm)

o Book follow up scan (USGA) at 28 – 34 weeks
o Consult Paediatrician after delivery
• Hydronephrosis (AP width >= 8 mm)
o Refer patient to Fetal Medicine Team for further management (USG9)

CUHK medic 2010 36

Short humerus / Short femur

Refer patient to Fetal Medicine Team for further management (USG9 appointment in W7EA
session)

Anti-D Immunoglobulin Updated:10/31/2002

Indications

For prophylaxis for non-sensitized Rhesus D negative mothers.

Timing of administration

• See Rhesus D negative

Regimen

For all gestations and all sensitizing events:

• 250ug (1250iu) imi

• should be given as soon as possible after the event and always within 72 hours.
Beyond that, anti-D Ig should still be given within 10 days of the event
• no need for routine Kleihauer test after a sensitizing event
• no need to repeat anti-D Ig injection if it has been given within prior 4 weeks for
another sensitizing event.

CUHK medic 2010 37

Labour

Third stage of labour Updated:10/29/2008

Routine management of third stage of labour

Give oxytocic agent prophylaxis on delivery of baby

• For low risk cases:

o syntometrine im 1 ampoule im (will not be available by the end of 2008)
o syntocinon when syntometrine is contraindicated or unavailable
 5 units iv bolus over 1-2 minutes
 May need to give slower injection over at least 5 minutes if
patient has cardiac disease or particularly at risk of
hypotension
 10 units im is an alternative to iv, when iv access is not available

• For high risk cases such as parity >=4, mulitple pregnancy, co-existing fibroids,
polyhydramnios, placenta praevia, abruptio placentae:
o syntocinon infusion 40 units in 500ml crystalloid Q4H, or
o Carbetoicin 100mcg im

• Deliver the placenta:

o Attempt controlled cord traction when there is signs of separation:
 lengthening of cord
 gush of blood
 contracted uterus with rising of its fundus to umbilical level
o Empty urinary bladder if placenta is separated but retained.
o Do not apply fundal pressure and cord traction at the same time as uterine
inversion may occur.
o Examine placenta for completeness and any abnormalities.

• Inform Medical Officer if prolonged 3rd stage (retained placenta) or postpartum

haemorrhage.

• Take cord blood for blood gas assay (arterial and venous), thyroid function and
G6PD.
• Give newborns injection:
o vitamin K1 to all newborns.

CUHK medic 2010 38

 o hyperhep(hepatitis immunoglobulin) to newborns of hepatitis B carrier
mother.

Postnatal discharge Updated:11/6/2004

Time of discharge

• Usual length of stay after term delivery (calculated from the time of birth of the baby):
o Uncomplicated labour and vaginal delivery (included instrumental):
 3 days for parity 1 patients,
 2 days for patients of parity 2 or above
o Complicated labour and vaginal delivery: 3 days or more
o Caesarean section: 4 days or more

Patient's request for early discharge within 48 hours after birth

• Early discharge is allowed only if the following criteria are fulfilled:

o Uncomplicated vaginal delivery
o Patient should have been observed for at least 24 hours after birth
o Midwife has assessed the following:
 Patient is mobile with adequate pain control.
 Bladder and bowel functions are adequate.
 No problem in feeding baby.
 Stable emotion.
 Advice on perineal care has been given.
 Advice on postnatal follow-up and health check for both the mother
and the baby has been given.
 Patient is accessible to medical and social support including MCH,
postnatal ward hotline, postnatal clinic at Li Ka Shing Outpatient
Clinic, community nursing service, medical social worker when
needed.
 Patient can be contacted for follow-up.
o Doctor or intern has assessed the following:
 Perineal wound is normal.
 No postpartum haemorrhage or ongoing bleeding.
 No fever (> 38 degrees for two or more readings of at least one hour
apart) within 24 hours before discharge.
 Rh immunoglobulin has been given if indicated.

CUHK medic 2010 39

  No intrapartum or postpartum complications that require inpatient
medical treatment or observation.
 Follow up plan has been drawn for any antepartum, intrapartum or
postpartum problems or complications.
 Contraceptive advice has been given.
• For cases not fulfilling the above criteria: Decision should be made by a medical
officer on individual basis (or agreed by a medical officer after assessment by an
intern). If patient insists early discharge against medical advice, she should sign the
"Discharge with acknowledgement of medical advice" (DAMA).

Consultation
Anaesthetic consultation Updated:7/30/2002

• Patients with the following list of disorders require assessment by the obstetric
anaesthetic team.
• Schedule admission of these patients at early third trimester(or earlier if indicated) for
consultation or liaise with anaesthetist to see as outpatient.

Cardiac disorders

• Cyanotic heart disease or complex heart disease

• Valvular heart diseases:
o Moderate to severe mitral regurgitation
o Mitral stenosis
o Pulmonary stenosis / regurgitation
o Aortic stenosis / regurgitation
o Hypertrophic obstructive cardiomyopathy
• Cardiomyopathy
• Cardiac arrhythmia which either requires treatment or increases peripartum risk
• Pulmonary hypertension
• Coronary heart disease
• Pacemaker in-situ

Respiratory disorders

• Severe asthma
• Previous tracheostomy or other problem with the major airway
• Previous pneumonectomy

Skeletal disorders

• Chest deformity e.g. scoliosis, kyphosis

CUHK medic 2010 40

 • Rheumatoid arthritis with risk of cervical joint subluxation

Miscellaneous

Any other underlying conditions that potentially will affect blood transfusion, general and
regional anaesthesia:

• Intracranial space occupying lesions

• Increased intracranial pressure
• Refusal of blood transfusion e.g. Jehovah's witness
• Cross match problems
• Bleeding tendency (e.g. thrombocytopenia < 50, Von Willebrand's disease)
• Patient currently put on anticoagulant or aspirin
• Past history of anaesthetic problems
• Any other moderate or severe systemic disturbance due to medical or surgical
disease, or systemic disturbance which poses a constant threat to life and is
incapacitating.

Neonatologist consultation Updated:11/28/2008

Indications for neonatalogists to standby at delivery in PWH

• Multiple gestation
• Premature labour (<34 weeks)
• Estimated fetal weight < 2 kg
• Vaginal breech delivery
• Difficult delivery e.g. shoulder dystocia
• Suspected fetal distress (non-reassuring fetal heart rate patterns)
• Moderate or thick meconium-stained / blood stained amniotic fluid
• Oligohydramnios or no liquor
• Suspected intrauterine infection / chorioamnionitis
• Prolapsed cord
• Fetuses with known or suspected malformation that might require immediate medical
attention at birth, e.g. exomphalos, hydrocephalus, diaphragmatic hernia
• Abruptio placenta
• Placenta previa
• Severe hypertension of the mother requiring i.v. sedation / eclampsia

Other conditions in which the obstetrician anticipates adverse neonatal outcome

Conditions required neonatal medical officer"s assessment after delivery

• Fetal conditions

CUHK medic 2010 41

 o Congenital malformations
o Respiratory depression at birth
• Maternal disorders:
o endocrine diseases, e.g. diabetes mellitus, thyrotoxicosis
o autoimmune diseases, e.g. systemic lupus erythematous, myasthenia gravis,
immune thrombocytopenic purpura
o infectious risk e.g. syphilis, Group B streptococcus carrier
o medical diseases on drugs that may affect the baby, e.g. anti-epileptic, anti-
psychotic
o substance abuse
o Unattended delivery
o Other conditions as instructed by obstetricians

Conditions requiring notification of NNU upon admission to labour ward

• Gestation of 35 weeks or less

• Severe IUGR or severe oligohydramnios
• Major congenital disorders which may require special neonatal care or immediate
surgery
• Multiple pregnancy
• Other conditions as instructed by obstetricians

CUHK medic 2010 42

Drugs

Steroid cover Updated:5/23/2005

Indications for steroid cover during labour, delivery and surgery

• Patients on long-term oral corticosteroids > 10 mg prednisolone daily (or equivalent)

or have received this dose in the last three months.
• Dosage of various kinds of steroid that is equivalent to 10mg prednisolone:
Dexamethasone or Betamethasone 1.5mg
Methylprednisolone 8mg
Hydrocortisone 40mg
Cortisone acetate 50mg
• Steroid cover is not indicated when:
o oral daily prednisolone intake is 10mg or less or the last dose of steroid is
more than 3 months ago.
o short course of steroids for 1 - 2 week.

Regimen

Labour and intrapartum caesarean section

• Give usual dose of steroid before labour

• Give 25mg ivi hydrocortisone Q6H at onset of labour till delivery
• Resume usual steroid dose post-delivery
• In case of complicated instrumental delivery or emergency caesarean section,
continue IV hydrocortisone 25 mg Q6H till 24 hour after delivery or longer till oral
intake is resumed

Minor sugery

• For example: cervical cerclage, fetoscopic surgery, first trimester surgical TOP,
operation for ectopic pregnancy.
• Give usual dose of steroid pre-operatively
• Give stat 25mg ivi hydrocortisone on-call to OT
• After uneventful surgery, resume usual steroid dose on resumption of oral intake

CUHK medic 2010 43

Intermediate surgery

• For example: elective or pre-labour emergency caesarean section, appendicectomy,

cholecystectomy, ovarian cystectomy complicating pregnancy
• Give usual dose of steroid pre-operatively
• Give stat 25mg ivi hydrocortisone on-call to OT
• then 25mg ivi hydrocortisone Q6H for 24 hours post-operatively or longer till oral
intake is resumed
• After uneventful surgery, resume usual steroid dose on resumption of oral intake

Major surgery or complications

• For example: internal iliac artery ligation, uterine artery embolization or caesarean
hysterectomy; septicaemia; DIC
• Increase to IVI hydrocortisone dose to 50 mg Q6H and gradually wean off at 48-72
hrs post-op/post-delivery
• Maintain this regimen until light diet started and usual steroid dose is resumed

Corticosteroid Updated:7/14/2008
For enhancement of fetal lung maturity:

• Dexamethasone
• Betamethasone

For Maternal indications:

• steroid cover during surgery / labour in patients who have received prolonged steroid
treatment

Dexamethasone Updated:7/3/2008

Indication

• Give >=24 and <34 week for fetal lung maturation

Regimen

• 6mg im/iv Q12H for 4 doses

Contraindications

• chorioamnionitis
• active TB

CUHK medic 2010 44

Special precautions

• Poorly controlled diabetes mellitus

Repeat dexamethasone

• It should not be routinely given, but can be considered in cases in which the ongoing
risk of preterm delivery remain high
• Decision should be made by a specialist
• No more than 3 courses in total should be given
• The repeat course should not be given in less than 1 week interval
• Should not be given in case of PPROM

Nevirapine Updated:11/6/2002

Nature

• A non-nucleoside reverse transcriptase inhibitor of HIV-1.

Indication

• To reduce the risk of vertical transmission of HIV from HIV-positive mothers to their
babies.
• Not routinely given, but individualized treatment.

Regimen

• Intrapartum maternal therapy:

o 200mg po single dose 1 hour prior to Caesarean section or at the onset of
labour
• Neonatal therapy:
o To be decided by paediatrician.

Contra-indication

• Hypersensitivity

Toxicity

• Rash
• Deranged liver function (reported with multiple doses in non-pregnant patients)

CUHK medic 2010 45

Discussion / Justification

• If the mother has not been treated with antenatal Zidovudine, a two-dose
intrapartum/newborn Nevirapine is superior to Zidovudine alone by 47% and as
effective as Zidovudine + Lamivudine in reducing vertical transmission rate.
• Due to the high frequency of nevirapine-resistant mutations of the HIV-1 virus,
Lamivudine + Zidovudine is the preferred regimen to Nevirapine for intrapartum
treatment for HIV +ve mothers who have not received antenatal Zidovudine therapy.
• The addition of intrapartum Nevirapine to Zidovudine for patients who have received
full antenatal Zidovudine has not been shown to be of benefit.

References

• Dorenbaum A, Cunningham CK , Gelber RD. Two-dose intrapartum/newborn

Nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission. A
randomized trial. PACTG 316. JAMA 2002;288(2):189-198.
• Mandelbrot L, Landreau-Mascaro A, Rekacewicz C et al. Lamivudine-Zidovudine
combination for prevention of maternal-infant transmission of HIV-1. JAMA.
2001;25:285(16):2083-93.

Lamivudine Updated:11/6/2002

Lamivudine therapy

Nature

• A nucleoside reverse transcriptase inhibitor of retrovirus including HIV.

Indication

• To reduce the risk of vertical transmission of HIV from HIV-positive mothers who have
not received antenatal Zidovudine therapy.
• Not routinely given, but individualized treatment.

Regimen

• Intrapartum maternal therapy

o orally 150mg every 12 hours till delivery
o combined with oral Zidovudine
• Neonatal therapy by paediatrician

Discussion / Justification

CUHK medic 2010 46

 • If the mother has not been treated with antenatal Zidovudine,Lamivudine +
Zidovudine is preferred to Nevirapine for the intrapartum treatment for HIV +ve
mothers who had not received antenatal Zidovudine therap, due to the high frequency
of nevirapine-resistant mutations of the HIV-1 virus.
• Early observational study suggested Lamivudine might provide additional benefit to
Zidovudine in reducing HIV vertical transmision rate.
• However, Lamivudine is associated with high frequency of Lamivudine-resistant
mutations of the virus and there is insufficient data to recommend routine addition of
Lamivudine to Zidovudine for patients who have received full antenatal Zidovudine
therapy.

References

• Mandelbrot L, Landreau-Mascaro A, Rekacewicz C et al. Lamivudine-Zidovudine

combination for prevention of maternal-infant transmission of HIV-1. JAMA. 2001 Apr
25;285(16):2083-93.
• The Petra Study Team. Efficacy of three short-course regimens of zidovudine and
lamivudine in preventing early and late transmission of HIV-1 from mother to child in
Tanzania, South Africa, and Uganda (Petra study): a randomised, double-blind,
placebo-controlled trial. Lancet 2002;359:1178-86.

Zidovudine Updated:11/1/2002

Zidovudine therapy

Nature

• A nucleoside reverse transcriptase inhibitor of retrovirus including HIV.

Indication

• To reduce the risk of vertical transmission of HIV from HIV-positive mothers to their
babies

Regimen

• Antenatal maternal therapy:

o 300mg b.d. orally
o Specialist from QEH(SMS)/DH(SPP) may give the dosage differently in order
to improve compliance
• Intrapartum maternal therapy
o If patient had antenatal Zidovudine therapy

CUHK medic 2010 47

  2mg/kg iv loading dose over 30-60min, then 1mg/kg per hour iv till
clamping of cord
o If patient had not received antenatal Zidovudine therapy
 300mg oral therapy for loading following by 300mg q3h till delivery
 Combined with Lamivudine
• Neonatal therapy
o Give Zidovudine syrup 2mg/kg po 4 doses/day for 6 weeks
o or if not tolerate orally,give iv 1.5mg/kg over 30min Q6H
o start therapy within 8 to 12 hours of birth
o if no intrapartum therapy was given, start therapy immediately after delivery

Monitoring of Zidovudine therapy

• To be performed by specialist from QEH(SMS)/DH(SPP)

o baseline CBP, LFT, CPK then
o CBP Q2weeks for 1 month, then Q4 weeks
o LFT, CPK Q4 weeks
o Consider discontinuation if:
 Hb<8g/dl
 Platelet<100x109/L
 WCC<75x109/L
o ALT/AST >5X normal

Discussion / Justification

• Zidovudine is the mainstay of treatment for the prevention of perinatal HIV

transmission and should be recommended because it is found to be safe to both the
mother and the baby on the 5-year follow-up studies from the PACTG 076 trial.
• If the mother has not been treated with antenatal Zidovudine, a two-dose
intrapartum/newborn Nevirapine is superior to Zidovudine alone by 47% and as
effective as Zidovudine + Lamivudine in reducing vertical transmission rate.
• Singel agent nevirapine is associated with high frequency of nevirapine-resistant
mutations of the HIV-1 virus
• The addition of Nevirapine to standard Zidovudine therapy has not been shown to be
of benefit

References

• Conner EM, Sperling RS, Gelber R et al. AIDS Clinical Trials Group (ACTG) 076.
Reduction of maternal-infant transmission of HIV type 1 with zidovudine treatment. N
Engl J Med 1994; 331: 1173-80

CUHK medic 2010 48

 • Culnane M, Fowler M, Lee S et al. Lack of long-term effects of in utero exposure to
zidovudine among uninfected children born to HIV-infected women. JAMA 1999;
281(2): 151-157
• Hanson IC, Antonelli TA, Sperling RS et al. Lack of tumours in infants with perinatal
HIV-1 exposure and fetal/neonatal exposure to zidovudine. J Acquir Immune Defic
Syndr Hum Retroviraol 1999; 20: 463-467
• Dorenbaum A, Cunningham CK , Gelber RD et al. Two-dose intrapartum/newborn
Nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission. A
randomized trial. PACTG 316. JAMA 2002;288(2):189-198.
• Mandelbrot L, Landreau-Mascaro A, Rekacewicz C et al. Lamivudine-Zidovudine
combination for prevention of maternal-infant transmission of HIV-1. JAMA. 2001 Apr
25;285(16):2083-93.

Oxytocic agent Updated:8/13/2008

Drugs

• Oxytocin deviatives
o Syntocinon
o Syntometrine
o Carbetocin
• Prostaglandins deviatives
o PGE2
o Hemabate
o Misoprostol
o Cervagem

Indications

• Rippening of cervix: PGE2

• Induction or augmentation of labour: syntocinon
• Prophylaxis and treatment of postpartum haemorrhage: syntocinon, syntometrine,
hemabate
• For termination of pregnancy or treatment of abortion: misoprostol, cervagem

Syntocinon Updated:10/29/2008

Indications

• Induction of labour
• Augmentation of labour

CUHK medic 2010 49

 • Prophylaxis and treatment of postpartum haemorrhage in the third stage of labour

Regimen

• For induction and augmentation of labour:

o Start infusion using either infusion drip set or syringe pump (see table 1), and
titrate the infusion rate accordingly.
o Maintain the infusion rate if adequate contractions (3 to 4 contractions per 10
minutes) are achieved, till the next cervical assessment.
o Inform medical officer if more than 20 mu/min of oxytocin is required to
achieve optimal uterine contractions.

• For intrapartum managment third stage of labour:

o iv bolus 5 units over 1-2 minutes, or
o im bolus 10 units if no iv access available and in absolute emergency
(unlicensed route)
 patients with cardiac disease or those particularly at risk of
hypotension should have the iv bolus 5 units given slower i.e. over 5
minutes
o iv infusion 40 units in 500ml crystalloid solution Q4H once

Table 1. Syntocinon Infusion

Time after Oxytocin dosage Infusion rate for 10 units in Infusion rate for 5 units in
starting (milliunits per 500ml of Hartmann 50 ml of Hartmann
minutes) solution (ml/hour) solution (ml/hour)
0 1 3 0.6
30 2 6 1.2
60 4 12 2.4
90 8 24 4.8
120 12 36 7.2
150 16 48 9.6
180 20 60 12.0
210 24 72 14.4
240 28 84 16.8
270 32 96 19.2

Remark

• Midwives can adminster syntocinon bolus injection at third stage of labour according
to departmental standing order.

References: Thomas TA and Cooper GM. Maternal deaths from

anaesthesia. An extract from Why Mothers Die 1997-1999, the

CUHK medic 2010 50

Confidential Enquiries into Maternal Deaths in the United Kingdom.
Br J Anaesth 2002;89:499-508. FDA website:
http://www.drugs.com/pro/syntocinon.html

Carbetocin - provisional Updated:8/13/2008

Pharmacology

• a long-acting synthetic nonapeptide analogue of oxytocin with agonist properties

Indication

• first line prophylaxis against postpartum haemorrhage in high risk cases during the
third stage of labour.

Contraindications

• allergic to carbetocin, known vascular disease, especially coronary artery disease;

hepatic or renal disease

Regime

• 100mcg im or iv injection(1 ampoule / 1ml)

Misoprostol Updated:1/8/2009

Nature of Misoprostol (Cytotec)

• A PGE-1 analogue of the prostaglandin group

Indications

• First line treatment for first and second trimester miscarriages to evacuate the uterus
• First line treatment for second trimester medical induced abortion
• First line treatment for cervical ripening prior to mechanical cervical dilatation for first
trimester suction termination of pregnancy

Caution

• Patients with high risk for uiterine rupture, hypersensitivity, severe cardiac disease.

Adverse reactions

CUHK medic 2010 51

 • Uterine rupture

Side effects

• GI upset, vomiting, diarrhoea, pyrexia

Route of administration

• Oral or vaginal

Regimen

• For medical evacuation of the uterus for first trimester miscarriage, single dose of
800micrograms vaginally.
• For medical evacuation of the uterus for second trimester abortion (spontaneous or
induced), 400micrograms every 3 hours vaginally for 5 doses. May repeat the course
if necessary. If 2 courses fail, consider change to gemeprost.
• For cervical ripening prior to mechanical cervical dilatation for first trimester suction
termination of pregnancy, 200micrograms single dose vaginally 3 hours before the
procedure

Discussion / Justification

• Vaginal Misoprostol is more effective than Gemeprost in second trimester TOP.

• Vaginal route of Misoprostol is more effective than oral Misoprostol in second
trimester induced abortion
• For cervical priming, oral Misoprostol is better than vaginal Gemeprost with greater
baseline cervical dilatation and easier dilatation.
• For cervical priming, 200mcg vaginally is as effective as 400mcg vaginally
• For cervical priming, vaginal Misoprostol is more effective if given 2-4hrs prior to
surgery than oral Misoprostol given 8-12 hrs prior to surgery.

References: Wong KS, Ngai CSW, Wong AYK et al. Vaginal

Misoprostol compared with vaginal Gemeprost in termination of
second trimester of pregnancy. Contraception 1998;58:207-210.
Gilbert A, Reid R. A randomized trial oral versus vaginal administration of Misoprostol for the
purpose of mid-trimester TOP. ANZJOG 2001;41(4):407-410. Ngai SW, Au Yeung KC, Lao T
et al. Oral Misoprostol versus vaginal Gemeprost for cervical dilatation prior to vacuum
aspiration in women in the sixth to twelfth week of gestation. Contraception 1995;51:347-350.
Ngai SW, Chan YM, Tang OS et al. The use of Misoprostol for pre-operative cervical dilatation
prior to vacuum aspiration: a randomized trial. Human Reprod 1999;14:2139-2142. Lawrie A,
Penney G, Templeton A. A randomized comparison of oral and vaginal Misoprostol for cervicla
priming before suction termination of pregnancy. BJOG 1996;103(11):1117-9. Carbonell JL,

CUHK medic 2010 52

Velazco A, Rodriguez Y et al. Oral versus vaginal Misoprostol for cervical priming in first-
trimester abortion: a randomized trial. Eur J Contraception Reprod Health Care
2001;6(3):134-140

Sulprostone Updated:6/22/2002

Indication

• A PGE2-analogue for induction of abortion or induction of labour after intra-uterine

death when other treatment has failed
• Decide treatment by FHKAM and senior call

Contraindications

• Asthma
• Cardiac disease
• Hepatic or renal failure

Regimen

• Add 500mcg to 250ml of NS for infusion

• Infuse at 100mcg per hour
• May infuse continuously for 10 hours
• Never exceed infusion rate of 500mcg per hour
• Maximum totol dosage of 1500mcg

Side effects

Nausea, vomiting, diarrhoea, headache, fever

Warfarin Updated:10/11/2007

Indication

• As prophylaxis and treatment of thromboembolism in postpartum (it is rarely used

antenatally with the exception of metabllic valve replacement)

Regimen

CUHK medic 2010 53

 • Baseline INR before commencement
• Start loading dose 5 mg daily at both Day 1 and day 2
• Check INR from Day 3 onwards
• Titrate the warfarin dosage to reach the target INR
• The sliding scale is a reference for warfarin dose at day 3 and day 4 while further
dosage will be adjusted according to the response to previous dose
• Please consult specialist in medical medicine or physician for the management in all
cases on warfarin
• It is preferred to start warfarin at evening and blood taking for INR at morning)

INR Warfarin dosage

<=1.5 5 mg
> 1.5 - 2.0 4 mg
> 2.0 - 2.5 3 mg
> 2.5 - 3.0 2 mg
> 3.0 - 3.5 1.5 mg
> 3.5 omit warfarin for 1 day

CUHK medic 2010 54

Misc

CS wound complication Updated:6/22/2002

Management of wound dehescience and wound infection

Initial assessment

• Inform medical officer and Midcall-1 in charge of the case and the principal surgeon
for the operation.
• Initial wound assessment should be performed by a senior midwife, an intern and the
medical officer in charge.
• Record the size and depth of the wound, the presence or absence of
haematoma/pus/necrotic tissue/cavity and surrounding cellulitis.
• Take a wound swab for culture and sensitivity.

Care of the wound

• Irrigate wound with normal saline and dress the wound one to three times daily.
Frequency of dressing is to be decided by the Medical officer in charge. Usually once
daily dressing would reduce disturbance of the wound and promote healing.
• Liaise with midwife for the best type of dressing.

Antibiotic treatment

• Empirical treatment of Augmentin 375mgtds should be started while awaiting for swab
culture result.
• Patients allergic to penicillin should use erythromycin 500mg qid.
• Augmentin has good coverage for Group B strep, most G-negative oragnisms, most
anaerobes and also Staph. aureus (methicillin-sensitive), although sensitivity of these
organisms to Augmentin is not always tested e.g. Staph. aureus
• If in doubt of the sensitivity of the cultured organism to Augmentin, please consult
microbiologist before changing the already-started antibiotic regimen.
• Antibiotics should continue for at least 7-10 days.

Resuturing of the wound

• Time of resuturing is to be decided by the Medical Officer in charge

• General anaesthesia is preferred to resuture the wound, unless the patient prefers
local anaesthesia

CUHK medic 2010 55

 • Re-suturing should be performed either in the main Gynaecological operation theatre
(under GA) or the ward treatment room under aseptic technique (under LA).
Surgeons should be properly gowned up.
• Removal of the new sutures should be performed at least 7-10 days after re-suturing.
Patient can be managed as out-patient after re-suturing and followed up in the ward
for the removal of sutures.
• In case of a second wound dehiscence, Midcall 1 is to be involved to take personal
care of this complicated patient.

Discussion / Justification

Management of wound dehescience and wound infection

Initial assessment

• Inform medical officer and Midcall-1 in charge of the case and the principal surgeon
for the operation.
• Initial wound assessment should be performed by a senior midwife, an intern and the
medical officer in charge.
• Record the size and depth of the wound, the presence or absence of
haematoma/pus/necrotic tissue/cavity and surrounding cellulitis.
• Take a wound swab for culture and sensitivity.

Care of the wound

• Irrigate wound with normal saline and dress the wound one to three times daily.
Frequency of dressing is to be decided by the Medical officer in charge. Usually once
daily dressing would reduce disturbance of the wound and promote healing.
• Alginate should be used if packing is needed for wounds with lots of discharge.

Antibiotic treatment

• Empirical treatment of Augmentin 375mgtds should be started while awaiting for swab
culture result.
• Patients allergic to penicillin should use erythromycin 500mg qid.
• Augmentin has good coverage for Group B strep, most G-negative oragnisms, most
anaerobes and also Staph. aureus (methicillin-sensitive), although sensitivity of these
organisms to Augmentin is not always tested e.g. Staph. aureus
• If in doubt of the sensitivity of the cultured organism to Augmentin, please consult
microbiologist before changing the already-started antibiotic regimen.
• Antibiotics should continue for at least 7-10 days.

Resuturing of the wound

CUHK medic 2010 56

 • Time of resuturing is to be decided by the Medical Officer in charge
• General anaesthesia is preferred to resuture the wound, unless the patient prefers
local anaesthesia
• Re-suturing should be performed either in the main Gynaecological operation theatre
(under GA) or the ward treatment room under aseptic technique (under LA).
Surgeons should be properly gowned up.
• Removal of the new sutures should be performed at least 7-10 days after re-suturing.
Patient can be managed as out-patient after re-suturing and followed up in the ward
for the removal of sutures.
• In case of a second wound dehiscence, Midcall 1 is to be involved to take personal
care of this complicated patient.

CUHK medic 2010 57