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: Tam: Materials included inc luded are only meant for reference, and a nd 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 Fetall medicine Feta medicine.... ........ ........ ....... ...... ...... ...... ...... ...... ...... ...... ...... ..... ..34 Second Trimester Trimester Sonographic Soft Markers Mar kers for f or Triso Trisomy my 21... ..... .... .... .... .... .... ..... ..... .... .... .... ..35 Labour Lab our.... ........ ........ ........ ....... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... .....38 Drugss.... Drug ......... ......... ........ ........ ........ ........ ........ ....... ...... ...... ...... ...... ...... ...... .....43 Misc............. .......................... ......................... ....................... ................ ........ ... 55
CUHK medic 2010
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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, praevia , abruptio placentae, placentae, genital tract lesions
•
Document the amount of bleeding by history and speculum examination.
•
Perform CTG if >= 26 weeks.
•
Consider induction Consider induction of labour or 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 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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APH
APH of unknown origin
Updated:7/14/2008
Diagnosis and Management of Antepartum Haemorrhage of Unknown Origin •
Rule out other causes: placenta praevia, praevia , abruptio placentae, placentae, genital tract lesions
•
Document the amount of bleeding by history and speculum examination.
•
Perform CTG if >= 26 weeks.
•
Consider induction Consider induction of labour or 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 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 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. labor. Ultrasound Obstet Gynecol. 2003 Jun;21(6):552-5.
Cervicovaginal fibronectin test
Updated:7/14/2008
Introduction •
Fetal fibronectin (fFN) is an extracellular extracellular matrix protein found in the decidua basalis next to the placental intervillous intervillous space. It acts like a ‘glue’ attaching 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 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. 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 t he 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 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 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 CUHK medic 2010
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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:
o
Regimen:
•
30ml of 0.3M po once
Panadol o
Purpose:
o
for post-delivery pain relief
Regimen:
•
premedication prior to emergency caesarean section
500mg po QID prn
Potassium permaganate (KMnO4), Zinc oxide, hirudoid, sitz bath o
Purpose:
o
for local treatment of perineal wound
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:
o
for routine newborn immunization
Regimen:
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hepatitis B vaccine 0.5ml imi
polio 0.25ml po
BCG vaccine
7
•
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:
•
Arrange a routine follow-up appointment at general gynaecology clinic in the
o
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 CUHK medic 2010
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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 t reatment 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 s hould 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
o
Fetal growth restriction or features of utero-placental insufficiency
≥
90 µmol/l or oliguria (< 500 ml/24 h)
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
•
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
≤
34 weeks
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)
o
Use a lower dose at 0.5 g per hour in case of renal impairment
Monitoring while on MgSO4
Hourly urine output
Check deep tendon reflex hourly (e.g. biceps reflex if patient is /has been on regional anaesthesia)
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Check respiratory rate hourly
22
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)
o
Stop labetalol if maternal heart rate falls below 70/min
Avoid in the presence of pulmonary edema, heart failure or with asthma
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)
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Consider other alternative antihypertensive if hydrallazine fails to control
23
BP or causes maternal side effects (e.g. tachycardia >120/min)
o
Caution: Maternal hypotension may occur with bolus or infusion regimen
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%
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•
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
Normal pregnancy Therapeutic Loss of patellar reflex Prolonged AV conduction Respiratory failure Cardiac arrest
Serum level (mmol/l) 1 2-4 5 6 7.5 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
o
Regimen: 5-10 mg slow IV bolus (given over about 1 minute)
MgSO4 is used to prevent further recurrent convulsion
If eclampsia occurs before commencement of MgSO4, start loading dose infusion over 5 min
CUHK medic 2010
If eclampsia occurs during initial loading dose, complete the loading dose 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.
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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 CUHK medic 2010
Updated: 2007 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 membranes
Ampicillin 2.0g ivi
Vancomycin 1.0g iv infusion
Intrapartum
Ampicillin 500mg ivi Q6H
Vancomycin 1.0g iv infusion Q12H
Postpartum
Not required
Not required
Remarks •
Risk of infective endocarditis under an ordinary elective or pre-labour caesarean section is very low so that antibiotic cover is not indicated for the above cardiac conditions
•
•
Vancomycin infusion guideline o
reconstitute in 20 ml water, and dilute with 200 ml NS
o
infuse over at least 100 min
Consult physician o
for the vancomycin dosage in case of severe renal impairment
o
for opinion if patient allergic to both ampicillin and vancomycin
Discussion / Justification AHA has reviewed the topic and updated the guideline on antibiotic prophylaxis in May 2007. Reference: AHA Prevention of Infective Endocarditis. A guideline from the American Heart Association Rheumatic fever, endocarditis, and Kawasaki disease committee, council on cardiovascular disease in the young, and the council on clinical cardiology, council on cardiovascular surgery and anesthesia, and the quality of care and outcomes research interdisciplinary working group. Circulation. published online, Apr 19, 2007.
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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
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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
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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
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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.
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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 marker s 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.
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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
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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)
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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.
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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.
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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.
o
Patient can be contacted for follow-up.
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.
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Rh immunoglobulin has been given if indicated.
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
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•
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
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•
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, antipsychotic
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
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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 Methylprednisolone Hydrocortisone Cortisone acetate
•
1.5mg 8mg 40mg 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
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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
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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)
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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
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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:
o
Hb<8g/dl
Platelet<100x109/L
WCC<75x109/L
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
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•
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
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•
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 starting (milliunits per minutes)
Infusion rate for 10 units in Infusion rate for 5 units in 500ml of Hartmann 50 ml of Hartmann 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
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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
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•
Uterine rupture
Side effects •
GI upset, vomiting, diarrhoea, pyrexia
Route of administration •
Oral or vaginal
Regimen •
For medical evacuation of the uterus for f irst 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
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Velazco A, Rodriguez Y et al. Oral versus vaginal Misoprostol for cervical priming in firsttrimester 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
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•
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
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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
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•
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.
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