Obstetric Conditions

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ANTENATAL CARE (2016 WHO MODEL)

Prioritize on person-centered health and well-being to prevent maternal and perinatal morbidity and mortality and provide a positive pregnancy experience through timely and appropriate evidence-based practices implemented throughout normal pregnancy and childbirth.

Recommended interventions:   

  1. Nutrition interventions
  2. Maternal and fetal assessment
  3. Preventive measures
  4. Interventions for common physiological symptoms
  5. Health system interventions to improve utilization and quality of ANC

Frequency and timing of contacts in the 2016 WHO ANC model

  • First trimester: Up to 12 weeks
  • Second trimester: 20 weeks and 26 weeks
  • Third trimester: At 30, 34, 36,38 and 40 weeks.

Note: Inform the woman to return for delivery after one week if not delivered

Hemoglobin (once every 3 months), blood grouping and rhesus, VDRL, PITC (at booking visit and 3 months after), HBsAg and Hepatitis C antibody test, urine dipsticks (at each visit), at least an early USS (if not available and if necessary, then refer) 

TREATMENT/MANAGEMENT

  • Full history and examination
  • Preventive measures: Folic acid 0.4mg PO daily (3 months preconception up to 12 weeks GA), Insecticide treated net, Tetanus Vaccine (TTV) (schedule: at 0, 4weeks after 1st dose, 6 months after 2nd dose, one year after 3rd dose, one year after 4th dose), SP 3 tablets stat every 4-6 weeks, albendazole 400mg stat dose (Once off).
  • 60mg Elemental Iron daily or 300mg Ferrous Sulphate or equivalent or multimineral supplements (MMS), single dose 1500/75mg Sulfadoxine Pyrimethamine (schedule: every month from >/= 13 weeks), single dose 400mg Albendazole or 500mg Mebendazole, COVID Vaccine
  • Counsel on healthy eating and keeping physically active, early presentation if unwell

 

HYPERTENSIVE DISORDERS IN PREGNANCY

CLINICAL DESCRIPTION

Systolic BP greater than 140 mm Hg and Diastolic BP greater than 90 mm Hg on at least two occasions of four hours apart, hypertensive disorders in pregnancies are major cause of perinatal morbidity and mortality.

CLINICAL FEATURESSIGNS AND SYMPTOMS

Classification of hypertensive disorders in Pregnancy

Chronic hypertension 

Onset before pregnancy or onset at < 20 weeks gestation or persistent HTN after 12 weeks post-partum, baseline proteinuria may or may not exist.

Gestational HTN 

Onset after 20 weeks gestation and HTN resolves by 12 weeks postnatal, no proteinuria.

Preeclampsia super imposed on chronic hypertension 

HTN before pregnancy or onset at <20 weeks gestation or persistent after 12 weeks post-partum plus.

New onset proteinuria or worsening of pre-existing proteinuria 

 

Preeclampsia 

Gestational hypertension accompanied by one or more of the following new-onset conditions:

Proteinuria 

Signs & symptoms of significant end organ dysfunction

Visual disturbance (Photopsia and or scotomata)

Severe headache or persistent headache

Altered mental status

Persistent right upper quadrant pain or epigastric pain unresponsive to analgesia

Thrombocytopenia(< 100 platelets/microL)

Progressive renal insufficiency (serum creatinine >0.9mg/dl or 97.3 micromole/L), acute kidney injury

Pulmonary oedema

 

Left ventricular failure

Placental insufficiency (oligohydramnios, IUGR, fetal demise) 

Eclampsia 

Preeclampsia plus new-onset, generalized, tonic-clonic seizures or coma 

TREATMENT

PHARMACOLOGICAL

Management of Gestational hypertension 

At the health centre 

  • If >/=160/110mmHg
    • Give Hydralazine 5mg slow IV push over 20 minutes
    • or Nifedipine 10mg PO stat
  • If </= 160/110mmHg
    • Give Methyldopa 500mg PO stat
  • Refer to the hospital

At the hospital

  • Control blood pressures with Methyldopa, Nifedipine or Hydralazine to levels of less than 160mmHg systolic and less than 110mmHg
  • If blood pressures are still >/= 160/110mmHg after a maximum of 20mg of Hydralazine and at the district hospital, discuss with a consultant and refer
  • If the blood pressure is still high and at the central hospital, give Hydralazine infusion
  • Monitor for features of preeclampsia
  • Review in high-risk antenatal clinic if stable
  • Deliver at 38 weeks 6 days

Management of Pre-eclampsia

At the health Centre 

  • If >/=160/110mmHg
    • Give Hydralazine 5mg slow IV push or nifedipine 10mg po stat
  • If </= 160/110mmHg
    • Give Methyldopa 500mg po stat
  • If patient has severe features start magnesium sulphate
    • Give a loading dose of 4g Magnesium Sulphate 20% solution in 500 ml of Normal Saline infused over 10 minutes plus 5 g of Magnesium Sulphate 50% solution in each buttock deep IM with 1 ml of 1% lignocaine
    • If only 50% Magnesium sulphate solution is available: mix 8mls of 50% solution of Magnesium sulphate with 12mls of normal saline to make 20% Magnesium sulphate solution 
  • If gestational age is less than 34 weeks, give Dexamethasone 6mg IM 12 hourly for 48hours
  • Refer immediately to the next level of care

At the hospital

  • All women with pre-eclampsia should be hospitalized and placed in labour ward or HDU for evaluation.
  • Blood pressure management as above; If the blood pressure are still high and at the central hospital, give hydralazine infusion
  • If the blood pressures are still high, then start labetalol 20mg IV slow push
  • Blood pressures should be consistently maintained below 160mmHg systolic and below 110 mmHg diastolic. Avoid lowering BP abruptly. DO NOT GIVE Nifedipine sublingual
  • If patient has severe features start magnesium sulphate as at the health Centre
    • Monitor urine output, respiratory rate.
    • Monitor for signs of Magnesium sulphate toxicity (Absent deep tendon reflex, respiratory rate < 10/ minute, Respiratory distress (oxygen saturations < 92%).
    • If convulsion occurs within or after 15 minutes after the loading dose, reload patient by giving 2g MgSO4 in 250 mL of normal saline or ringers lactate given over 20 minute.
    • Withhold or delay drug if:
      • Respiratory rate falls below 16 per minute.
      • Patellar reflexes are absent.
      • Urinary output has fallen below 30 mL per hour over the preceding 4 hours.
    • In case of respiratory arrest:
      • Shout for help
      • Assist ventilation with mask and bag.
      • Give Calcium Gluconate 1 g (10 mL of 10% solution) in 100ml N/S IV slowly over 10-20minutes.
  • If gestational age is less than 34 weeks, give Dexamethasone 6mg IV 12 hourly for 48hours.
  • Do urgent FBC, U & Creatinine, AST & ALT.
  • Fetal monitoring in pre-eclampsia should include assessment of fetal biometry, amniotic fluid.
  • If pre-eclampsia with severe features deliver immediately through induction of labour and for those with contra-indications to induction of labour perform a caesarean section.
  • If pre- eclampsia without severe features, consider delivery at 34-week gestation or earlier if severe features develop.
  • If facility has nursery deliver after completion of dexamethasone, if no nursery refer patient to a facility with neonatal care.

Postpartum

  • Keep on Magnesium sulphate 24 hours after delivery and continue to monitor BPs.
  • If still high, keep on Nifedipine.
  • Discharge after 48 hours of being stable.
  • Review in clinic after one week after discharge.

Management of Eclampsia 

  • Check circulation, airway, breathing (CAB). Correct hypoxia with oxygen as needed.
  • Protect patient from injury (left lateral position in bed with rails or on floor)
  • Admit to LW or HDU
  • Blood pressure control as described above
  • Magnesium Sulphate protocol as described above
  • If at the health centre refer immediately
  • If at the hospital control blood pressures and seizures and deliver by the quickest method

 

PRETERM LABOUR AND BIRTH

CLINICAL DESCRIPTION

Onset of contractions that cause progressive cervical dilation at < 37 weeks gestation. It’s associated with significant neonatal morbidity and mortality, especially between 28-34 weeks gestation.  

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Lower abdominal pain, lower back pain, may have rupture of the membranes or not, contractions, cervical dilatation, and effacement on VE.

INVESTIGATIONS

  • FBC, Urine dipsticks and urine microscopy
  • Check MPs and MRDT

TREATMENTPrevention

  • Screen and treat asymptomatic UTI / bacteriuria.
  • If previous preterm birth and current singleton gestation, then treat with Hydroxyprogesterone Acetate 250mg.
  • Offer a choice of either prophylactic vaginal progesterone or prophylactic cervical cerclage to women with: 
    • A history of spontaneous preterm birth or mid-trimester loss between 16+0 and 34+0 weeks of pregnancy and in whom a transvaginal ultrasound scan has been carried out between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of < 25 mm.
  • Consider prophylactic cervical cerclage for women in whom a transvaginal ultrasound scan has been carried out between 16+0 and 24+0 weeks of pregnancy that reveals a cervical length of < 25 mm and who have either: 
    • Had PPROM in a previous pregnancy or a history of cervical trauma

Established preterm labor

  • Refer to district hospital if at health Centre          
  • At the district or tertiary hospital:
    • Monitor fetal heart rate and contractions
    • IV line with NS at maintenance rate 
    • Send investigations if available: FBC, urinalysis / urine dipsticks, speculum exam to check for abnormal discharge.
    • Do a wet prep/mount for trichomonas and bacterial vaginosis
    • USS for presentation, AFI, placental location, EFW, EGA and anatomy 
    • Give Steroids if gestation age is <34 weeks
      • Betamethasone 12 mg IM every 24 hours, 2 doses; or 
      • Dexamethasone 6 mg 12 hourly, 4 doses 
    • Tocolytic medications to delay delivery for 48 hours (for steroids) if contractions are present:
      • Nifedipine (immediate release) 20 mg load then 10 mg PO if still contracting after 30 minutes and 10mg 2 hourly (hold if maternal BP < 90/50 mm Hg) 
    • Or
      •  Indomethacin 50-100 mg load then 25- 50mg PO 6 hourly for 48 hours  (Only if <32 weeks)
    • Or
      •  Salbutamol 250 ug IV slow push over 5 minutes

Delivery and neonatal care: Refer to district hospital or tertiary hospital if at health centre.

  • Inform NICU so that neonatologist or pediatrician may attend delivery
  • Deliver with intact membranes if possible
  • Minimize trauma by easing out the head in second stage of labour
  • Forceps may be used to assist delivery; avoid vacuum extraction
  • Clear airway immediately, if necessary, avoid hypothermia and transfer neonate to NICU as soon as possible
  • Consider Caesarean delivery if breech presentation
  • Consider using Magnesium sulfate for neuroprotection if viable, EGA <32 weeks, and concern for imminent preterm birth (dosage as per preeclampsia protocol; or if IV infusion available, give 4g IV loading dose over 30 minutes, followed by 1 g per hour maintenance). 
    • If antenatal magnesium sulfate has been started for fetal neuroprotection, tocolysis should be discontinued.
    • For planned preterm birth for fetal or maternal indications, magnesium sulfate should be started ideally within 4 hours before birth.
    • Magnesium sulfate should be discontinued at delivery, if delivery is no longer imminent, or when a maximum of 24 hours of therapy has been administered.

 

PRETERM PRELABOUR RUPTURE OF MEMBRANES (PPROM)/PRELABOUR RUPTURE OF MEMBRANES (PROM)

CLINICAL DESCRIPTION

Rupture of the membranes before labour (PROM is >37 weeks gestation while PPROM is before 37weeks).

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • History of draining liquor / watery vaginal discharge

TREATMENT

Management if gestation less than 34 weeks

  • No digital vaginal examination
  • Perform sterile speculum examination and rule out cord prolapse
  • Check vital signs and assess fetal heart rate 4 hourly
  • Provide a pad and observe for color, amount, and smell of liquor daily

PHARMACOLOGICAL 

If at a Health Centre:

  • If draining for > 12 hours, commence Erythromycin 250mg 6 hourly for 7 days 
  • Give Dexamethasone 6mg IM 12 hourly for 48 hours/ Betamethasone 12mg IM daily for 48 hours  
  • Refer immediately

At the Hospital

  • Manage as described above
  • Deliver at 34 weeks if there are no signs of chorioamnionitis
  • If signs of intra-uterine infection (temperature > 37.50C, uterine tenderness, purulent or offensive liquor,), or fetal distress, plan urgent delivery regardless of gestational age

Management if gestation 34 weeks or greater

  • Do sterile speculum exam to confirm draining and rule out cord prolapse
  • If membranes have been ruptured for more than 12 hours, give antibiotics:
    • Give Ampicillin 2g IV 6 hourly once labour starts.
  • Or 
    • Benzylpenicillin 2 MU IV 6 hourly until delivery and continue until 48 hours post delivery.
    • Give Erythromycin 250mgs 6 hourly if the patient is not in labour.
  • If labour does not begin spontaneously within 24 hours induce labour, if no contraindication to vaginal delivery. Perform c-section if no contraindication. 

 

CHORIOAMNIONITIS

CLINICAL DESCRIPTION

Intra-uterine infection in pregnancy.

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Foul-smelling vaginal discharge after 28 weeks of pregnancy, Fever/chills, abdominal pain, uterine tenderness, maternal and fetal tachycardia, maternal tachypnoea.

TREATMENT

PHARMACOLOGICAL

At the Health Centre

  • Give Benzylpenicillin 2.5 MU IV stat or
  • Give Ampicillin 2gms IV stat

Refer to hospital

At hospital

  • Give Metronidazole 500mg IV 8 hourly, and Ampicillin 1g 6 hourly/Benzylpenicillin 2 MU IV 6 hourly, Gentamycin 240 mg IM single dose daily.
  • Deliver urgently, Induce, or accelerate labor with Oxytocin if the cervix is favorable and no contraindications; do caesarean section if necessary.
  • If mother has amnionitis or if membranes were ruptured for more than 12 hours before delivery, start newborn on Benzylpenicillin 50,000 IU/kg/dose IM 12 hourly, and Gentamycin 5 mg/kg IM od for 5 days if birth weight >1500 g).
  • Continue for 48 hours after the fever subsides, but not less than 5 days.

ANTEPARTUM HEMORRHAGE

CLINICAL DESCRIPTION

Bleeding from the genital tract occurring from 28+0 weeks of pregnancy and prior to the birth of the baby.

CLINICAL FEATURES

  • Sudden onset abdominal pain, with or without vaginal bleeding, woody hard uterus or prolonged contractions, fetal distress / fetal demise, +/- hemodynamic instability, +/- coagulopathy

TREATMENT

PHARMACOLOGICAL

Management at the Health Centre 

  • Initial: ABCDE approach
  • If patient stable:
    • Full history and physical examination including vital signs.
    • Insert 2 large bore cannula, start 1litre of Ringer's Lactate or normal saline.
    • Abdominal palpation for SFH, contractions, tenderness, signs of acute abdomen and FHR assessment
    • Avoid digital vaginal examination; rather do a sterile speculum examination.
    • Request blood and blood products as required.
    • Ultrasound examination to rule out placenta previa (if available).
    • Once placenta previa is ruled out, do a vaginal examination. 
    • Explain the findings to the patient. 
    • Plan for urgent delivery.