WINDHOEK HOSPITALS COMPLEX

Department of Obstetrics and Gynecology

Guidelines
Foreword

(Dr Adewale)

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Disclaimer:
The Guideline Development Committee (GDC) made every effort to ensure that the contents
of this document are up to date evidence-based guidelines. The ultimate judgement regarding
a particular clinical management plan must be made by the attending doctor in the light of
clinical presentation by the patient. The endlessness evolution of medicine means that it’s the
user’s responsibility to ensure the information being accessed for patient care is current.

Acknowledgement:
The GDC would like acknowledge and thank the following international Obstetrics and
Gynaecology organisations: ACOG, FIGO, ISUOG, NICE, RCOG, RANZOG, SASOG and
SOGC. We have used the guidelines of these major organisations in the compilation of these
protocols. Lastly, we would like to thank the World Health Organisation (WHO) that works
worldwide to promote health, keep the world safe, and serve the vulnerable. We dedicate
these work to the women of Namibia.

This document is intended as a practical guide to patient management tor Medical officers,
Medical interns and medical students attached to the Windhoek Hospitals Complex, and may
be used by medical practitioners from other centres that refers to the Windhoek Hospitals
Complex. It will be amended every 2 years to provide latest available evidence.

Copyrights:
All rights reserved. No part of this document may be reproduced, distributed or transmitted in
any form or by any means, including photocopying, recording or other electronic or
mechanical methods without the prior written permission of the GDC and the Windhoek
Hospitals Complex Head of Department.

For more information, email: whcguidelines@gmail.com

Guideline Development Committee (GDC)

Windhoek Hospitals Complex Guidelines book 1st Edition
Windhoek
February 2022
© by Guideline Development Committee (GDC), Windhoek Hospitals Complex. All rights
reserved.

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 Table of Contents
Methods of dating pregnancy..................................................................................................... 6
Early pregnancy complication ................................................................................................. 10
Septic Incomplete Miscarriage ................................................................................................ 13
Manual vacuum aspiration (MVA) .......................................................................................... 15
Ectopic pregnancy .................................................................................................................... 17
Pregnancy of unknown location (PUL) ................................................................................... 19
Gestational Trophoblastic Disease (GTD) ............................................................................... 20
Abnormal Uterine Bleeding (AUB) ......................................................................................... 23
Postmenopausal bleeding (PMB) ............................................................................................. 26
Pelvic inflammatory disease (PID)/ Acute salpingo-oophoritis (ASO) ................................... 28
Screening for Trisomy 21 and other chromosomal abnormalities ........................................... 30
Preterm Labour (PTL).............................................................................................................. 32
Preterm Prelabour Rupture of Membranes (PPROM) ............................................................. 38
Prelabour rupture of membranes (PROM) ............................................................................... 41
Induction of Labor (IOL) ......................................................................................................... 43
Augmentation of labor (AOL) ................................................................................................. 47
Management of Prolonged Pregnancy ..................................................................................... 50
Intra-uterine fetal demise (IUFD) and Stillbirth ...................................................................... 52
Antepartum Hemorrhage (APH) .............................................................................................. 55
Placenta praevia and Placenta Accreta Spectrum: Diagnosis and Management ..................... 57
Hypertensive Disorders of Pregnancy ..................................................................................... 61
Diabetes Mellitus in pregnancy (DIP) ..................................................................................... 66
Diagnostic criteria and severity of Diabetic Ketoacidosis ....................................................... 70
Cardiac Disease in Pregnancy .................................................................................................. 71
Acute pulmonary oedema ........................................................................................................ 73
Malaria in pregnancy ............................................................................................................... 74
Fetal growth restriction (FGR)................................................................................................. 78
Multiple pregnancy .................................................................................................................. 81
Management of Labour ............................................................................................................ 86
Postpartum haemorrhage (PPH) .............................................................................................. 89
Managing Maternal Sepsis ....................................................................................................... 92
Postpartum Contraception ........................................................................................................ 95
Peri-operative care ................................................................................................................... 98
Evidence-Based Caesarean Section ....................................................................................... 103

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Appendix A ............................................................................................................................ 106
Windhoek Hospitals Complex Induction of labor checklist .................................................. 106
Appendix B ............................................................................................................................ 107
FIGO Misoprostol Recommended Dose Regimens ............................................................... 107
Appendix C ............................................................................................................................ 108
Windhoek Hospitals Complex Augmentation of labor chart ................................................. 108
TRIAL OF LABOUR AFTER CAESAREAN DELIVERY CHECK LIST FORM ............ 109
Appendix E ............................................................................................................................ 110
Timing of Delivery at or after 34 Weeks Gestational Age .................................................... 110
Appendix F............................................................................................................................. 112
Windhoek Hospital Complex In-patient Diabetes Glucose control chart .............................. 112
Appendix G ............................................................................................................................ 113
Cardiac disease ANC record .................................................................................................. 113
Appendix H ............................................................................................................................ 114
Acute severe hypertension pathway (BP ³160/110) .............................................................. 114
Appendix I ............................................................................................................................. 115
Emergency treatment algorithm for Eclamptic seizures ........................................................ 115
Appendix J ............................................................................................................................. 116
Surgical site infection management algorithm ...................................................................... 116
Appendix K ............................................................................................................................ 117
CTG Interpretation algorithm ................................................................................................ 117

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Methods of dating pregnancy

Significance: Accurate dating of pregnancy is very crucial because management decisions

during pregnancy are strongly influenced by consideration of foetal development, which
closely correlates with gestational age.

Different methods for dating pregnancy or estimating date of delivery:

1. Reliable last normal menstrual period (regular menses, no recent use of contraception,
use 1st date of the last menses).
2. First trimester ultrasound scan using a crown-lump length (7-60 mm) (up to 13+6
Weeks) is the most accurate method to establish or confirm gestational age: Gold
standard.
3. Foetal biometry in the second trimester < 24+0 weeks (or when CRL >84mm).
4. Symphysis fundal height (Limited > 36 weeks due to fetal head decent into the pelvis,
uterine abnormalities, multiple pregnancyand may lead to suboptimal dating).
5. ART-derived gestation should be used for pregnancies conceived via assisted
reproduction technique: Embryo age & date of transfer.

Please take note:

1. The EDD confirmed/derived from the earliest sonographic assessment of gestational
age (CRL up to 13+6 weeks or foetal biometry at 14+0 to 23+6 weeks) becomes the
patient's EDD, and this EDD is NOT changed by subsequent ultrasound
examinations.
2. In multiple gestation - the EDD should be based on the measurements for the larger
twin.
3. If the LNMP is unreliable or not known and there was no ultrasound done < 24+0
weeks, then the pregnancy is considered sub-optimally dated. Assess the patient as
“Unsure GA” give the estimated fetal weight (Will guide management).

Dating pregnancy using LNMP

1. Assess the certainty of the dates
2. Naegele’s rule - is a simple method of pregnancy dating. The EDD is calculated by
counting back three months from the LMP and adding seven days.
Example. LNMP 15 August 2021 >>>> 15+7= 22; August – 3months = May, So
EDD is 22 May 2022.

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Dating pregnancy using LNMP and ultrasound
If the woman is certain about her LNMP and has no ultrasound done at or before 24+0 weeks
– date the pregnancy using her sure dates and not a late ultrasound.
Assess the discrepancy between GA based on LMP and the ultrasound done before 24+0
week and adjust as per table below (meaning use sonar instead of dates).

[1]

Accurate measurement of CRL is crucial!

Gestational sac (GS)

Mean sac diameter measurements are not recommended for estimating the due date.

Yolk sac (YS)

YS should not be used to date pregnancy.

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Uterine size
The uterus remains a pelvic organ until approximately 12 weeks of gestation. After 20 weeks,
the Symphysis-to-Fundal Height in centimetres correlate with the week of gestation.

[2]
Sub optimally dated pregnancy
A pregnancy without an ultrasound examination that confirms or revises the EDD before 24+0
weeks of gestational age should be considered sub-optimally dated. Assess patient as “Unsure
GA” give the Estimated Fetal Weight (EFW) to guide management.

A single late examination cannot reliably distinguish between a pregnancy that is misdated
and younger than expected and a pregnancy that is complicated by fetal symmetric growth
restriction.
In these cases, serial measurements three to four weeks apart can be helpful.
• Normal interval growth supports the sonographic estimate of gestational age, while
suboptimal interval growth suggests a growth-restricted fetus who may be further
along in gestation than predicted by biometry.
• Accelerated fetal growth suggests a large for gestational age fetus who may be less far
along than predicted by biometry. Thus, serial examinations in this setting allow the
clinician to make a more reliable clinical assessment of the EDD.

The management of such patients should be discussed with the consultant.

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References:
1. Methods for Estimating the Due Date. ACOG committee opinion number 700. May
2017.
2. Measuring Fundus Height During Pregnancy. [Homepage on the internet] Available
from: https://www.stepwards.com/?page_id=10721 [Cited 2022 February 10].
3. Butt K, Lim K. Determination of Gestational Age by Ultrasound. JOGC. 41(10);
2019. P1497-1507.
4. Kaelin AA, Xia J, Servante JA, et al. Routine ultrasound scans for babies before 24
weeks of pregnancy. Cochrane Database of Systematic Reviews 2021, Issue 8. Art.
No.: CD014698. DOI: 10.1002/14651858.CD014698.
5. WHO recommendations on antenatal care for a positive pregnancy experience. WHO
Library Cataloguing-in-Publication Data. Geneva: World Health Organization 2016.

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Early pregnancy complication

Miscarriage: spontaneous loss of pregnancy before a viable gestation (WHO < 24+0 weeks or
EFW < 500g). Due to limited resources a viable gestation in Namibia is 28+0 weeks or an
EFW > 1000g. Management of a peri-viable (24+0 – 27+6 Weeks) pregnancy should be
discussed with the consultant.

Clinical symptoms of miscarriage

• Pelvic pain, vaginal bleeding, passage of pregnancy tissue, loss of pregnancy
symptoms.
• Asymptomatic: diagnosed first at dating or combined screening ultrasound.

Classification of miscarriages
Based on trimester: First trimester miscarriage (< 13+6 weeks) or Second trimester/ mid-
trimester miscarriage (> 13+6 weeks).
Types:
Spontaneous
Recurrent (3 or more consecutive pregnancy losses)
Induced (commonly referred to as abortion/ unsafe termination of pregnancy (TOP)

Clinical description

Threatened Light spotting vaginal bleeding with or without pain with a closed
miscarriage internal cervical os.
Ultrasound: Active fetal cardiac activity
Inevitable Increasing pain and vaginal bleeding with an open cervical os.
miscarriage Ultrasound: Active fetal cardiac activity
Incomplete Moderate to severe vaginal bleeding, often with clots Passage of some
miscarriage products of conception (POC) “meaty structure”,
Cervical os is open with palpable retained products or visible on
speculum
Ultrasound: Retained products of conception, > 15mm
Complete A previously sited intrauterine pregnancy (IUP) which is deemed to be
miscarriage completely evacuated. Diagnosis can be made after viewing the
products of conception which were passed. In the absence of visualized
POC or previously documented IUP the patient must have serial ß-hCG
48-hours apart to confirm the diagnosis.
Cervical os is closed.
Ultrasound: No Retained products of conception, endometrial thickness
< 15mm
Missed May be asymptomatic: incidental finding or spotting vaginal bleeding;
miscarriage cervical os is closed.
Ultrasound: Embryo with CRL ≥ 7mm with absent fetal cardiac activity

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 Blighted ovum/ Spotting PV bleeding, cervical os closed;
anembryonic Ultrasound: no embryo or yolk sac seen in a gestational sac with a
pregnancy mean sac diameter of ≥ 25 mm.
Alternatively: ≥ 11 days after a scan demonstrating a gestational sac
with a yolk sac, but an absent embryo or ≥ 2 weeks (14 days) after a
scan demonstrating a gestational sac without an embryo or a yolk sac.

Intrauterine pregnancy of uncertain viability

Features suggestive of a miscarriage

Findings close to Crown-rump length of < 7mm and no heartbeat
decision Mean sac diameter of 16-24 mm and no embryo
boundaries Absence of an embryo >=6 weeks after last menstrual period
Management: Counsel the patient & repeat an ultrasound in 11 -14 days
Scan repeated at No embryo with fetal heart activity 7 days after a scan:
interval - in which embryo was visualized*
- in which a gestation sac ≥12mm MSD (with or without yolk sac)
was visualized*
MSD less than doubled 14 days after scan in which empty sac with MSD <
12mm was seen*
* Suggested new additions
*MSD =Mean Sac Diameter

General clinical approach:

1. Assess hemodynamic status of patient (vitals and clinical presentation) – if patient is
unstable call MO right away and commence resuscitation.
2. Bookings bloods: Rh, RPR, Hb, offer VCT HIV
3. Do an ultrasound for all pregnant women (preferable transvaginal in early gestation) to
rule out the complications of early pregnancy (Confirm intrauterine gestation)
4. Classify the type of miscarriage
5. Counsel the woman and be sensitive
6. Physical examination including bimanual assessment for uterine size
7. Women with (consecutive) recurrent pregnancy losses should be referred to the
specialist clinic for further work up and pre-conception counselling (Do not screen for
APS on admission as this does not change the current management. If RPL
suspected, discuss with consultant for further work-up plan on an out- patient basis)

Management of miscarriage
1. Threatened miscarriage
o Reassure patient.
o Discharge home but inform patient to come back if bleeding worsening or exceeds
14 days from the day of presentation and re-scan.
o There is no evidence that bed rest improves outcome.
o Patients with ≥ 1 previous miscarriage give: Utrogestan 400mg PV BD (PRISM
trial) or Dydrogesterone (Dupahstan) 40mg daily po till 16 weeks

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 2. Inevitable miscarriage
o Counsel the patient extensively if gestation is peri-viable (discuss with
consultant).
o Otherwise offer active management: Augment contractions with oxytocin or
misoprostol 200µg pv/sl/bucc q6h.
o Adequate analgesia.
o If patient declining active management: discuss with consultant.

3. Non-septic incomplete miscarriage

Uterine size <14 week o Manual Vacuum Aspiration (MVA)

Non-septic o Medical management (Selected cases:
Consultant decision)
Uterine size >14 weeks Evacuation in theatre
Peri-viable • Rates of perinatal and neonatal morbidity and mortality are high
(24+0 – 27+6 in pregnancies complicated by previable ROM
Weeks) • Neonatal complications include pulmonary hypoplasia, limb
Rupture of deformities (eg, clubbed feet) and other components of fetal
Membranes compression syndrome.
(ROM) • Maternal complications: Maternal sepsis, prolonged
hospitalization
• The couple must be counselled for medical termination of
pregnancy

4. Complete miscarriage
o Unless there is evidence of products expelled or previously documented.
intrauterine pregnancy– a complete miscarriage should not be entertained (NB:
exclude ectopic pregnancy).
o Consider sending products of conception for karyotype.
o Counsel the patient.
o Offer family planning.

5. Missed miscarriage
• < 13 weeks counsel patient for induction of expulsion: Misoprostol 400mcg
SL stat 1-hour before MVA or PV 3-hours before MVA.
If patient declined intervention: <13 weeks can be managed as an outpatient (if able
to follow up)– Misoprostol 800mcg PV stat; ask patient to follow up in 72 hours and
assess for repeat dose if no expulsion. Ultrasound review in 7 days.

• >13weeks’ gestation – Admit

Misoprostol 200µg PV/ bucc/ or sublingual every 4-6 hours (maximum 5 doses)
Once fetus expelled – assess if complete. If incomplete – manage as per incomplete
miscarriage protocol.

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Septic Incomplete Miscarriage

Definition: Refers to any miscarriage, spontaneous or unsafe termination of pregnancy, that is

complicated by a pelvic infection.

Recognizing a septic miscarriage

• Fever - temperature > 38oc, Cold extremities, Tachypnoea, Tachycardia, altered mental
state, Hypotension, Tender lower abdomen, Cervix open with a foul-smelling discharge,
signs of cervical trauma or a necrotic cervix.

Routine investigation to rule out multi-organ dysfunction

• ABG
• Bloods: FBC, U&E, LFTs, clotting profile, CRP, Blood cultures, offer VCT HIV
• Imaging: CXR

Management principles
• Follow principles of management and goal directed resuscitation of sepsis.
• In addition: Remove source of infection (Evacuate uterus/ Hysterectomy).
• Rule out septic shock:
o Shock index not responding to fluid resuscitation; requiring vasopressors.
o Lactate > 2 mmol/L

Sepsis 6 ‘Hour-1 bundles’

• Adequate hydration (IV fluids crystalloids): 30 ml/kg bolus if hypotension, (SBP <
100 mmHg or lactate > 4 mmol/l)
o Start vasopressors if not responding to initial fluid resus
§ MAP < 65 mmHg/ lactate > 2 mmol/L
o Adrenalin infusion
§ 10 mg/200ml NaCl - Start at 5 ml/h, max 20 ml/h
§ Low dose: 0.05 – 0.1 mcg/kg/minute
§ High dose: > 0.1 mcg/kg/minute
• Antibiotics
o Ampicillin 2g q6h IVI, plus
o Gentamicin 5mg / kg IVI every 24 hours plus
o Metronidazole 500mg q8h IVI
• Resuscitation goals:
o MAP > 65 mm Hg or SBP > 100 mm Hg
o CVP > 8 mm Hg
o SaO2> 90% and RR < 30 bpm
o Haematocrit > 30%
o Lactate < 2 mmol/L
• Trace the blood results as soon as possible
• Consider acute care/ ICU booking

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 • Definitive Management
o Indications for a hysterectomy
§ Septic shock
§ Two or more organ system dysfunction (including ARDS)
§ Necrotic/ gangrenous cervix
§ Perforated uterus
§ Acute abdomen/ Pyo-peritoneum
o In the absence of the above: Prompt uterine evacuation in theatre

References:
1. Early pregnancy loss. ACOG Practice bulletin. Number 200. November 2018
2. Sagili H, Divers M. Review Modern management of miscarriage. TOG. 2007; 9:102–
108.
3. Patient counselling following periviable premature rupture of the membranes. SMFM
Guidelines. Available from: https://www.smfm.org/publications/177-patient-counseling-
following-periviable-premature-rupture-of-the-membranes [Accessed 09 January 2022]
4. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International
Guidelines for Management of Sepsis and Septic Shock 2021. Crit. Care Med. 2021
November; 49 (11). Pe1063-e1143.
5. Lee HJ, Park TC, Kim JH, et al. The Influence of Oral Dydrogesterone and Vaginal
Progesterone on Threatened Abortion: A Systematic Review and Meta-Analysis.
BioMed Research International. 2017.

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Manual vacuum aspiration (MVA)

• Definition: Procedure done early in pregnancy, which uses the suction of a syringe to
evacuate retained products of conception from the uterus.
• Indication: Incomplete miscarriage.

In all cases:
1. Essential testing Hb, RPR, Rh, VCT HIV
2. Ultrasound
3. Counselling

Clinical prerequisites: hemodynamically stable, no symptomatic medical illness, HB ≥

10g/dl, height of fundus ≤ 14 weeks uterus size after passing the products of conception, no
signs of septic ICA/ unsafe TOP.

NB: IF THE ABOVE PREREQUISITES ARE NOT MET THE PATIENT MUST BE
BOOK FOR AN EVACUATION IN THEATER.

Manual Vacuum Aspiration (MVA)

1. Written informed consent
2. Analgesia: Local cervical block and Pethidine 100 mg IMI stat or Diclofenac 75mg
IMI stat.
3. Lithotomy position: bimanual examination to confirm size and position of uterus.
4. Clean perineum, insert Cusco speculum to visualise cervix, clean cervix and vagina
with chlorhexidine in water solution.
5. Paracervical block with 1-2 % Lignocaine 10ml: 3-4ml per side, avoid 3 and 9
o’clock positions.
6. Stabilise cervix with swab holding forceps. Insert tip of suction curette into cervix.
Now connect the suction catheter to the rest of the assembled apparatus.
7. Open the valve of the syringe and rotate the catheter slowly and repeatedly through a
full circle.
8. The procedure is completed when no more products are obtained, fresh bright blood,
bubbling blood and gritty feeling.
9. The pulse, blood pressure, awareness and bleeding should be observed at least every
30 minutes until discharge.
10. If Rh negative, administer Anti-D 100µg (500IU) IMI. If RPR positive, administer
first dose of benzathine benzylpenicillin IMI and make arrangements for subsequent
treatments and do contact tracing.

Discharge TTO
• Analgesia
o Ibuprofen 400mg q8h po
o Paracetamol 1g q6h po
• Antibiotics
o Flagyl 400mg q8h po 7/7
o Doxycycline 100mg q12h po 7/7
• Contraception: LARC

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Reference:
1. Steps for Performing Manual Vacuum Aspiration (MVA) Using the Ipas MVA Plus
and Ipas easygrip Cannulae. [Homepage on the internet] Available:
https://www.ipas.org/wp-content/uploads/2020/06/PERFMVA-E19.pdf [Accessed 10
January 2022].

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Ectopic pregnancy

Definition: Implantation of a pregnancy outside of the endometrial cavity.

Risk factors
• History of an Ectopic pregnancy, advanced maternal age, history of sterilisation or tubal
surgery, smoking, history of STI/ASO, previous pelvic surgery.

Clinical presentation
Classical triad: Amenorrhea, spotting vaginal bleeding and abdominal pain.
Unruptured ectopic pregnancy: Some cases will not have the typical severe abdominal pains
(stable ectopic) thus clinical presentation may be confused with a miscarriage.
Ruptured ectopic pregnancy: Can result in life-threatening intrabdominal concealed
haemorrhage and patients often presents critically sick in hypovolemic shock with an acute
abdomen: Identify hypovolemic shock (Shock index < 1).
Pelvic ultrasound is the most valuable tool in such cases (with the aid of a quantitative (ß-
hCG).

Diagnosis
Ultrasound:
o No evidence of an intrauterine pregnancy on transvaginal ultrasound (TVUS) and any
of the following:
o Blob sign: Inhomogeneous adnexal mass
o Bagel sign: Empty extrauterine gestation sac
o ± Free fluid in the peritoneum
ß-hCG: Discriminatory zone
o ß-hCG > 1500 mIU/mL and transvaginal ultrasound: no evidence of an intrauterine
pregnancy
o ß-hCG > 3000 mIU/mL and transabdominal ultrasound: no evidence of an intrauterine
pregnancy
o Suboptimal rising serial ß-hCG 48 hours apart: < 35%

Special investigations: Rh, RPR, FBC ± ß-hCG, ± type and screen

Management
• Principles:
o Confirm that the patient is pregnant.
o Evaluate the hemodynamic status
o Determine the site of the pregnancy
o Hemodynamic unstable: resuscitation and immediate surgical treatment

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 Definitive management options:
Expectant Medical Surgical
Indications o Asymptomatic o Asymptomatic & o Ruptured ectopic
o Lower initial serum β- hemodynamically stable pregnancy
hCG level (preferably < o Low serum β-hCG, o Failed medical
1000IU/L) ideally less than 1500 management
o Low serum progesterone IU/l but can be up to
o Decreasing trend of β- 5000 IU/l
hCG levels o No fetal cardiac activity
o Pretreatment β-hCG ratio seen on ultrasound scan
< 0.8 o An unruptured ectopic
o Absence of an ectopic pregnancy mass ≤ 35
gestation sac mm
o Ectopic pregnancy o Certainty that there is no
diameter < 40mm intrauterine pregnancy
o TVUS monitored o Willingness to attend for
decrease in size of follow-up
o No known sensitivity to
methotrexate
o Interested in future
fertility
o Raising or plateauing
hCG following liner
salpingectomy
Intervention None: ‘wait and see’ Methotrexate Laparoscopy (Gold
standard) v.
laparotomy
salpingectomy v.
salpingotomy

Medical Management: Single Dose Methotrexate Regimen

Day 1 Day 4 Day 7
Labs β-hCG, FBC, β-hCG β-hCG, FBC, UKE, LFTs
UKE, LFTs
Rhesus, RPR
Action Give None β-hCG decline <15 % from Day 4 to Day 7: TVUS,
Methotrexate MTX, return to day 1 of protocol. Repeat MTX up to a
(50mg/m2 BSA total of 4 doses
IMI) β-hCG decline >15 %: Check β-hCG at 1 week intervals
until < 15 IU/l

References:
1. Royal College of Obstetricians and Gynaecologists (RCOG). Diagnosis and
Management of Ectopic Pregnancy. Green-top Guideline No. 21. London: RCOG;
2016.
2. Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. UpToDate.
Available from: https://www.uptodate.com/contents/ectopic-pregnancy-clinical-
manifestations-and-diagnosis [Accessed 10 February 2022].

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Pregnancy of unknown location (PUL)

Definition: refers to a clinical scenario when a woman presents with a positive urine
pregnancy test but the location of the pregnancy (either intrauterine or extrauterine) cannot be
located using transvaginal ultrasonography (TVS) at the initial scan.
PUL is a classification and not a diagnosis and further tests and follow-up are then required
before the location and/or the viability of a pregnancy can be defined.

PUL classification

[1]

Management protocols: β-hCG ratio

[2]
Management
• If the patient is haemodynamically stable, PUL should be managed expectantly until
the outcome is determined.
• Like EP, PPUL can be managed either expectantly, medically (Methotrexate) or
surgically (laparoscopy/uterine curettage).

References:
1. Bobdiwala S, Al-memar, Farren J, et al. Factors to consider in pregnancy of unknown
location. Women’s health. 2017; 13(2) 27–33.
2. Bobdiwala S. Guha S, Van Calster B, et al. Hum Reprod. 2016, 31(7):1425-35.

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Gestational Trophoblastic Disease (GTD)

A. Benign

Benign (Premalignant):
1. Partial Hydatiform Mole (PHM)
2. Complete Hydatiform Mole (CHM)
3. Atypical placental site nodule

Clinical Presentation
• Positive pregnancy (History suggestive of pregnancy and positive pregnancy test)
• Irregular vaginal Bleeding: most common
• Excessive uterine enlargement more than the actual (calculated) LNMP
• Grape-like/cystic products of conception on exam or US
o Other Less common presentation:
§ Hyperemesis gravidarum
§ Hyperthyroidism
§ Abdominal distension due to Teca-Luteal cysts
§ Pre-eclampsia

Clinical Examination:
• Full detailed clinical history
• Full systemic examination
• Gynaecological exam: Including speculum, bimanual examination
Investigations: should be done Pre-operative
• Bloods: Full blood count, urea and electrolytes, Rhesus, thyroid function tests, HIV
testing, ß-hCG, Crossmatch: Group and Screen
• Chest XR
• Pelvic Ultrasound examination: Initial US should be done on admission, and
confirmed by
MO/Specialist, including dopplers of the pelvis exclude invasive mole
o CHM: polypoid appearance, thickened cystic appearance of villous tissue
o PHM: Enlarged placenta, or cystic changes within the decidua reaction,
associated with either empty sac or delayed miscarriage

Management: Stable Patient

• Suction Curettage is the preferred choice:
• Medical management of POC should be avoided
• Performed in Theatre, Lithotomy position.
• Performed under ultrasound Guided: minimise risk of perforation and ensure uterus
is empty
• At EVAC cervical dilators can be used if necessary
• Performed by the Senior person: MO under Specialist Supervision
• Appropriate evacuation equipment: Ideally Metal suction (molar suction set),
recommended suction pipe size is 12-14mm and Suction pressure must be strong
• Oxytocin should be administered only when the uterus is empty to avoid embolising
and dissemination of trophoblastic tissue through the venous system: Risk of ARDS
• Risk of bleeding increases with uterine size: Blood and Products Should be
readily available when uterus size is greater than 16 weeks
• Products of conception MUST be sent for histopathology

20
 • Anti-D prophylaxis should be administered after EVAC to Rh-negative women
(ideally for PHM)
• Hysterectomy is an option if childbearing is complete. (Decreases the risk for
persistent disease and chemotherapy)

Management: Unstable, Significant haemorrhage

• Expediting surgical management in case of unstable bleeding patient is a priority
• Must be discussed with Specialist on can and should be involved in physical
management of the patient.
• Consider uterine Balloon to reduce risk of hysterectomy

ß-hCG Follow up after treatment: Ideally dedicated unit. Refer to Gynaecological

oncology unit for follow-up
• CHM:
o Weekly/ every alternative week Serum ß-hCG
o If ß-hCG revert to normal within 56 days of pregnancy event, follow up
will monthly ß-hCG up to 6 months from date of evac.
o If ß-hCG has not reverted to normal within 56 days follow up with
monthly ß-hCG up to 6 months from date of normalization of ß-hCG
• PHM
o Follow up is concluded once the ß-hCG is normal (ß-hCG <5) on 2
occasions at least 4 weeks apart

Role of second Evacuation: Limited role

• Must be discussed with Gynae onco unit.
• Considerations in woman with persistent PV bleeding and when there is obvious
retained POC on ultrasound.

Contraception
• Advise not to conceive until follow up is complete
• Any form of contraception can be recommended: Oral and injectable, LARC
• IUD (LOOP) is contraindicated

Prophylactic administration of Methotrexate/Actinomycin D

• MDT approach
• Restricted to special situation: where the risk of GTN is much greater than normal
• Where adequate ß-hCG follow-up is not possible

B. MALIGNANT

Gestational trophoblastic Neoplasia

1. Invasive Mole
2. Choriocarcinoma
3. Placental site trophoblastic tumour (PSTT)
4. Epithelioid trophoblastic tumour (ETT)

21
Criteria for diagnosis post molar GTN
• Histological diagnosis of choriocarcinoma
• Plateau of ß-hCG lasts for 4 measurements over the period of 3 weeks or longer
that is days 1, 7, 14, 21
• Rising of ß-hCG for 3 consecutive weekly measurement over a period of at least 2
weeks or more, that is days 1, 7, 14

Investigations FOR GTN:

• Full blood count, ß-hCG, urea and electrolytes, LFT Rhesus, thyroid function tests,
HIV testing
• Chest XR: If CXR/CT chest has metastasis, do Brain MRI
• Ultrasound/CT abdomen, Pelvic U/S

14. Management GTN:

• After primary work up refer to Gynae onco Unit
• Management is MDT
• Choice of treatment depends on WHO Staging and classification system and
FIGO Risk Score

References:
1. Ngan HYS, Seckl MJ, Berkowits RS, eta al. Diagnosis and management of
gestational trophoblastic disease: 2021 update. IJOG. 2021; 155 ( S1). 86-93.
2. Snyman LC. Gestational trophoblastic disease: An overview. SA Journ of Gyn Onco.
2009; 1(1); 32 – 37.

22
Abnormal Uterine Bleeding (AUB)

Definition: a broad term that describes irregularities in the menstrual cycle involving
frequency, regularity, duration, and volume of flow outside of pregnancy in a woman of the
reproductive age.

FIGO AUB System 1. Nomenclature and Definitions of AUB Symptoms

Normal Abnormal
Amenorrhea Duration Normal (≤ 8 days)
Infrequent (> 38 days) Prolonged (> 8 days)
Frequency Normal (≥ 24 - ≤38 Regularity Normal (≤ 7 - 9 days)
days)
Frequent (<24 days) Irregular (≥ 8-10 days)
Light None
Volume Normal Intermenstrual Random
Heavy Bleeding Cyclic
Unscheduled bleeding on Progestin ± Not applicable (Not on hormonal medication)
Estrogen (COC pills, rings, patches None (On hormonal medication)
or injections) Present

FIGO AUB System 2. PALM- COEIN System for Classification of Causes of AUB in the
reproductive years.
• Structural criteria (PALM): Polyp; Adenomyosis; Leiomyoma; and Malignancy
and hyperplasia.
• Non- structural anomalies (COEIN): Coagulopathy; Ovulatory dysfunction;
Endometrial disorders; Iatrogenic causes and one reserved for entities categorized as
“Not otherwise classified”.

Evaluation
• A detailed History and Full gynaecological exam (When stable)
• Perform an ultrasound on all patients with AUB (Exclude organic causes) ± Saline
infusion Sonohysterography (SIS).
• Bloods: FBC, UKE, ± Clotting profile, ± TSH, ± LFTs, ± von Willebrand factor
antigen, ± cross match
• Urine pregnancy test
• Indications for endometrial biopsy:
o Age 35 or older plus one or more risk factors for endometrial cancer (obesity,
diabetes, high blood pressure, PCOS).
o Age under 35 plus several risk factors for endometrial cancer (see above).
o Bleeding that is persistent, irregular, or heavy despite treatment.
o All women over 45 years of age.

Management
• Treatment of AUB depends on multiple factors, such as the aetiology of the AUB,
fertility desire, the clinical stability of the patient, and other medical comorbidities.
• Treatment should be individualized based on these factors. In general, medical
options are preferred as initial treatment for AUB.

23
Acute abnormal uterine bleeding: Hormonal methods are the first-line in medical
management.
Life-threatening AUB:
• Fluids resuscitation: Crystalloids + colloids including blood if Hb < 7g/dl
• Conjugated equine oestrogen 25mg IVI q 4-6h for 24-hours, plus
• Tranexamic acid 1g q8h IVI
• ± Tamponade of uterine bleeding with a Foley bulb (26F +30ml sterile water)
Stable AUB:
• Short term: Monophasic COC that contain 30 - 35µg of ethinyl oestradiol q8h po for
7 days or Provera 20mg q8h po for 7 days) plus
• Tranexamic acid 1g q8h IVI

Long-term/ definitive treatment of chronic AUB:

• Based on the PALM-COEIN acronym for aetiologies of chronic AUB, specific
treatment options for each category are listed below:

Polyps: are treated through hysteroscopic surgical resection.

Adenomyosis: COCs, levonorgestrel-releasing intrauterine device (IUD) or surgical via
hysterectomy or less often, adenomyomectomy is performed.
Leiomyomas (fibroids): can be treated through medical or surgical management depending
on the patient's desire for fertility.
• Medical management options control symptoms include COCs, and tranexamic acid
with non-steroidal anti-inflammatory drugs (NSAIDs).
• Definitive management is surgery: UAE, myomectomy or hysterectomy.
• Others: HIFU, RFA
Malignancy or hyperplasia: can be treated through surgery, ± adjuvant treatment depending
on the stage.
• Hyperplasia without atypia : Levonorgestrel-releasing intrauterine device (IUD) or
Oral progestogens.
• Atypical hyperplasia: hysterectomy.
Coagulopathy: can be treated with tranexamic acid or desmopressin (DDAVP).
Ovulatory dysfunction: Lifestyle modification in women with obesity, PCOS, or other
conditions in which anovulatory cycles are suspected.
• Endocrine disorders: cabergoline for hyperprolactinemia and levothyroxine for
hypothyroidism.
• Symptomatic control of AUB include the levonorgestrel intrauterine system,
monophasic COCs (monthly or extended cycles), progestin therapy (oral or
intramuscular), tranexamic acid, and nonsteroidal anti-inflammatory drugs.
Endometrial disorders: no specific treatment as mechanisms are not clearly understood
Iatrogenic causes: should be managed based on the offending drug and/or drugs.
• If a certain contraception method is the suspected culprit for AUB, alternative
methods can be considered, such as the levonorgestrel-releasing IUD, COCs (in
monthly or extended cycles), or systemic progestins.
Not otherwise classified: include entities such as endometritis and AVMs. Consider an
endometrial biopsy to rule out genital TB.

24
References:
1. Munro MG, Critchley HOD, Fraser IS. The two FIGO systems for normal and
abnormal uterine bleeding symptoms and classification of causes of abnormal uterine
bleeding in the reproductive years: 2018 revisions. Int J Gynecol Obstet 2018; 143:
393–408.
2. Davis E, Sparzak PB. Abnormal Uterine Bleeding. [Updated 2021 Jul 14]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK532913/ [Accessed 10 January
2022].
3. Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-
Aged Women. ACOG committee opinion number 557.

25
Postmenopausal bleeding (PMB)

Definition: Vaginal bleeding after 1 year of amenorrhoea around the menopausal period

Aetiology
• Exogenous oestrogen use, atrophic endometritis/vaginitis, endometrial carcinoma,
endometrial or cervical polyps, endometrial hyperplasia, Other: cervical cancer,
sarcomas, trauma and local lesions on the vulva

Basic clinical approach:

1. History: specific history on hormone use, pap-smear history, contact bleeding, gastro-
intestinal or urologic disease
2. Clinical examination: General examination, organ systems, genital examination:
vulva, vagina, cervix, speculum as well as bimanual examination, adnexa

Transvaginal ultrasound
This is the first step in special investigations. Identification of polyps and intracavity
fibroids can be enhanced through concurrent saline intrauterine infusion
(sonohysterography). Measurement of endometrial side-to-side thickness is of great
importance as values of 4mm and less are associated with a very low risk of endometrial
carcinoma.

Endometrial sampling (ES)

This must be performed in all women with the problem or peri- and postmenopausal
bleeding. The cervix should be stabilised and cleansed. The ES catheter (Pipelle,
endocurette) is introduced through the cervix up to the fundus. The vacuum is created,
and the ES catheter is twirled and moved inside the uterine cavity. The specimen will
appear in the vacuum tube and should be placed in formalin. The sample should be taken
3 times.

Hysteroscopy and curettage

Hysteroscopy can through visualisation improve diagnostic accuracy and does allow for
directed biopsies. This procedure is considered second line in the work up of a patient
with PMB.

26
 Protocol: Postmenopausal bleeding

History and examination

Uterine abnormality
Cervical abnormality do a
Pelvic ultrasound
BIOPSY
• ± Papsmear
• Transvaginal ultrasound,
measurement of ET Manage or
refer
Manage or refer • Endometrial sampling

Insufficient tissue for Hyperplasia without atypia/ Atypical hyperplasia

diagnosis oestrogen effect endometrial carcinoma

Mirena, if
declined mirena
Give Provera
ET < 4mm ET > 4mm: 20mg dly REFER for staging,
reassure and repeat TAH BSO and
offer sampling consideration for
treatment reacts to nodal dissection
follow up result.
after 6 Consider
months Hysteroscopy

If persistent
PMB
consider
hysteroscopy

Reference:
1. Bokour SH, Timmermans A, Mol AW, et al. Management of women with
postmenopausal bleeding: evidence-based review. TOG. 2012; 14:243–9.

27
Pelvic inflammatory disease (PID)/ Acute salpingo-oophoritis (ASO)

Definition: Infection of the upper female genital tract; usually the result of infection
ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis,
tubo-ovarian abscess and/or pelvic peritonitis.

Risk factors: Ealy sexual debut, multiple sexual partners, sex during menses, history of PID,
low socioeconomic status, age < 25 years old and bacterial vaginosis.
Diagnosis
There is no single historical, physical or lab finding that is both sensitive and specific for the
diagnosis of PID.
• Delaying treatment may increase the risk of long-term sequelae such as ectopic
pregnancy, infertility, and chronic pelvic pain.
• A low threshold for empiric treatment for PID is recommended.

Minimum criteria for diagnosis include a clinical triad of:

• Lower abdominal pain
• Cervical motion tenderness and/or uterine tenderness and/or adnexal tenderness:
Plus, any of the following criteria:
• Temperature ≥ 38° C, abnormal cervical discharge, pelvic abscess or inflammatory
complex on bimanual examination, leucocytosis >10 x 109 WBC/L, elevated ESR or
elevated C-reactive protein, gram stain of the endocervix showing gram negative
intracellular diplococci and positive urine chlamydia or gonorrhoea test.

Special investigations:
• Urine pregnancy test
• Bloods: FBC, UKE, CRP, ESR, RPR, offer VCT HIV, ± endocervical swab/ urine for
STI screen (especially patient with recurrent infections)
• Imaging: Transvaginal ultrasound

PID Clinical stages: Gainesville classification

Stages Clinical description Goals of therapy

Stage I Early Salpingitis with Adnexal tenderness Elimination of symptoms
and infections
Stage II Late Salpingitis with pelvic peritonitis Preservation of fallopian
tube function
Stage III Pyosalpinx: Tubo-ovarian complex or abscess Preservation of ovarian
or ESR ≥ 60 function
Stage IV Ruptured tubo-ovarian complex Septicemia Preservation of the patient’s
with generalized peritonitis life
Stage V Adult Respiratory Distress Syndrome (ARDS)

28
Management
Principles:
• Hospitalise all patients with stage II–V PID for parenteral antibiotic or those with
failure to respond to outpatient oral therapy.

Out-patient therapy In-patient therapy

• Ceftriaxone 500 mg IMI stat, plus First line:
• Doxycycline 100 mg po BD for 14 days • Ceftriaxone 1 g IV every 24 hours, plus
(Alternative: Azithromycin 1 g po stat ), • Doxycycline 100 mg q12h po, plus
plus • Metronidazole 500 mg IVI q12h
• Metronidazole 400 mg po BD for 14 Continue IV therapy until there is definite
days clinical improvement (within 24-48 hours).
Thereafter, change to:
Amoxicillin/clavulanic acid, oral, 875/125
mg 12 hourly and Doxycycline 100 mg q12h
po to complete 10 days
therapy.
Second line: if no response after 48 hours
• Clindamycin 900 mg IVI q8h, plus
• Gentamicin loading dose IV or IM (2
mg/kg), followed by a maintenance dose
(1.5 mg/kg) every 8 hours
Indications for surgery:
• PID stage IV
• The diagnosis is uncertain (usually appendicitis),
• There is no adequate response after 48 -72 hours of appropriate therapy
• After 4–6 weeks there still is a large or symptomatic pelvic mass.
• The patient deteriorates on treatment, or patient is severely ill

References:
1. Centres for Disease Control and Prevention (CDC). Sexually Transmitted Infections
(STI) Treatment Guidelines, 2021. Available from:
https://www.cdc.gov/std/treatment-guidelines/pid.htm [Accessed 17 January 2022].
2. National Department of Health, South Africa. Essential Drugs Programme. Hospital
level (Adults) Standard Treatment Guidelines and Essential Medicines List. 5th ed.
2019.

29
Screening for Trisomy 21 and other chromosomal abnormalities

Pregnant age ³ 35 years

or
History of congenital abnormality in previous pregnancy

Determine Gestational Age

D< 14 Weeks f> 14 Weeks

Previous Patient ³ 35
Patient ³ 35
congenital years
years
abnormalities

D1st 22nd
DRefer for
Trimester Trimester
appropriate
screening for screening for
screening
trisomy 21 trisomy 21

• 1st Trimester screening: Combined screening: Sonar- NT, absent or hypoplastic nasal
bone, Ductus venosus- absent or reversed
• 2nd Trimester screening: Detailed Anatomy scan at 18 -22 weeks (assess for soft
markers) & Quadruple tests (LATER if available)
• Soft markers for Trisomy 21:
Ventriculomegaly (LV > 10mm), Mega cisterna magna (CM > 10mm), Thickened
nuchal fold (>6mm), Echogenic intracardiac foci, Echogenic bowel, Pyelectasis (AP
diameter > 4mm), short, long bones (humerus and femur)
• If screen +: offer invasive testing: 10 -14 weeks- CVS and > 16 weeks offer
amniocentesis.

30
Reference:
1. Fox CE, Kilby MD. Prenatal diagnosis in the modern era. TOG. 2016; 18(3): 213-
219.

Number

31
Preterm Labour (PTL)

Definition: labour is a clinical diagnosis and is made when regular painful uterine.
contractions is present with one or more of the following features are present:
o Cervical dilatation and progressive cervical changes (effacement and dilatation)
o A show
o Ruptured membranes
Pre-term labour is defined as the onset of labour at a gestational age of > 26+0 weeks and <
36+6 weeks.
Key: Managing the lower extremity of the gestational age depend on the setting according to
the viability, i.e: WCH/ KSH use 26+0 weeks (800g).

General considerations
1. All patients with a diagnosis or suspected diagnosis of pre-term labour should be
investigated for underlying infection that can cause pre-term labour. Underlying
infections should be treated appropriately. Patients with chorioamnionitis should be
delivered as soon as possible, aim for a normal vaginal delivery.
2. In cases where the diagnosis is not clear, it is reasonable to assess the patient after 4
hours for cervical changes before commencement of tocolysis.
3. A significant number of patients with pre-term labour have sub-clinical chorio-
amnionitis.
4. The patient should be allowed to deliver after one course of tocolysis and
administration of steroids.

Workup
1. Rule out chorioamnionitis & ruptured membranes
2. Urine for MCS (Rule out asymptomatic bacteriuria that can cause PTL)
3. If suspected sepsis, Bloods: FBC, UKE, CRP, Blood culture

Management
Tocolysis
1. The aim of tocolysis is to gain time to administer steroids. Steroids given to the
mother has been shown to be an effective intervention to ensure some protection to
the premature neonate against the morbidity caused by prematurity.
2. PTL between 35+0 – 37 weeks, allow labour to progress, give intrapartum antibiotic
prophylaxis for GBS prophylaxis.
3. PTL between 26+0 – < 34+6 weeks: Tocolyse & administer steroids
4. PTL < 26+0 weeks or EFW < 800g: allow labour to progress i.e.: Miscarriage
5. Patients should be examined and assessed for contraindications of the drugs to be
used. Special caution to rule out underlying cardiac lesions before administering
nifedipine.
6. Nifedipine is regarded as the drug of first choice a WCH/KSH complex.
7. Indomethacin in the recommended dose will not cause premature closure of the
ductus arteriosus in foetuses < 2 kg/ < 32 weeks.
8. Atosiban is recommended for patients with cardiac diseases.
9. Tocolysis should be discontinued after 48 hours. Longer use has not been shown to be
of benefit. i.e: Steroids mature.

32
 10. Contraindications for Tocolysis: If ≥ 34+6 sure gestation or EFW ≥ 2000g in unsure
gestation, pathological or suspicious fetal heart rate pattern, lethal fetal anomaly, intra
uterine fetal death, suspected chorioamnionitis (clinical signs of infection), severe
hypertensive conditions in pregnancy, abruptio placentae, severe IUGR (<3rd
percentile).

The following options are available:

DRUG DOSE ROUTE DURATION

Nifedipine 10 mg po stat, Oral, capsule 24 hours
Repeat every 15 NB: MAINTAIN BP
minutes ´ 4, then > 90/50 mmHg
20mg q6h for 24
hours (4 doses)
Indomethacin 100 mg po stat Rectal 24hours
loading, then 25-
50mg q6h

Atosiban Initial bolus 6.75mg IVI 24 hours

IVI over 1min, then
300µg/min for 3
hours, then
100µg/min for 24
hours

Antibiotics
Routine antibiotics for PTL is not recommended (ORACLE II) unless sepsis is confirmed;
however if delivery is inevitable, or confirmed PTL < 37 weeks; intrapartum antibiotic
prophylaxis against Group B streptococcus should be given.
• Ampicillin 2g q6h IVI (stop after delivery)

Antenatal Corticosteroids (ACS)

Recommended for PTL between 26 – < 34+6 weeks/ EFW 800g - < 2000g
PTL < 26 weeks or EFW < 800g and > 34+6 weeks/ EFW ³ 2000g: No steroids, allow
delivery
DRUG DOSE ROUTE DURATION
Dexamethasone 8mg q8h IMI 3 doses
Betamethasone 12mg q24h IMI 2 doses
*Steroids options: equal efficacy however Dexamethasone is cheaper and widely accessible
Repeat/ rescue dose: conflicting data, There is currently limited evidence to recommend
repeat courses of ACS if a woman remains at imminent risk of preterm birth seven days after
administration of ACS.
Practice points: Repeat ACS should not be administered just because a woman who has
received a first course remains undelivered. Clinical review must occur to assess whether she
is still at risk of preterm birth within the next seven days. The decision to repeat ACS must be
by the consultant. The maximum number of corticosteroid courses given in any one
pregnancy should not exceed three.

33
Magnesium sulphate for fetal neuroprotection
Administer between 26 – < 32 weeks if delivery is imminent in next 24 hours.
• Dose: Load with MgSO4 4g in 200ml Normal saline IVI slowly over 20-30minutes
• Maintenance dose: 1g per hour IVI until delivery or for a maximum of 24 hours.
Repeat doses: In the event that birth does not occur after giving MgSO4 for neuroprotection
of the preterm birth (less than 32 weeks gestation) again appears imminent (planned or
definitely expected within 24 hours), a repeat dose of MgSO4 may be considered.

CTG Monitoring
Start CTG monitoring from ≥ 28 weeks/ EFW 1000g (A decision to monitor < 28 weeks/
EFW 1000g must be discussed with a consultant).

34
 Protocol: Preterm labour

Confirm diagnosis of
preterm labour

Asses gestational
age or
Estimated fetal
weight
Rule out underlying causes
eg. UTI, chorioamnionitis etc

Gestation ≥ 26 weeks and

<34 weeks
or
Estimated fetal weight
≥ 800g and <2kg

Gestational age < 26 weeks or EFW < 800g

Gestation >34 weeks or estimated fetal
weight> 2kg

Tocolysis for 24 hrs, Administer steroids

Allow delivery

35
Preventing Preterm labour

Primary: Aimed at all women to reduce risk.

Secondary: Aimed at reducing risk in women with known risk factors.
Tertiary: Aimed at improving outcomes for preterm infants.

1. Advocate for early booking, i.e: antenatal care, stop smoking, lower workload.
2. Universal screening: Routine cervical length measurement between 16 – 24 weeks.
3. Transcervical cerclage: ³ 3 mid-trimester pregnancy loses suggesting of cervical
insufficiency or women with a history of PTL and a short cervix (< 25mm).
i. ³ 3 PTL < 33weeks
4. Transabdominal cerclage: Failed cervical cerclage.
5. Decrease multiple pregnancies from assisted reproductive techniques.
6. Avoid short inter-pregnancy interval < 6 months, associated with greatest risk (WHO
24 months).
7. Tocolysis.

36
 Protocol: Preventing Preterm Labour

Prevention of PTL

History of PTL / < 3

No history of PTL midtrimester pregnancy
losses

Universal screening: Universal screening:

Transvaginal cervical Transvaginal cervical
length 18- 22 weeks length 16 – 22 weeks

Cervical length > 25mm Cervical length < 25mm Cervical length < 25mm

Consider progesterone: Counsel for vaginal

Routine antenatal care Uterogestan 200mg PV nocte progesterone or Transcervical
Crinone 8% vaginal gel 90mg cerclage (patient to decide)
mane
Consider progesterone:
Uterogestan 200mg PV nocte
Crinone 8% vaginal gel 90mg
mane

References:
1. Royal College of Obstetricians and Gynaecologists (RCOG). Preterm Labour, Tocolytic
Drugs. Green-top Guideline No. 1B. London:RCOG; 2011.
2. Stock SJ, Thomson AJ, Papworth S; the Royal College of Obstetricians, Gynaecologists.
Antenatal corticosteroids to reduce neonatal morbidity and mortality. BJOG 2022;
https://doi.org/10.1111/1471-0528.17027
3. Management of Preterm Labor practice bulletin number 171
4. Royal College of Obstetricians and Gynaecologists (RCOG.Group B Streptococcal
Disease, Early-onset. Green-top Guideline No. 36. London:RCOG; 2011.
5. Kenyon SL, Taylor DJ, Tarnow-Mordi W. Broad-spectrum antibiotics for spontaneous
preterm labour: the ORACLE II randomised trial. March 2001 31;357(9261):989 - 994.

37
Preterm Prelabour Rupture of Membranes (PPROM)

Definition: PPROM is defined as rupture of membranes from 26+0 to 37 completed weeks.

Rupture of membranes must be confirmed by doing a sterile speculum and liquor is seen
draining through the cervical os.
Other confirmatory test:
• Litmus test: Draining fluid is alkalic, therefore a red litmus paper turn blue.
• Fern test: Ferning pattern is observed under the microscope.
• Ultrasound assessment of the amniotic fluid index.
• Others: Amniosense: a panty liner that changes colour at pH >5.2
o Amnioquick: rapid test based on the detection in vaginal samples of IGFBP-1
(Insulin-Like Growth Factor Binding Protein-1), which is found in high
concentration in amniotic fluid. Or
o Amniosure: rapid test detection of PAMG-1 (Placenta Alpha Microglobulin-1)
found in the amniotic fluid.

General considerations
1. All patients with a diagnosis or suspected diagnosis of PPROM should be investigated
for underlying infection that can cause PPROM. Underlying infections should be
treated appropriately. Patients with chorio-amnionitis should be delivered.
2. A significant number of patients with PPROM have sub-clinical chorio-amnionitis;
have a high index of suspicion.
3. NB: Avoid digital examination, unless there is strong suspicion that a woman may be
in labour.
4. All women should be hospitalised for expectant management. (The median latency after
PPROM is 7 days and tends to shorten as the gestational age at PPROM advances).
5. Daily CTG is recommended:
• Start CTG monitoring from ≥ 28 weeks/ EFW 1000g (A decision to monitor <
28 weeks/ EFW 1000g must be discussed with a consultant)
6. Patients managed expectantly should be observed daily for signs and symptoms of
chorioamnionitis (Gibbs criteria). These include:
• Maternal fever ≥ 38 degrees Celsius on one occasion. Plus 2 of:
o Maternal tachycardia (HR > 100 bpm)
o Baseline fetal tachycardia (FHR > 160 bpm for 10 min or longer,
excluding accelerations, decelerations and periods of marked
variability or, where continuous monitoring is not available, an
FHR exceeding 160 bpm during and after at least three consecutive
contractions)
o Purulent fluid from the cervical os.
o Uterine tenderness.
o Maternal WBC ≥ 15,000 per mm in the absence of corticosteroids.
7. Growth scan every 2 weeks.
8. Routine blood tests (CRP, WCC) are not recommended for hospitalized inpatient
undergoing expectant management. NB: Use the Gibbs criteria to assess for chorio-
amnionitis.

38
Management

Key: Managing PPROM the lower extremity of the gestational age depends on the setting
according to the viability, i.e: WCH/ KSH use 26+0 weeks/ 800g. PPROM < 26 weeks/ 800g
is associated with significant neonatal morbidity and mortality and the couple must be
counselled for medical TOP.

Antibiotics
• Erythromycin 250mg q6h po for 10 days (ORACLE I) / Azithromycin 500mg od po
for 3 days or
• Ampicillin 2g q6h IVI for 48 hours, then Amoxil 500mg q8h po for 5 days plus
Azithromycin 500mg od po for 3 days. Add Metronidazole 400mg q8h po for 5 days
if patient goes for caesarean delivery.
• Chorioamnionitis: Ampicillin 2g q6h IVI and Gentamycin 240mg daily IVI.

Antenatal Corticosteroids
Recommended for PPROM between 26 – < 34+6 weeks/ EFW 800g - < 2000g
PPROM < 26 weeks or EFW < 800g and > 34+6 weeks/ EFW ³ 2000g: No steroids, allow
delivery.
Options: equal efficacy however Dexamethasone is cheaper and widely accessible
• Dexamethasone 8mg q8h IMI (3 doses)
• Betamethasone 12mg IMI 24 hours apart (2 doses

Key: If patient goes into labour while undergoing expectant management: if steroids are
onboard, allow labour to progress. Give MgSO4 if < 32 weeks.

Amnioinfusion in PPROM: Might improve neonatal outcome, limited evidence to be

recommended as part of routine clinical practice; not recommended.

Timing of delivery: Deliver at 34weeks or estimated fetal weight ≥ 2000g

39
 Protocol: Preterm Prelabour Rupture of Membranes

Confirm diagnosis of Rule out and treat

preterm rupture of underlying causes e.g.
membranes UTI, chorioamnionitis etc.

Signs of
chorioamnioniti
Asses gestational age or s
estimated fetal weight
Deliver

Gestational > 26 weeks Gestational age < 26

and or estimated fetal weeks or EFW Gestation >34 weeks or
weight 800g - 2kg <800g estimated weight > 2kg

Admit to hospital and Counsel the couple

administer steroid & on expectant Antibiotics and
antibiotics management vs induce labour
Medical TOP

Observe for signs of

chorioamnionitis
Deliver when:
• Signs of
chorioamnionitis
Signs of No signs of • Gestation > 34
chorioamnioniti chorioamnionitis weeks or EFW > 2kg
s • Pathological EFM
(CTG)
Deliver

References:
1. Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes
from 24+0 Weeks of Gestation (Green-top Guideline No. 73). London:RCOG, 2019.
2. Kenyon SL, Taylor DJ, Tarnow-Mordi W. Broad-spectrum antibiotics for preterm,
prelabour rupture of fetal membranes: the ORACLE I randomised trial. ORACLE
Collaborative Group. Lancet 2001 Jul 14;358(9276):156.
3. Prelabour Rupture of Membranes. ACOG practice bulletin Number 217. March 2020.

40
Prelabour rupture of membranes (PROM)

Definition: rupture of membranes before the onset of labor after 37 weeks gestation.
Immediate risks, but uncommon, include:
• Cord prolapse
• Cord compression
• Placental abruption

Delayed risks include

• Maternal infection and puerperal sepsis.
• Neonatal infection (can result in devastating sequelae including death, chronic lung
disease & cerebral palsy).

Diagnosis
• History and physical examination
o (Digital cervical examinations increase the risk of infection & generally
should be avoided unless the patient appears to be in active labour or delivery
seems imminent)
• Sterile speculum examination: NB: see PPROM confirmatory test
o Visualization of amniotic fluid passing from the cervical canal & pooling in
the vagina
o Simple pH test of vaginal fluid (litmus paper)
o Arborization (ferning) of dried vaginal fluid, which is identified under
microscopic evaluation
o To inspect for cervicitis and prolapse of the umbilical cord or fetal parts,
assess cervical dilatation and effacement, & obtain cultures as appropriate.
• Ultrasound
o Ultrasonographic examination of amniotic fluid volume may be a useful
adjunct but is not diagnostic

Management
• Determine the gestational age, fetal presentation, maternal & fetal well-being
• The examination should exclude evidence of intrauterine infection & abruptio
placentae
• If the patient is not labour has not occur at time of presentation, proceed to delivery:
ACTIVE MANAGEMENT
o Active management vs Expectant management: Level I Evidence
§ A reduction in time from membrane rupture to birth
§ A reduction in maternal chorioamnionitis and/or endometritis /
postnatal septicaemia
§ No increase in caesarean birth
§ No difference in epidural analgesia
§ A reduction in admission to a neonatal special care or intensive care
unit
§ No difference in definite early onset neonatal sepsis
§ No difference in serious maternal morbidity, mortality or perinatal
mortality
§ Increased rate of IOL
§ Longer average lengths of labour

41
 • IOL commenced as per local protocol & caesarean section for obstetric indication
o Mechanical methods of induction eg. balloon catheters, are associated with an
increased risk of infection; avoid.

Antibiotics: Antibiotic use in term PROM after 12 hours appears to be associated with a
reduced risk of maternal infectious morbidity.
• Ampicillin 1g q6h IVI & Flagyl 400mg q8h po
Group B streptococcal prophylaxis should be given based on prior culture results.

References:
1. Prelabor Rupture of Membranes. ACOG practice bulletin Number 217. March 2020.
2. Scorza W E.; Lockwood, C.J.B., V A. Management of prelabour rupture of the fetal
membranes at term. 2020 [cited 2020 28 July]; Available from:
https://www.uptodate.com/contents/management-of-prelabor-rupture-of-the-fetal-
membranes-at-term [Accessed 19 January 2022].
3. Middleton, P., et al., Planned early birth versus expectant management (waiting) for
prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst
Rev, 2017. 1(1): p. Cd005302.

42
Induction of Labor (IOL)

Induction of labor refers to aartificial stimulation of uterine contractions before the true onset
of spontaneous labor. The goal of induction is to achieve a successful vaginal delivery.

Indications and contraindications of Induction of labor

Indications Contraindications
Absolute indications • Suspicious or Pathological CTG
• Hypertensive disorders: GHPT, • Placenta or vasa previa
PET/Eclampsia • Umbilical cord presentation
• Late-term pregnancy: > 41 weeks or Post • Transverse lie or breech presentation
term • Prior classical or inverted T uterine
• Premature rupture of membranes/ Prelabor incision
ROM • Significant prior uterine surgery (e.g.
• Chorioamnionitis myomectomy, previous uterus rupture)
• Fetal complications: Isoimmunization, • Active genital herpes
oligohydramnios, Intrauterine growth • Pelvic structural deformities associated
restriction with CPD
• Maternal medical complications: Diabetes • Invasive cervical carcinoma
mellitus, renal disease, chronic pulmonary • Previous pelvic surgeries like
disease vesicovaginal fistula/rectovaginal
• Intrauterine fetal death fistula/pelvic floor repair (third or fourth
• Previous stillbirth degree perineal tears repair),
trachelorrhaphy.
Relative indications
• Polyhydramnios
• Fetal anomalies requiring specialized
neonatal care
Psychosocial conditions: Previous
precipitate labor, distance from hospital

Prerequisites prior to starting an Induction of Labor

Maternal criteria Fetal criteria

• Confirm indication • Confirm gestational age (Avoid IOL <
• Rule out contraindications 39 weeks, unless medically indicated)
• Perform clinical pelvimetry to rule out • Assess fetal lung maturity status if
CPD required
• Assess cervical condition (Bishop score) • Estimate fetal weight (clinically or
• Discuss risks and benefits with patient USG)
and relatives • Umbilical artery dopplers
• Written informed consent • Confirm fetal presentation and lie
• Confirm fetal well-being: 20 min CTG

43
Prediction of Induction of labour success
IOL is more likely to be successful in:
• Term pregnancy
• Multiparous women
• Women with ruptured membranes
• Women with previous vaginal deliveries
• Non-obese women (BMI < 30kg/m2)
• Fetus < 4000g
• Favourable Modified Bishop score > 6

Modified Bishop’s Score

Score Bishop Score

Cervix Modifiers
0 1 2 3
Dilatation Closed 1-2 3-4 5 Add 1 point for:
• Preeclampsia
Length >4 3-4 1-2 0 • Each previous NVD
Consistency Firm Medium Soft - Subtract 1 point for:
• Late-term
Position Posterior Midline Anterior - pregnancy
• Nulliparity
Station -3 -2 -1, 0 ³ +1 • PPROM
Total score: 13; Favourable Score: 6 - 13; Unfavourable Score: 1 - 5

Methods of Cervical Ripening

Mechanical methods Surgical methods Medical methods

• Membrane sweeping • Amniotomy • Oxytocin
• Mechanical dilators • Prostaglandins
• Transcervical Foley • E1 (Misoprostol)
balloon catheter • E2 (Dinoprostone)

44
Windhoek Hospital Complex IOL Protocol

If unfavourable Modified Bishop scope

1st Line:
Combined method: Mechanical (transcervical foley balloon catheter) + Pharmacological
(Misoprostol 25 µg q2h po) shortens the time to delivery interval
§ Oral Misoprostol 25µg q2h po x 8 doses (Dissolve 1 tablet of Misoprostol 200µg in
200ml of water, give 25ml every 2 hours)
§ CTG before and after each dose
Alternatives (2nd line):
§ Dinoprostone tablets (Prostins) 2mg stat then, 1mg q6h pv x 3 doses
§ Dinoprostone Gel: Prandin gel 2mg stat then, 1mg q6h pv x3 doses / Prepidil gel
0.5mg q6h pv x3 doses
§ Dinoprostone inserts (Propess, Cervidil) 10mg pv insert for 24 hours (0.3mg/hr)
After 24 hours remove the insert

If favourable Bishop score

• Artificial rupture of membrane.
• Oxytocin (Use augmentation of labour protocol).

Previous caesarean section: (Per specialist advice)

• Foley balloon catheter
• NO misoprostol
• Consider PGE2 vaginal gel

Complications Associated with IOL

• Frequently encountered with oxytocin or prostaglandin administration.
• Tachysystole: Persistent pattern of ≥ 5 contractions in 10 minutes.
• Hypertonus: A single contraction lasting longer than 2 minutes.
• Hyperstimulation: Tachysystole or hypertonus associated with FHR abnormalities.
• Uterus rupture.

Failed Induction
• No criteria for a failed induction
• Individualise: Indicated (Emergency; e.g: Pre-eclampsia) vs Elective IOL (e.g: Late-
Term):
• Indicated IOL offer only 1 cycle and elective IOL can have a repeat 2nd cycle
or an extended continuous induction with oral misoprostol for u to a maximum
of 72 hours.
• Allow time for cervical ripening
• IOL has contributed to the increasing caesarean section rate.

Important to remember:
• Avoid oxytocin use within 6 hours after the last dose of misoprostol.
• Avoid oxytocin use within 30 minutes after removing the Dinoprostone vaginal insert.

45
References:
1. Inducing labour clinical guide. NICE guideline [CG70]. London: NICE. 2008.
2. Induction of labour. ACOG practice bulletin number 107. Washington DC. 2009.
3. Ornat L, Alonso-Ventura V, Bueno-Notivol J, et al. Misoprostol combined with
cervical single or double balloon catheters versus misoprostol alone for labor
induction of singleton pregnancies: a meta-analysis of randomized trials. J Matern
Fetal Neonatal Med. 33 (20). 3453 -3468.
4. New FIGO Guidelines for Misoprostol Use. [Homepage on the internet]. Available
from: https://www.mhtf.org/2017/06/29/new-figo-guidelines-for-misoprostol-use/
[Accessed 12 December 2021].

46
Augmentation of labor (AOL)

Definition: refers to the process of stimulating the uterus to increase the frequency, duration
and intensity of contractions after the onset of spontaneous labour.

Indications and contraindications

Indications Contraindications
• Failure to progress dur to uterine inertia • Suspicious or pathological CTG
(Hypoactive uterine contractility) • Previous caesarean section
• Contractions: < 2/10min lasting • Previous myomectomy or transmural
< 30 seconds incision
• Minimal descent of presenting part (<1 • Previous uterine rupture
cm) in second stage after 30 - 45 • CPD
minutes of active pushing with • Placenta praevia or vasa praevia
contractions less than 3/10 minutes • Transverse lie

General principles
• AOL reclassify the labour to High-Risk, meaning the patient requires close monitoring.
• All women should be provided with verbal and written informed consent on the risks and
benefits of AOL.
• Continuous CTG is advised for all patients during AOL.
• Do an Hb in case the patient require an emergency caesarean section.
• Monitor the patient’s progress using the labor care guide (LCG), there must be progress,
otherwise abort the AOL and bail out by emergency caesarean section.
• Notify the anesthetist on call in case the patient requires an emergency caesarean section.
• For induction of labor: use oxytocin only in patients with bishop score > 6 and perform
artificial rupture of membrane if the membranes are intact, before AOL.
• Do not give oxytocin within 6 hours of the last dose of Misoprostol and Prostaglandin E2
gel or within 30 minutes after removal of Prostaglandin E2 pessary (Propess)
• The recommended safe maximum dose of IV oxytocin is 20mU/min.

Preparing the infusion

• Regimen 1: Add 10 IU of oxytocin to 1000mL of normal saline or ringer lactate is
equivalent to 10,000 mU (10mU/ml).
o Start infusion at 6 mL per hour (60mU/hr = 1mU/min)
• Regimen 2: Add 12 IU of oxytocin to 200mL of normal saline or ringer lactate is
equivalent to 12,000 mU (60mU/ml).
o Start infusion at 1 mL per hour (60mU/hr = 1mU/min)
o Recommended for cardiac patients or patients at risk of pulmonary edema (e.g.:
Pre-eclampsia).
• Oxytocin should be given by infusion pump (e.g. IVAC).
• Regimen 3: Oxytocin dose without infusion pump
o There are 2 standard giving sets of drip rates:
§ Micro Drop factor: 60 drops in 1ml
§ Macro Drop factor: 20 drops in 1ml (Not recommended for use for
AOL)
§ Add 12 IU of oxytocin to 200mL of normal saline or ringer lactate is
equivalent to 12,000 mU (60mU/ml).

47
 § Start infusion at 60 drops per hour (60mU/hr = 1mU/min = 1drop/min)
o This regimen should be administered under a specialist supervision.

Dosage regimens for augmentation

Time since Oxytocin Volume of infusion (mL/hr.) Volume of infusion (drops/hr)
AOL dose(mU/min) Regimen 1: Regimen 2: Regimen 3
(min) (Using a Micro factor drip set)
0 1 6 1 20 drops
30 2 12 2 40 drops
60 4 24 4 80 drops
90 6 36 6 120 drops
120 8 48 8 160 drops
150 10 60 10 200 drops
180 12 72 12 240 drops
210 14 84 14 280 drops
240 16 96 16 340 drops
270 18 108 18 360 drops
300 20* 120 20 400 drops
*
Maximum recommended dose

Monitoring
1. Continuous CTG monitoring.
2. After every 30 min: assess CTG & contractions. Only increase dose when CTG is
normal and when less than 3 strong (> 40s) contractions in 10 minutes palpated.
3. Maintain the rate, when adequate uterine contractions are achieved (3-4
contraction in 10 minutes lasting 40-50 seconds) until delivery is completed.
4. STOP oxytocin and give plain normal saline whenever there is uterine
hypercontractility:
a. Tachysystole: more than 5 contractions in 10 minutes averaged over 30
minutes
b. Hypertonus: uterine contraction exceeding 2 minutes
c. Hyperstimulation: excessive uterine contractions (tachysystole or hypertonus)
with fetal heart abnormalities.
In the presence of the above: stop the AOL and commence with intrauterine
resuscitation (Put the woman in left lateral position & tocolysis; oxygen
administration is no longer recommended as part of routine intrapartum
resuscitation): If imminent delivery do an assisted delivery otherwise deliver
by emergency caesarean section.
o Tocolytic agent of choice: Salbutamol (available as 500g/ml
ampoule or other formulations)
o Add 1 ampoule to 9ml of saline (50µg/ml); give 1ml (50µg) IV
boluses up to 250 micrograms in total (often 100 micrograms
will be sufficient)
§ Ensure monitoring of maternal pulse whilst bolus doses
are administered; stop IV administration if maternal
pulse > 140bpm
§ Salbutamol is contraindicated in: Cardiac disease,
Hypertension, Hyperthyroidism

48
 5. Fetal rate abnormality may be the earliest sign of uterine rupture; have a high
index of suspicion
6. After 4 hours, stop AOL and bail out by caesarean delivery.

References:
1. WHO recommendations for augmentation of labour. WHO Library Cataloguing-in-
Publication Data. World Health Organization 2014.
2. Managing Complications in Pregnancy and Childbirth. [home page on the internet] [cited
2022 5 January]; Available from: https://hetv.org/resources/reproductive-
health/impac/Procedures/Induction_P17_P25.html [accessed 30 December 2021].
3. Raghuraman N, Temming LA, Doering MM, Stoll CR, Palanisamy A, Stout MJ, et al.
Maternal oxygen supplementation compared with room air for intrauterine resuscitation: a
systematic review and meta-analysis. JAMA Pediatr 2021;175:368-76. doi:
10.1001/jamapediatrics.2020.5351 [accessed 15 February 2022]
4. Oxygen Supplementation in the Setting of Category II or III Fetal Heart Tracings. ACOG
Practice Advisory. American College of Obstetricians and Gynecologists. January 2022.
Available from: https://www.acog.org/clinical/clinical-guidance/practice-
advisory/articles/2022/01/oxygen-supplementation-in-the-setting-of-category-ii-or-iii-fetal-
heart-tracings [accessed 19 December 2021]
5. Induction and Augmentation of Labour. South Australian Perinatal Practice Guideline.
Available from:
https://www.sahealth.sa.gov.au/wps/wcm/connect/ac7d37804ee4a27985598dd150ce4f37/Ind
uction+and+Augmentation+of+Labour_PPG_V9_0.pdf?MOD=AJPERES&amp;CACHEID=
ROOTWORKSPACE-ac7d37804ee4a27985598dd150ce4f37-nScZPv1 [accessed 9
December 2021].

49
Management of Prolonged Pregnancy

Definitions:
Recommended classification of pregnancy ³ 37 weeks of gestation.
Term pregnancy ³ 37+0 weeks
• Early term: 37+0 – 38+6 Weeks
• Full term: 39+0 – 40+6 Weeks
• Late term: 41+0 – 41+6 Weeks
• Post term: ³ 42+0 Weeks

1. Late term is defined as a pregnancy duration of ≥ 41 weeks by a certain dated pregnancy:

i.e.: Sure LNMP or Early ultrasound done before 24 weeks. The most common cause for late
term pregnancies is wrong dates.
2. Post-term pregnancy is defined as pregnancy duration of more than 42 weeks by a certain
dated pregnancy.
3. Post-maturity is a clinical entity diagnosed on a neonate after delivery.
• Loss of subcutaneous fat
• Dry cracked skin
• Absence of vernix caseosa + lanugo hair
• Abundant scalp hair
• Scaphoid abdominal shape

Symphysis-fundal height (SFH) measurement should be used to estimate gestational age after
24weeks if dates from LNMP are unknown or wrong in a normal singleton pregnancy. The
SFH is plotted onto the 50th centile on the SFH graph, allowing the corresponding gestational
age to be read from the graph.
The SFH measurement is of little value for estimating gestational age at < 20cm and ³ 35cm
(Corresponding to 20 and 35 weeks respectively).
Patients presenting late in the third trimester (> 35weeks by symphysis fundal height) should
be assessed and managed as UNSURE GESTATIONAL AGE, use the EFW to guide
management.

General considerations
1. The problem arising with post-term pregnancies is the increased risk of sudden
intrauterine fetal demise due to placental insufficiency.
2. There are no reliable methods to safely monitor the fetus in a pregnancy lasting more than
41 weeks.
3. It is advised that pregnancy should not be allowed to exceed 41 weeks, and pregnancies
exceeding 41 weeks should be terminated by induction or caesarean section (Obstetrics
indications).
4. Reducing prolonged pregnancy and need for IOL by:
• Early dating ultrasound
• Routine membrane sweeping at 38weeks – membrane sweeping makes
spontaneous labour more likely.

50
 Protocol: Management of prolonged pregnancies

Assess if pregnancy is
Late-term, Post-term or
Unsure gestational age

Unsure gestational age Late-term or

Post-term

Deliver
Ultrasound assessment
of amniotic fluid index
(AFI)

AFI < 6 or AFI ≥ 6 or

MVP > 2
MVP £ 2

Stretch and membranes

Deliver sweep

Weekly assessment of
AFI

Deliver when
AFI < 6 or MVP £ 2

References:
1. Definition of Term Pregnancy. ACOG committee opinion number 579.
2. Management of Late-Term and Post term Pregnancies. ACOG practice bulletin
number 146.

51
Intra-uterine fetal demise (IUFD) and Stillbirth

Definitions:
Intrauterine foetal demise refers to a foetus with no signs of life in utero after 20 weeks (or
EFW > 500g).
Stillbirth refers to the delivery of a foetus with no signs of life after viability; ≥ 28 weeks/
1000g (WHO definition).

Common causes of fetal death and risk factors

Maternal factors Placental factors Fetal factors

• Hypertensive disorders • Placental insufficiency • Rh isoimunisation
in pregnancy • Feto-fetal transfusion • Fetal growth restriction
• Diabetes mellitus: syndrome • Congenital abnormalities
Gestational or overt • Abruptio placentae • Feto-maternal bleeding
diabetes • Umbilical cord prolapse • Chorioamnionitis
• Collagen diseases and • True knots in the
antiphospholipid umbilical cord
syndromes, SLE
• Renal disease
• Infections including
syphilis, parvovirus B19,
coxsackie,
cytomegalovirus,
rubella, measles,
poliovirus, group B
streptococci, listeria,
ureaplasma urealyticum
and toxoplasmosis
• Sickle cell anaemia

Assessment
Objectives of evaluation of an intra-uterine death
• Try to establish the cause
• To distinguish between recurrent and non-recurrent causes
• To plan treatment when possible or other interventions during future pregnancies
• To assist in the grieving process
• Majority of IUFD/ stillbirths that are unexplained are believed to be caused by missed
intrauterine foetal growth restriction.

• Confirm the fetal death by ultrasound (Signs: skin oedema, Spalding sign, absent
foetal cardiac activity)
• Rule out life-threatening conditions: Pre-eclampsia, abruption placenta

52
Recommended investigations:
Maternal bloods: FBC, clotting profile, fibrinogen, random blood glucose, syphilis,
Antiphospholipid syndrome antibodies(anticardiolipin, anti-β 2-glycoprotein-I antibodies and
lupus anticoagulant). Consider screening for TORCH infections and thyroid disease if
indicated by clinical history or examination.
Stillborn Fetus: general examination noting any dysmorphic features, Placenta histology (all
patients), karyotypic analysis and discuss an option of autopsy.

Management:
• Discuss expectant (Risk of DIC) vs immediate delivery
o If delayed delivery consider weekly DIC screen (FBC, Fibrinogen)
• Adequate intrapartum analgesia
• Postpartum suppress breastmilk: Bromocriptine 2.5mg dly po 7/7 or Carbegoline
(Dostinex) 1mg po stat
• Psychosocial support for grief counselling

53
Management of Subsequent Pregnancy After Stillbirth

Pre-pregnancy or Initial Prenatal Visit

• Detailed medical and obstetric history
• Evaluation and workup of previous stillbirth
• Determination of recurrence risk
• Smoking cessation
• Weight loss in obese women (pre-pregnancy only)
• Genetic counselling if family genetic condition exists
• Diabetes Mellitus screen
• Acquired thrombophilia testing: lupus anticoagulant as well as IgG and IgM for both
anticardiolipin and b2-glycoprotein antibodies
• Support and reassurance

First Trimester
• Dating ultrasonography
• First-trimester screen: pregnancy-associated plasma protein A, human chorionic gonadotropin,
and nuchal translucency; uterine artery dopplers
• Support and reassurance

Second Trimester
• Fetal sonographic anatomic survey at 18–20 weeks
• Offer genetic screening if not performed in the first trimester or single marker alpha fetoprotein
if first trimester screening already performed
• Support and reassurance
• OGTT at 24 – 28 weeks

Third Trimester
• Sonographic screening for fetal growth restriction after 28 weeks
• Antepartum fetal surveillance starting at 32 weeks of gestation or 1–2 weeks earlier than
previous stillbirth
• Support and reassurance

Delivery
Planned delivery at 38 0/7 weeks of gestation or as dictated by other maternal or fetal comorbid
conditions. In cases of severe patient anxiety, where there is a preference to proceed with early term
delivery (37 0/7 weeks to 38 6/7 weeks) to prevent recurrent stillbirth, such decisions must incorporate
the understanding of the increased risks of neonatal complications with early term delivery compared
with the potential benefit.

References:
1. Reddy UM. Prediction and prevention of recurrent stillbirth. Obstet Gynecol 2007;
110:1151–64.
2. Late Intrauterine Fetal Death and Stillbirth. Green-top Guideline No. 55
3. Management of Stillbirth. ACOG Obstetric Care Consensus. March 2020.
4. Adam, S. Soma-Pillay, P. Obstetric Essentials. 2018. 3rd Edition. University of Pretoria.

54
Antepartum Hemorrhage (APH)

Definition: vaginal bleeding of any amount that occurs in a pregnant patient after viability;
i.e: a certain gestation > 28 weeks or an EFW > 1000g.

Etiological classification
1. Abruptio placentae
2. Placenta previa
3. Genital tract causes, i.e.: Cervical or vaginal causes, heavy show
4. Antepartum Hemorrhage of unknown origin (Unexplained APH)

An immediate approach to managing a patient with APH

1. CAB of Resuscitation if necessary
2. Call for HELP
3. Insert 2 peripheral lines, use a jelco not smaller than 18G (green)
4. Give face mask oxygen 40%
5. Do an Arterial Blood Gas
6. Do blood tests: Type and screen, order blood if in hypovolemic shock (i.e. HB <
10g/dl or Lactate > 4), FBC, UKE, LFTs and Clotting profile
7. Catheterize and monitor input and output
8. Ultrasound: Assess fetus viability, placental location before per vaginal examination.
9. Expedite delivery if excessive bleeding

General considerations
1. Patients with abruptio placentae can be severely shocked even though can present
with minimal vaginal bleeding (i.e: concealed hemorrhage).
2. Abruptio placentae with an intrauterine fetal demise is associated with massive blood
loss: Routinely Order 4 units of packed RCC and 4 units of FFP as part of adequate
resuscitation.
3. Patients with an abruptio placentae can have underlying Pre-eclampsia despite being
normotensive at presentation. The “Normal BP” can be because of hypovolemic
shock. Do a URINE DIPSTIX to test for proteinuria if present have high index of
suspicion for pre-eclampsia.
4. In women presenting with APH < 37 weeks 0 days of gestation, where there is no
maternal or fetal compromise and bleeding has settled, there is no evidence to support
elective premature delivery of the fetus. Any APH ≥ 37 weeks, delivery is
recommended.
5. Following APH from APH of unknown origin, the pregnancy should be reclassified
as ‘high risk’ and ANC should be at the high-risk clinic. Elective delivery (IOL/
Caesarean section for obstetrics indications) is recommended at 38 weeks.
6. Risk factors for placental abruption: Previous abruption placentae, Pre-eclampsia,
Fetal growth restriction, Non-vertex presentations, Polyhydramnios, Advanced
maternal age, Multiparity, Low BMI, Pregnancy following assisted
reproduction, Intrauterine infection, PPROM, Abdominal trauma, Smoking/ drug
misuse
7. Abruptio placentae Grading: Sher Severity Grading System
§ Grade 1 (Herald Bleed): Mild PV bleeding, soft non-tender uterus,
normal CTG, may be asymptomatic
§ Grade 2: Tender uterus, moderate PV bleeding/ concealed
haemorrhage, suspicious or pathological CTG

55
 § Grade 3:IUFD, hypovolemic shock, woody hard uterus
3A: No Coagulopathy
3B: Coagulopathy present (DIC)

Abruptio placenta protocol

dAbruptio Placenta

Live fetus,
FHR >100/min IUFD
on CTG/ US

Immediate delivery • Caesarean section: If there’s an

obstetric indication
Mode: NVD if fully dilated,
AROM, consider assisted • Otherwise, aim for NVD
delivery, otherwise emergency • Do artificial rupture of the membranes,
caesarean section Adequate analgesia (Morphine)
• Aim to deliver within 8 hours
• Consider Augment labor with oxytocin
• Caesarean section if: Life-threatening
hemorrhage, Patient not near delivery
after 8 hours

NB:
• Patients with an abruptio placenta have an active on-going bleeding from the uterus;
the only way to stop the delivery is by delivering i.e: contracting uterus after delivery.
• These patients must be managed in High-care.
• Be aware of post-partum hemorrhage, Active management of the 3rd stage is
mandatory, in addition add Oxytocin 30U to run as an infusion.
• Be aware of complications: DIC, Renal failure, Pulmonary edema.

56
Placenta praevia and Placenta Accreta Spectrum: Diagnosis and Management

Placenta praevia and placenta accrete spectrum are associated with high maternal and
neonatal morbidity and mortality.

Definitions:
Placenta praevia: the term ‘placenta praevia’ is used when the placenta lies directly over the
internal os > 16 weeks.

Low- lying placenta: For pregnancies > 16 weeks of gestation, the placenta should be
reported as ‘low lying’ when the placental edge < 20 mm from the internal os, and as normal
when the placental edge is ³ 20 mm from the internal os on TAS or TVS.
A TVS is recommended at 32 weeks of gestation to diagnose persistent low-lying placenta
and/or placenta praevia.

Risk factors
• Previous placenta previa
• Previous caesarean section: rate increase with the number of caesarean sections
• 1x caesarean section (C/S): 3%, 2x C/S: 11%, 3x C/S: 40%, 4x C/S: 60% and 5x C/S:
67%
• Previous uterus surgery: myomectomy, curettage
• Hysteroscopy
• Assisted reproductive technology
• Advanced maternal age

Diagnosis
The mid-pregnancy routine fetal anomaly scan should include placental localisation thereby
identifying women at risk of persisting placenta praevia or a low-lying placenta.

1st trimester markers

• A gestational sac implanted in the lower uterine segment or in a CS scar
• Multiple hypoechoic spaces within the placenta (lacunae).
• Caesarean section scar pregnancy
2nd trimester markers
• Placenta located in the lower 1/3 of the uterus
• Multiple vascular lacunae in 1st and 2nd trimesters
• Loss of the normal hypoechoic retroplacental zone
• Abnormality in the uterine-serosa-bladder interface
• Retroplacental myometrial thickness < 1 mm
• Turbulent blood flow through lacunae with colour Doppler
Value of MRI: No difference between ultrasound and MRI in sensitivity or specificity for
detection of invasive placenta, may have role in posterior placentation.

Placenta Accreta Spectrum (PAS): a spectrum disorder ranging from abnormally adherent to
deeply invasive placental tissue.

57
FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders

Grade 1: Abnormally adherent placenta (placenta adherenta or creta)

Description: the villi adhere superficially to the myometrium without interposing decidua.
Clinical criteria at vaginal delivery
• No separation with synthetic oxytocin and gentle controlled cord traction
• Attempts at manual removal of the placenta results in heavy bleeding from the
placenta implantation site requiring mechanical or surgical procedures.
If laparotomy is required (including for caesarean delivery)
• Same as above
• Macroscopically, the uterus shows no obvious distension over the placental bed
(placental “bulge”), no placental tissue is seen invading through the surface of the
uterus, and there is no or minimal neovascularity.
Grade 2: Abnormally invasive placenta (Increta)Clinical criteria
Description: the villi penetrate deeply into the uterine myometrium down to the serosa.
At laparotomy
• Abnormal macroscopic findings over the placental bed: bluish/purple colouring,
distension (placental “bulge”).
• Significant amounts of hypervascularity (dense tangled bed of vessels or multiple
vessels running parallel craniocaudally in the uterine serosa)
• No placental tissue seen to be invading through the uterine serosa.
• Gentle cord traction results in the uterus being pulled inwards without separation of the
placenta (so-called the dimple sign).

Grade 3: Abnormally invasive placenta (Percreta)

Description: where the villous tissue perforates through the entire uterine wall and may
invade the surrounding pelvic organs, such as the bladder.

Grade 3a: Limited to the uterine serosa

Clinical criteria
At laparotomy
• Abnormal macroscopic findings on uterine serosa surface (as above) and placental
tissue seen to be invading through the surface of the uterus
• No invasion into any other organ, including the posterior wall of the bladder (a clear
surgical plane can be identified between the bladder and uterus)

Grade 3b: With urinary bladder invasion

Clinical criteria
At laparotomy
• Placental villi are seen to be invading into the bladder but no other organs
• Clear surgical plane cannot be identified between the bladder and uterus
Grade 3c: With invasion of other pelvic tissue/organs
Clinical criteria
At laparotomy
• Placental villi are seen to be invading into the broad ligament, vaginal wall, pelvic
sidewall or any other pelvic organ (with or without invasion of the bladder).

58
Acute management of bleeding Placenta Praevia
• Active ongoing significant bleeding: Immediate delivery by caesarean section, inform
consultant on-call, counsel for a possible caesarean hysterectomy regardless of the
gestational age.
• If < 34 weeks and bleeding subside, manage conservatively: keep in hospital, observe
vital signs, maintain Hb ³ 10g/dL and give steroids. Deliver electively by caesarean
section between 34- 36 weeks.
• If ³ 34 weeks and bleeding: Deliver immediately by caesarean section, if minor
bleeding at night consider delaying till morning when more members of the team are
available, anesthetist consultant, gynae consultant, urologists.

59
 Protocol

Routine screening
18 – 24 weeks

Placenta Previae Low lying placenta PAS

Asymptomatic Bled < 34 weeks Rescan at 32 weeks Inpatient

management,
elective e delivery ³
35+0 – 36 weeks
Assess Inpatient
management,
socioeconomic
status, consider deliver ³ 34 +0
weeks The six elements considered to be
inpatient reflective of good care are:
management • Consultant obstetrician planning
Elective delivery at and directly supervising delivery.
36 +0 weeks • Consultant anaesthetist planning
Persistent low- Placenta > 20mm
and directly supervising
lying placenta from internal os
anaesthesia at delivery.
• Blood and blood products
available in BRB box
Rescan at 36 weeks Manage as any • Multidisciplinary involvement in
other pregnancy, preoperative planning.
IOL at 41 weeks • Discussion and consent, including
if late term possible interventions (such as
Placenta < 20mm Placenta > 20mm hysterectomy, leaving the placenta
from internal os from internal os in situ, cell salvage and
interventional radiology).
• Availability of a high care/ ICU
Counsel for delivery
bed
by caesarean section
at 39 +0 weeks

References:
1. Placenta Praevia and Placenta Accreta: Diagnosis and Management (Green-top
Guideline No. 27a). London: RCOG. 2011.
2. Antepartum Haemorrhage (Green-top Guideline No. 63). London: RCOG. 2011.
3. Jauniaux E, Ayres-de-Campos D, Langhoff-Roos J, et al. FIGO classification for the
clinical diagnosis of placenta accreta spectrum disorders. Int J Gynecol Obstet 2019;
146: 20–24.

60
Hypertensive Disorders of Pregnancy

Definition and diagnostic criteria

§ Pre-Hypertension: BP ³ 130 – 139/85 – 89mmHg on 2 occasions 30 minutes – 2
hours apart.
§ Chronic hypertension: Pre-existing hypertension or BP ³140/90mmHg before 20
weeks’ gestation on 2 occasion 4 hours appart or a single BP ³160/110mmHg.
§ Gestational hypertension: Hypertension (BP ³140/90mmHg on 2 occasion 4 hours
appart or a single BP ³160/110mmHg) arising de novo after 20 weeks’ gestation in
the absence of proteinuria and without biochemical or haematological abnormalities.
§ Pre-eclampsia: Hypertension (BP ³140/90mmHg on 2 occasion 4 hours appart or a
single BP ³160/110mmHg) arising de novo after 20 weeks’ gestation accompanied by
³ 1 of the following new-onset conditions:
1. Proteinuria: Dipsticks ≥1+ (spot urine protein/creatinine ratio (PCR) should be
performed), PCR ratio ≥30 mg/mmol (0.03g/mmol) or 24-hour urine specimen ≥300
mg (0.3g)
2. Maternal organ dysfunction, including:
• Neurological complications (examples include eclampsia, altered mental status,
blindness, stroke, clonus, severe headaches, and persistent visual scotomata)
• Pulmonary edema
• Liver involvement (elevated transaminases, eg, alanine aminotransferase or
aspartate aminotransferase >40 IU/L) with or without right upper quadrant or
epigastric abdominal pain.
• AKI (creatinine ≥90µmol/L) or doubling creatinine in the absence of renal disease
• Haematological complications (thrombocytopenia–platelet count <100 x 109/l,
disseminated intravascular coagulation, haemolysis).
3. Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical
artery [UA] Doppler wave form analysis, or IUFD).

One or more of the following indicates “Pre-eclampsia with severe features”

• Persistent severe hypertension, BP ³160/110mmHg on 2 occasions 4 hours apart
despite treatment
• HELLP syndrome
• Thrombocytopenia < 100x109/l
• Symptoms of imminent eclampsia
• Pulmonary edema
• AKI: Creatinine > 96µmol/L or doubling
• The following are NOT diagnostic criteria for the diagnosis of preeclampsia with
severe features: edema, proteinuria, fetal growth restriction, uric acid

Chronic hypertension with superimposed pre-eclampsia

o Chronic hypertension + above
Eclampsia: De novo seizure associate with Hypertensive disorders of pregnancy.

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Screening for Preeclampsia
Universal screening: combined test is the most predictive
First Trimester
1. Maternal risk factors
• Prior pre-eclampsia
• Chronic hypertension
• Multiple gestation
• Pre-gestational diabetes
• Maternal BMI > 33
• Anti-phospholipid syndrome/systemic lupus erythematosus (SLE)
• Assisted reproduction therapies
2. Mean Arterial Blood pressure expressed in MoM
3. Uterine artery Pulsatility Index (PI): Assess for the presence of post-systolic notching
or PI > 95th centile.
4. Biomarkers: PLGF, PAPP-A

Second trimester: As above, PLUS: sFLT:PLGF < 38 has a NPV > 98% for ruling out pre-
eclampsia

Preventing pre-eclampsia
1. Low risk women: Calcium 1g dly po
2. High risk women: Calcium 1g dly and Aspirin 150mg po nocte start before 16 weeks
– 36 weeks (ASPREE trial), may be beneficial if started up to 28 weeks.

Management

Pre-hypertension
• Review BP in 7 days at ANC

Chronic hypertension
• Start alpha-methyldopa (500 mg 8-hourly) increasing to 750 mg 8-hourly. Patients
should be admitted if a second drug is necessary.
• Start Aspirin 150mg po nocte if < 28 weeks
• Baseline Bloods; Haemoglobin (Hb), platelets, ALT/ AST, Urea, and creatinine tests
• Sonar for fetal evaluation, need to be done
• Baseline Urine PCR
• Book renal ultrasound and echocardiogram
• Fortnight ANC follow up
• Elective delivery at 38 weeks

Gestational Hypertension
• Start alpha-methyldopa (500 mg 8-hourly) increasing to 750 mg 8-hourly. Patient
should be admitted if a second drug is necessary.
• Consider starting Aspirin 150mg po nocte if < 28 weeks
• Bloods: Haemoglobin (Hb), platelets, ALT & AST, Urea, and creatinine tests
• Sonar for fetal evaluation
• Baseline Urine PCR
• Fortnight ANC follow up

62
 • Elective delivery at 38 weeks
Second line: Nifedipine XL 30 – 60mg q12h po (Maximum dose 90mg daily)
Third line: Hydralazine 25mg 8-hourly, increasing to 50mg 6-hourly

When using medicines to treat hypertension in pregnancy, aim for a target blood pressure of
135/85 mmHg (CHIPS Trial).

Pre-eclampsia without severe features

• Admit, inpatient expectant management
• Start alpha-methyldopa (500 mg q8h po)
• Ultrasound scan to estimate gestational age and fetal wellbeing
• Bloods: Hb, platelets, urea, creatinine, liver enzymes (ALT)
• Urine PCR
• Confirm diagnosis
• Deliver: ³ 34+0 weeks (PHOENIX trial)/ worsening maternal condition/ fetal
compromise (i.e.: pathological CTG/ poorly controlled BP’s)

Pre-eclampsia with severe features

1. Stabilise woman as described below:
• Start one IV line with 200 mL Ringer’s lactate/or 200 mL normal saline (whichever is
available); run IV line slowly, it is just for access.
• Start magnesium sulphate (load with 4 g intravenous infusion (IVI) in 200 mL normal
saline/Ringer’s lactate over 20 minutes.
• Magnesium sulphate maintenance: Zuspan regimen, 1g/hr (1st line) or Prichard
regimen in there is no an infusion pump or a dial flow infusion set.
• Manage acute severe hypertension: 1st line - Nifedipine 10 mg po stat. This can be
repeated every 30 minutes if the blood pressure does not drop below 160/110 mmHg.
If the woman is unable to swallow, place the 10 mg nifedipine under the woman’s
tongue.
o Second line: Labetalol IVI boluses: start with 20mg, if persistent severe
hypertension repeat boluses in increasing doses: 20mg, 40mg, 80mg (Maximum
320mg/24 hours).
o If the BP remain uncontrolled: Labetalol infusion 1-2mg/minute instead of
boluses (add 200mg in 200ml Normal saline, titrate with IVAC pump, starting at
20 ml/hour (333µg/min) and titrate by doubling dose at intervals of 30 minutes
until BP controlled. Do not exceed 160ml (160mg) per hour).
2. Administer alpha-methyldopa 1g po stat loading dose and thereafter 750 mg 8-hourly
3. Insert a urinary catheter and monitor urine output every hour. If urine output drops to
<25 mL/hour, one additional bolus of 200 mL can be given
4. Fluids: Ringer’s lactate or Normal saline run @ 80ml/h (Due to the lack of infusion
pumps add MgSO4 12.5g to 1 litre ringer’s lactate/ 0.9% normal saline and run at
80ml/hr = MgSO4 1g/hr i.e: giving MgSO4 & fluid maintenance with one infusion
pump ).
5. Bloods: Hb, platelets, urea, creatinine, liver enzymes (ALT & AST), Urine PCR
6. Sonar for fetal evaluation: Determine if the fetus is alive on admission, ONLY
monitor the foetus once the woman is stable.
7. Give steroids to stimulate fetal lung maturity if GA <34+6 weeks
8. Woman must be monitored and transferred in the lateral position.

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 9. Delivery
o If eclamptic or HELLP or organ dysfunction, steps for immediate delivery should
be initiated as soon as woman is stabilised.
o Immediate delivery if ³ 34+0 weeks gestation.
o Consider giving corticosteroids and initiate delivery after 48 hours if between 26+0
– 34+6 weeks, provided woman is stable (no eclampsia, no HELLP, normal
platelets and creatinine, and BP controlled easily with disappearance of
symptoms). (MEXPRE Latin study).
o Vaginal delivery is preferred, unless caesarean section is indicated for obstetrics
indications.

Eclampsia
Call for Help
Immediate Management
• Place the patient in the left lateral position with side rails up.
• Clear and maintain the airway with oropharyngeal airway.
• Check breathing, circulation and catheterize.
• Administer oxygen, 6 to 8L / per minute. Intubate if GCS < 8/15.
• Set up an IV line
• Arrest seizures with loading dose of MgSO4
• Reduce BP as per regime, aim BP 120 – 140/90-100mmHg
• The patient must be stabilised in terms of Blood pressure, fluid balance, blood gases,
biochemistry and coagulopathy before delivery is planned.
• This may take 2 – 3 hours
• Inform Consultant and the Paediatric doctor
• Eclampsia is not an indication for caesarean delivery. In patients with a favourable
Bishop score (Bishop Score >7), start IOL. The aim is for the patient to be in
established labour within 8 hours (i.e: after 5 doses of oral misoprostol) after
convulsions are controlled and then delivery within 12 hours from initiation of
induction.
• For those in labour, AROM and augment labour
• On no account should a diuretic be given unless the patient is in cardiac failure or has
pulmonary oedema.
• The patient is monitored in High Care for the next 24 hours after delivery to complete
the MgSO4 maintenance dose.

Postpartum treatment
• Never discharge home before 24 hours.
• Continue magnesium sulphate up to 24 hours after delivery or 24 hours after last fit.
• Keep women with eclampsia and those with organ dysfunction for at least 3 days.
• Do not routinely stop anti-hypertensive drugs abruptly; do a stepwise reduction in
dose or withdrawal of one type of anti-hypertensive if on more than one drug.
• Antihypertensive drug of choice: calcium channel blockers and/or diuretic (>48
hours). ACE inhibitors and diuretics can be used in combination postpartum.
o 1st line: Nifedipine XL 30-60mg bd po or Amlodipine 5-10mg dly po
o Enalapril 5mg dly
o Hydrochlorothiazide 12.5mg po dly

64
 • Women with pre-eclampsia are at risk of venous thromboembolism, give prophylactic
anticoagulant, i.e: LMWH (Clexane).
• Ensure appropriate contraception is provided.
• Counsel patient about future pregnancies and long-term outcomes (risks of
developing pre-eclampsia/eclampsia and/ or other cardiovascular complications in the
future such as chronic hypertension, renal disease, stroke, dementia and acute
myocardial incidents).
o Blood pressure monitoring at 6- and 12-months post-delivery.

Notes on Magnesium sulphate:

Check the following signs 4 hourly and make sure they are normal before commencing the
next dose of magnesium sulphate.
• Presence of patellar reflexes
• Respiratory rate < 16 breaths per minute
• Urine output > 30 mls per hour
Toxicity Manifests with: Loss of patellar reflexes, Weakness; Drowsiness, Nausea, Muscle
paralysis, Respiratory Depression and Cardiac Arrest.
Antidote to Magnesium Sulphate Toxicity.
• Give 10 ml of 10% Calcium Gluconate (1 gram) over 10 minutes.
• Discontinue MgSO4

Notes on managing non-viable (<28 weeks) pregnant women with early onset pre-eclampsia
Preterm pre-eclampsia with serious maternal complications (e.g.: eclampsia, CVA,
pulmonary oedema, uncontrolled severe hypertension, renal dysfunction (creatinine
>120mmol/L), coagulopathy (platelets < 100 twice)), pregnancy termination should be
‘strongly advised’.

References:
1. Brown MA, Magee LA, Kenny LC, et al. Hypertensive Disorders of Pregnancy:
ISSHP Classification, Diagnosis, and Management Recommendations for
International Practice. Hypertension. 2018; 72:24-43. Available from: doi:
10.1161/HYPERTENSIONAHA.117.10803.
2. Poon LC, Shennan A, Hyett JA, et al. The International Federation of Gynecology
and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-
trimester screening and prevention. IJOG. 2019; 145: S1: 1 – 33.
3. Magee LA, von Dadelszen P, Singer J, et al; CHIPS Study Group*. The CHIPS
Randomized Controlled Trial (Control of Hypertension in Pregnancy Study): is severe
hypertension just an elevated blood pressure? Hypertension. 2016; 68:1153–1159.
doi: 10.1161/HYPERTENSIONAHA. 116.07862 .
4. Rolnik DL, Wright D, Poon LC, et al. Aspirin versus Placebo in Pregnancies at High
Risk for Preterm Preeclampsia. N Engl J Med 2017; 377:613-622.
5. Vigil-De Garcia P, Tejada OR, Minaca AC, et al. Expectant management of severe
preeclampsia remote from term: the MEXPRE Latin Study, a randomized, multicenter
clinical trial. Am J Obstet Gynecool. 2013 Nov;209(5): 425.e1-8.

65
Diabetes Mellitus in pregnancy (DIP)

Refers to impaired insulin production, resulting in abnormal metabolism of carbohydrates

and elevated levels of glucose in the blood.

Classification
Pre-existing diabetes: Type 1, type 2 or other form of diabetes that was diagnosed before the
pregnancy, with or without complications of diabetes.

Hyperglycaemia first detected in pregnancy

• Diabetes mellitus in pregnancy (also referred to as “overt diabetes”): identification of,
diabetes for the first time in pregnancy, using the (conventional) 2006 WHO criteria
for diabetes in non-pregnant adults.
• Gestational diabetes: defined as any degree of glucose intolerance with onset or first
recognition during pregnancy that is not clearly overt diabetes, with resolution post-
delivery.

Risks associated with uncontrolled diabetes in pregnancy

Maternal Foetal Neonatal

Pre-eclampsia Miscarriage Respiratory distress
Polyhydramnios Stillbirth syndrome
Pre-term delivery Macrosomia Hypoglycaemia
Acceleration of vascular Congenital abnormalities Hyperbilirubinemia
disease Hypocalcaemia
Hypomagnesemia
Polycythaemia

• Overt diabetes during pregnancy, whether symptomatic or not, is associated with

significant risk of adverse perinatal outcomes.
• During pregnancy a more intensive monitoring and treatment of hyperglycaemia is
recommended, and pharmacotherapy is much more likely to be required to control the
hyperglycaemia for patients with overt diabetes.

Pre-gestational diabetes management

• Preconception counselling and education
• Target HbA1C ≤ 6.5%
• Weight-loss education should be provided if the body mass index (BMI) > 27 kg/m2
• Regular exercise should be encouraged.
• Screen for and refer diabetic complications e.g., retinopathy, nephropathy and cardiac
disease
• In type 1 DM do TSH,
• Baseline UKE & urine-PCR
• Folate 5mg/day 6 weeks prior to conception

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Antenatal care
• Dietician
• Start on aspirin 150mg daily
• Early sonar for gestational age
• Detailed anatomy at 18 – 22 weeks
• Growth scans in 2nd and 3rd trimester every 4 weeks
• If controlled on the pregestational regimen, keep the patient on that regimen,
otherwise consider changing to the basal-bolus regimen
• If uncontrolled on Metformin, admit for 6-point glucose profile & sliding scale
• Add the total required insulin over 24 hours and start on basal bolus regimen (see
below)

Gestational diabetes mellitus (GDM)

Patients to be screened for Gestational Diabetes Mellitus (GDM) between 24 -28 weeks
• AMA ³ 35 Years old
• Persistent glucosuria (i.e: 3+ Gluc on dipstix)
• Previous fetal macrosomia (>4500g)
• Previous unexplained stillbirth
• Obesity (BMI > 30kg/m2 or MUAC >33cm)
• Previous GDM
• Family history, 1st degree relatives
• History of PCOS

Screening: IADPSG/ WHO/ FIGO Criteria

• 75g-2h-OGTT: Overnight fasting (> 8 hours)
• Gestational Diabetes: One abnormal value is diagnostic
o Fasting ³ 5.1mmol/l
o 1-h ³ 10mmol/l
o 2-h ³ 8.5mmol/l

• Overt DM / Type II DM in the presence of the following values

o Random HGT ³11.1mmol/l
o Fasting ³7.0mmol/l
o 2-h ³11.1mmol/l
o HbA1C >6.5%

GDM treatment decision guide

Based on fasting OGTT value and clinic random glucose

OGTT Clinic random glucose Recommended therapy

< 7.2mmol/L Lifestyle modification
Fasting OGTT < 6.9mmol/L 7.2 – 11.1mmol/L Lifestyle modification +
Oral hypoglycemic agents
> 11.1mmol/L Lifestyle modification +
Fating OGTT ³ 6.9mmol/L Oral hypoglycemia + Insulin

67
Management of diabetes during pregnancy
• Key to managing diabetes during pregnancy is self-monitoring of blood glucose at
least 4 times/ day
o Fasting once daily following at least 8 hours of overnight fasting
o Postprandial: 2-3 times daily, 1 or 2 hours after meals

Target venous plasma glucose levels (FIGO)

Time Desired Level (mmol/l)
Fasting 3.3 – 5.3
Pre-prandial 3.3 – 5.6
1-hour post prandial £ 7.8
2-hour post prandial £ 6.7
2am 3.3 - 5

Lifestyle modification
• All patients should be referred to a dietician for detailed dietary advice
• The diet should comprise approximately 40% carbohydrate (complex, low-glycaemic
index, high fibre), 40% fat (at least 50% unsaturated) and 20% protein
• Regular exercise is a primary tool in managing GDM
o Planned physical activity of 30 min/day
o Brisk walking or arm exercises while seated in a chair for 10 min after each meal
o Women physically active prior to pregnancy should be encouraged to continue
their previous exercise routine

Medical therapy
• Activity are the primary tools in the management of GDM
• In the short term, in women with GDM requiring drug treatment, metformin is the
first choice, metformin (plus insulin when required) performs slightly better than
insulin
• Dose: start at 500mg 12 hourly, titrate dose to maximum of 850mg 8 hourly according
to glucose control

Insulin therapy
• When blood glucose targets cannot be reached by diet and/ or oral agents, insulin is
required.
• Multiple injections of short- and longer-acting insulin are recommended, i.e.: basal-
bolus regimen

Total insulin requirements (FIGO)

st
1 trimester 0.7 – 0.8 IU/kg
2nd trimester 0.8 – 1 IU/kg
rd
3 trimester 0.9 – 1.2 IU/kg

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Basal bolus regimen: 1st line
2 types used = Actrapid/ Humalog (Short-acting) & Protophane (Long-acting)
Short-acting insulin comprises 50% of total daily insulin dose (Administered in 3 (tds)
equal doses 30 minutes before each meal.
Long-acting insulin comprises the other 50% of total daily insulin dose (Given as a single
dose at night 22h00).

Biphasic regimen:2nd line

Actraphane: The total daily insulin requirement is divided into thirds. 2/3 are given in the
morning and 1/3 at night.
Insulin Adjustments: Insulin therapy is adjusted according to blood sugar levels.
• Short-acting insulin adjusted according to the postprandial levels
• Long-acting insulin adjusted according to the 22h00 or morning reading
Insulin dose is increased / decreased by 2units for every 1 mmol/l above or below the target
blood sugar levels, respectively.
Timing and mode of delivery
IOL at 38 weeks or Elective caesarean for obstetrics indications.
Elective caesarean section when the best EFW ³ 4000g

Intrapartum care
• Put up a maintenance infusion of 10IU of actrapid in 1L 5% dextrose and infusion at
100ml/hr as soon as patient is nill per os
• Target for glucose control during labor and delivery: 4-7 mmol/l
o HGT > 8mmol/l put on infusion with 12-14IU actrapid in 1L 5% dextrose
administer at 100ml/hr.
o HGT < 4mmol/l put on infusion with 6-8IU actrapid in 1L 5% dextrose
administer at 100ml/hr.

Postpartum
• In general, GDM do not require pharmacotherapy
• At 6-8 weeks postpartum repeat OGTT, then repeat every 2-3 years
• Contraception: LARC.

References:
1. Hod M, Kaour A, Sacks DA, et al. The International Federation of Gynecology and
Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for.
diagnosis, management, and care. IJOG. 2015; 131; S3; S173 – S211.
2. Adam, S. Soma-Pillay, P. Obstetric Essentials. 2018. 3rd Edition. University of Pretoria.

69
Diagnostic criteria and severity of Diabetic Ketoacidosis
Timing IVI Fluids Insulin Electrolytes
Admission 0.9% NaCl/ Ringer’s lactate Regular insulin (e.g: Potassium
1 – 1.5l in the 1st hour Actrapid) infusion • If K+ > 5.5 mmol/l
(Rate: 15 ml/kg/h) should be commenced at a KCL should not be
After 1 hour Reassess: fixed rate of 0.1 unit/kg/h added to the infused
Hydration status hourly fluid
If sNa+ is normal or low: (Priming with • If K+ is 4.1 –5.5
0.9% NaCl/ Ringer’s lactate an IV insulin bolus (0.1 mmol/l, 20 mmol/l of
unit/kg) is not required KCL should be added
Rate: Depending on unless there is a delay in the to IV fluid
hydration - 500 ml/hr for 4 preparation of the fixed rate • If K+ is 3.1 – 4.0
hours, followed by 250 IV insulin infusion) mmol/l, 30 mmol/l of
ml/h for 8 hours, after KCL should be added
which the Usually prepared as to IV fluid
infusion rate can be reduced follows: 200 IU in 200ml • If K+ < 3.0 mmol/l, 40
to 150 ml/h 0.9% NaCl mmol/l of KCL should
be added to IV fluid
If sNa+ is elevated: change Assess HGT hourly:
to 0.45% NaCl Phosphate: replace only if
• Increase the insulin PO4 < 0.32 mmol/l (PO4
If HGT < 14mmol/l: rate by 1ml/hr if HGT 14mmol/l or 10ml IVI)
Change to 5% Dextrose or does not decrease by
5% Dextrose in 0.45% 3-4 mmol/h
NaCl • If HGT < 5.6 mmol/l The use of bicarbonate is
decrease the insulin not recommended.
rate by 1ml/h & give (Controversial: if pH < 7.0
25ml of 50% Dextrose consider NaHCO3
IVI stat 50mmol/l in 200ml of
• If HGT > 15.6 mmol/l 0.45% over 1 hour)
increase the insulin
rate by 1ml/h & give
regular insulin 8IU IVI
stat

When the patient can eat:

Give meal related boluses
of regular insulin in
addition to the IVI
When to stop the When the patient is ketones free; HGT < 15mmol/l; pH > 7.3; HCO3 > 15
The fixed-rate infusion can be discontinued after DKP resolution4 and after 30–60
DKA Regimen minutes from the first dose of subcutaneous rapid acting insulin, administered with a meal.

Mild Moderate Severe

pH 7.25 – 7.30 7.00 – 7.24 < 7.00
HCO3 15 -18 10 – 14.9 < 10
Ketonuria + + +
Sensorium Alert Drowsy Stupor/ Coma

Suggested frequency of monitoring laboratory and bedside parameters

Monitoring parameter Suggested

frequency
HGT Hourly
Urine for ketones 2 hourly
ABG 4 hourly
UKE 6 hourly

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Cardiac Disease in Pregnancy

Pre-pregnancy counselling, Risk Assessment:

All known cardiac disease women planning pregnancy should be offered pre-conceptional
counselling – a MDT approach.
Refer to a Specialists High Risk Clinic and Cardiologist Clinic.

Risk Assessment
• History and Clinical Examination
• Tests ECG, Chest X-ray, Echocardiography, Exercise test
• Those with Aortic disease may need CT/ MRI scan
Risk of Maternal cardiovascular complications
• Establish underlying cardiac diagnosis, ventricular and valvular function, functional
class (NYHA), presence of cyanosis, pulmonary artery pressures, and other factors,
and comorbidities.
• Disease-specific risk should be assessed using the modified World Health
Organization (mWHO) classification and document.
o Low risk: mWHO Class I & II
o Intermediate risk: mWHO Class II -III
o High Risk: mWHO Class III and Class IV (Pregnancy contraindicated)

Cardiac disease diagnosis in Pregnancy

• Detailed history and thorough clinical examination.
• Look for disproportionate or unexplained dyspnoea or new murmur or diastolic
murmur.
• Necessitates investigations – ECG, ECHO, Chest Xray, FBC, Proteinuria.
• Chest Xray and CT scan should be delayed in the first trimester unless deemed
necessary and consent taken from mother.
Antenatal care
Book early in 1st trimester with prompt referral to MDT (Specialist obstetrics clinic and
Cardiac clinic).
Detailed history and thorough examination
Do ECG and ECHO
Determine baseline maternal complication risk assessment based using mWHO classification
Use Cardiac disease ANC template (appendix)
• 2 to 4 Weekly contacts up to done 20weeks GA
• 2 weekly contacts 20 to 24 weeks GA
• Weekly contacts > 24 weeks GA
• Offer NT Scan at 13 weeks
• Do Fetal anomaly Scan at 18 -22 Weeks and Fetal echocardiogram for mothers with
congenital heart disease +/- genetic counselling
• Delivery plan done at 32-34 weeks GA (MDT – Cardiologists/Obstetricians/ and
Anesthesiologist referral)
• Document delivery plan, duration of stay in High Care/postnatal ward.
• See cardiac clinic at 6 weeks post delivery

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Intrapartum Care
1. Timing of Delivery
• Wait for spontaneous labor till 40 weeks gestation age
• At 40 weeks consider Induction of labour (Misoprostol, Dinoprostone are safe to use)
• Caesarean section to be offered on obstetric indications only.
o Cardiac indications for Caesarean section: Marfarn’s syndrome with an aortic
diameter > 40mm & warfarin use within 10 – 14 days
2. Labor
• Stop anticoagulation 12 - 24 hours prior to elective CS or induction of labour, or
immediately a woman presents in spontaneous labour
• IV access on admission, {Restrict fluids to 20mls per hour – using IVAC or rate
minder}
• Inform consultant on call
• Semi fowler’s position
• Use Labour care guide in active stage of labour
• Use pulse oximetry during labour
• Analgesia – epidural analgesia preferred
• The decision regarding prophylaxis should be determined on a case-by-case basis in
consultation with the consultant and the cardiologist
• Antibiotic prophylaxis should be administered in women with the following
conditions as they are at highest risk for intrapartum endocarditis:
o Any prosthetic valve, previous episode of infective endocarditis, unrepaired
cyanotic defects, completely repaired defects with prosthetic material or
devices, rheumatic heart disease, PPROM, chorioamnionitis
3. Second stage of labour
• Continuous CTG
• Passive stage can be delayed up to 2 hours
• Active stage – offer assisted vaginal delivery with forceps or a ventouse may be used
to further reduce maternal effort
• Consider Furosemide 20mg IVI stat; especially for stenotic cardiac lesions
4. Thirds stage of labour
• Standard AMTSL
• Admit into high care for 24 to 48 hours
• Restart anticoagulation 6 to 8 hours after delivery
A. Postnatal care
Standard postnatal care
Don’t discharge till 3rd day (NVD) and at least 4th day for CS patients
Reinforce discussion on LARC for contraception
Book cardiac clinic at 6-week visit

Reference:
1. 2018 ESC Guidelines for the management of cardiovascular diseases during
pregnancy. European Heart Journal (2018) 39, 3165–
3241doi:10.1093/eurheartj/ehy340

72
Acute pulmonary oedema

Definition: Pulmonary oedema is a condition characterised by accumulation of fluid within

the lung's interstitial and/or alveolar spaces. This process leads to diminished gas exchange at
the alveolar level, progressing to potentially causing respiratory failure.

Aetiology
• Cardiogenic
o Heart failure, pre-existing cardiac disease, peripartum cardiomyopathy
• Non-cardiogenic
o ARDS (Trauma, Sepsis, Multiple blood transfusions)
o Vascular endothelial damage: Pre-eclampsia
o Pulmonary embolism

Clinical signs
• Acute dyspnoea or extreme shortness of breath that worsens with activity or when
lying down
• A feeling of suffocating or drowning that worsens when lying down
• A cough that produces frothy sputum that may be tinged with blood
• Wheezing or gasping for breath
• Cold, clammy skin
• Anxiety, restlessness or a sense of apprehension
• Cyanoses
• A rapid, irregular heartbeat (palpitations)
• Accentuated pulmonic sounds and Basal rales
• Right-sided pleural effusion is common

Management
• Call for help, CAB
• Put the head side of the bed at ³ 45 degrees
• Administer 100% O2 face mask at 4L
• GTN (Nitrates) 0.5mg S/L stat
• Furosemide 80mg ivi stat, maintain 40mg bd (Dose0.5 to 1.0 mg/kg IV )
• Morphine 1-5mg ivi boluses PRN (Use with caution may cause respiratory depression
needing intubation)
• Ventilatory support may also be required if patient is hypoxic (PaO2 < 60mmHg)
• Treatment of the cause

Reference:
1. Malek R, Soufi S. Pulmonary Edema. [Updated 2021 Apr 26]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK557611/ [accessed 29 December 2021].

73
Malaria in pregnancy

Epidemiology
1. In Namibia falciparum malaria is the commonest and most sever malaria infection in
pregnancy.
2. In endemic areas, parasitaemia increases in pregnancy from 25% (non-pregnant
women) to 32% (pregnant women).
3. Infection peaks in the second trimester.
4. The parasites accumulate in the placenta
5. Morbidity and mortality from malaria is 2-10 times more if a pregnant woman is
infected, and the morbidity and mortality extend to the early postpartum period.

Prevention
1. Pregnant women are advised not to travel to malaria areas.
2. If such travel is necessary, then advise to use the following:
• Mosquito nets
• Topical mosquito repellents
• In the second and third trimesters Mefloquine can be given (WHO)
• Chloroquine and Proguanil can be given with addition of folic acid

Diagnosis
• No specific symptoms and signs, may present with a flu-like illness; more atypical
• Seek travel history in a pregnant woman with pyrexial of unknown origin
• The incubation period is typically 7 to 30 days
• Symptoms: Chills/sweats, headache, muscle pain (Myalgia), nausea & vomiting, diarrhea,
cough, generalized malaise
• Signs: Fever, jaundice, perspiration, pallor, splenomegaly, respiratory distress

Disease classification
• Severe complicated malaria
• The severe signs of malaria are non-specific
• The parasitemia of severe malaria can be less than 2%
• Pregnant women with 2% or more parasitized red blood cells are at higher risk of
developing severe malaria and should be treated with the severe malaria protocol

• Uncomplicated malaria
• < 2% parasitized red blood cells in a woman with no signs of severity and no
complicating features

74
 Features of severe and complicated malaria

Clinically and laboratory findings of severe or complicated malaria in adults

Clinical manifestations Laboratory tests

Impaired consciousness/ GCS Severe Anaemia (Hb < 8.0 g/dl)
± Convulsions (Cerebral malaria) Thrombocytopenia
Respiratory Distress syndrome, Pulmonary Hypoglycemia (HGT < 2.2 mmol/l)
oedema*
Circulatory collapse, Shock Metabolic Acidosis
Abnormal bleeding Renal impairment, UO < 0.4 ml/kg BW or
Creat > 265 µmol/l
Hemoglobinuria Hyperlactatemia
Hyperparesitemia (> 2%)
Algrid Malaria – Gram – Bacteria septicemia

Management
Principles:
• Malaria is a notifiable disease
• Treat malaria in pregnancy as an emergency
• Admit pregnant women with uncomplicated malaria to hospital and pregnant women
with severe and complicated malaria to an ICU
• If malaria tests are negative look for other causes
• If fever persists, take repeat malaria smears when temperatures are high
• Measure parasitaemia levels
• Treatment is based on clinical and laboratory findings with emphasis on parasitaemia

Drug Dosage Comments

Coartem > 35kg; 6 Doses in 3/7 Category C
4 Tabs stat; repeat in 8 hours, same dose bd on Days 2 CI 1st Trimester
&3
Artesunate IV 2.4 mg/kg at 0, 12 and 24 hours, then daily Treatment of choice for severe
thereafter falciparum malaria
Quinine IV 20 mg/kg loading dose in 5% dextrose over 4 hours Category C
and then 10 mg/kg IV over 4 hours every 8 hours Associated with severe and
oral quinine 600 mg tds for 5–7 recurrent hypoglycemia in late
pregnancy
Clindamycin IV 450 mg every 8 hours Category B
Oral 450 mg 3 tds 7 days
Doxycycline Category D; CI

75
Obstetric management specific to malaria infection in pregnancy
• Standard obstetric principles apply: the life of the woman comes first
• Stillbirth and premature delivery in malaria in pregnancy are best prevented with
prompt and effective antimalarial treatment
• Uncomplicated malaria in pregnancy is not a reason for induction of labour
• Peripartum malaria is an indication for placental histology and placenta, cord and
baby blood films to detect congenital malaria at an early stage

76
 Protocol: Management of Malaria in Pregnancy

Uncomplicated P. falciparum
malaria Severe P. falciparum malaria

Mild symptoms ambulant

patient normal mental function Admit ICU, IV Quinine
minimal vomiting no organ 20mg/kg loading dose over
dysfunction 4 hours: maintenance
10mg/kg over 4 hours every
8 hours
Once able to tolerate oral:
Coartem or Quinine plus
Doxy, Clindamycin
Artemether-
Artemether- Lumefantrine
Lumefantrine (Coartem)
(Coartem) or Quinine
or Quinine plus Doxy, Monitor serum glucose;
plus Doxy, Clinda Monitor systemic organs
Clindamycin for dysfunction/failure;
Consider medical TOP/
Delivery

Other plasmodium species; P

ovale, P vivax: Chloroquine +
Primaquine P malaria :
Chloroquine

References:
1. The Diagnosis and Treatment of Malaria in Pregnancy. Green- top Guideline No.
54B. London; 2010.
2. The prevention of malaria in pregnancy. Green- top Guideline No. 54a.
3. Sharma L and Shukla G (2017) Placental Malaria: A New Insight into the
Pathophysiology. Front. Med. 4:117. doi: 10.3389/fmed.2017.00117.

77
Fetal growth restriction (FGR)

Definition: failure of the fetus to grow according to its growth potential due to a pathological
factor, most commonly placental dysfunction.

Classification: 2016 Delphi consensus

EARLY-ONSET FGR <32 Weeks LATE-ONSET FGR ≥ 32 Weeks

PROBLEM: MANAGEMENT, easy to PROBLEM: DIAGNOSIS, often missed and

diagnose, often associated with pre- speculated to be the leading cause of
eclampsia unexplained stillbirths in Africa
Prevalence 30% Prevalence: 70%
Degree placental disease: high Degree placental disease: low
Frank hypoxia: CVS adaptation Subtle hypoxia: no CVS adaptation
Tolerance to hypoxia Low tolerance to hypoxia
Dopplers: Spectrum of Doppler alterations Cerebral blood-flow redistribution
that involves UA, MCA, DV
High perinatal mortality & morbidity Low mortality, poorer outcome, postnatal
morbidity (IUFD risk 40 -50%)

Diagnostic criteria: 2016 Delphi consensus

Small for gestational age (SGA): an estimated fetal weight or birth weight below the 10th
percentile for gestational age. Compared to appropriate grown foetus SGA foetuses are at
increased risk of perinatal mortality and morbidity.

Fetal growth restriction (FGR) should be based on a combination of measures of fetal size
percentile and Doppler abnormalities.

Early-onset FGR: GA<32 weeks, in Late- onset FGR: GA ≥32 weeks, in

absence of congenital anomalies absence of congenital anomalies
AC/EFW <3rd centile or UA-AEDF AC/EFW <3rd centile
OR OR
1. AC/EFW <10th centile combined with at least two out of three of the following
2. UtA-PI >95th centile and/or 1. AC/EFW <10th centile
3. UA-PI >95th centile 3 2. AC/EFW crossing centiles >2
quartiles on growth centiles*
3. CPR <5th centile or UA-PI >95th
centile

Risk factors
• Chronic hypertension
• Previous stillbirth
• Pre-eclampsia
• Autoimmune conditions: APLS, SLE
• Smoking and substance use
• Fetal congenital anomalies

78
 • Women with an abnormal uterine artery doppler at 20–24 weeks (defined as a
pulsatility index [PI] > 95th centile) and/or post systolic notching.

Screening for FGR/ SGA

• Universal uterine artery doppler screening at 18 – 23 weeks.
• Symphysis–fundal height in low-risk pregnancies.
• Fortnight growth scan and dopplers in high-risk pregnancies starting at 24–28 weeks.

Work up
• Detailed history
• Confirmation of gestational age should be the first step when FGR is suspected: first-
trimester crown–rump length is the most accurate method to date pregnancy when in
the range of 7–60 mm. In the absence of an early sonar dating may need to be based
on menstrual history or symphysis–fundal height.
• Detailed anatomy scan
• TORCHES, Zika virus, Malaria (If suspected)
• +/- Invasive: amniocentesis

Management of FGR/ SGA

Absolute indications for immediate delivery irrespective of gestational age:
• FGR with umbilical artery reversed end-diastolic velocity (REDV) by emergency
caesarean delivery.
• Pathological CTG by emergency caesarean delivery

FGR with umbilical artery absent end-diastolic velocity (AEDV) (TRUFFLE studies)
• Inpatient expectant management
• Give steroids
• Deliver from 32 weeks, if deliver < 32 weeks give MgSO4
• CTG q12hourly
• Umbilical artery and Ductus venous doppler 2 times per week
• Immediate delivery by caesarean delivery if pathological CTG, REDV or abnormal
ductus venosus doppler (Absent or reversed a-ware)

Postpartum assessment and counselling for future pregnancies in women with a history
of FGR
• Infants at risk of short- and long-term morbidity, follow up closely
• Mother at risk of future cardiovascular morbidity
• Sent the placenta for histology
• If placental insufficiency syndromes are confirmed: start Aspirin 150mg dly between
12-16 weeks.
• Women with a history of FGR should undergo close surveillance of fetal growth
starting at 24–28 weeks.

79
 Diagnosis Risk of Antenatal management Timing Delivery
morbidity
SGA (EFW at 3rd–9th Low Dopplers: 1 -2 weekly 37 weeks (DIGITAT
percentile, normal fluid and Doppler Growth: 2 weekly trial)
studies) • Mode of delivery: IOL
Uncomplicated FGR at <3rd percentile Low Dopplers: 1 -2 weekly 36–38 weeks
(normal AFI and Doppler studies) Growth: 2 weekly • Mode of delivery: IOL
FGR with mild abnormalities: Low Consider inpatient 34–37 weeks
Early Doppler changes: monitoring • Mode of delivery:
a. UA PI >95th percentile, or • Consider steroids for caesarean section or
b. MCA PI <5th percentile, or fetal lung maturation induction
c. CPR <5th percentile, or Dopplers: 1 -2 weekly
d. UtA PI >95th percentile Growth: 2 weekly
• Oligohydramnios
• Suboptimal interval growth
• Suspected pre-eclampsia

References:
1. Melamed N, Baschat A, Yinon Y, et al. FIGO (International Federation of
Gynecology and Obstetrics) initiative on fetal growth: Best practice advice for
screening, diagnosis, and management of fetal growth restriction. IJOG.152;S1: 3 –
17.
2. Bilardo CM, Hecher K, Visser GHA, et al. TRUFFLE Group. Severe fetal growth
restriction at 26-32 weeks: key messages from the TRUFFLE study. Ultrasound
Obstet Gynecol 2017; 50: 285– 290.
3. Lees CC, Stampalija A, Baschat A, et al. ISUOG Practice Guidelines: diagnosis and
management of small-for-gestational-age fetus and fetal growth restriction.UOG. 56;
2: 298 – 312.
4. Bers KE, van Wyk L, van der Post JA, et a. DIGITAT Study Group. Neonatal
morbidity after inductin vs expectant monitoring in intrauterine growth restriction at
term: a subanalysis of the DIGITAT RCT. Am J Obstet Gynaecol; 206: 344. E1-7.

80
Multiple pregnancy

• Multiple gestation is a pregnancy where more than one fetus develops simultaneously
in the uterus.
• There are significant risks to both mothers and babies.
• These risks include preterm delivery, intrauterine growth restriction, pre-eclampsia,
postpartum hemorrhage, GDM, anaemia, postpartum depression, venous
thromboembolism, caesarean section, structural abnormalities
• Monochorionic gestations carries an even higher rate of perinatal morbidity and
mortality.

Diagnosis
• Signs of Twin pregnancy
o Large for gestational age
o Multiple fetal heart rates are detected
o Multiple fetal parts are felt
o Pregnancy with Artificial Reproductive Technology (ART)

Zygosity and Chorionicity

Zygosity: Number of fertilized eggs and chorionicity: placentation

[1]

Antenatal Care

Booking visit:
1. Determine chorionicity:
• 1st trimester ultrasound (11-13w6d):
• Lambda sign/twin peak = dichorionic diamniotic (80%)
• T-sign = monochorionic twins (20%)

81
 [2]

• Check for separating membrane

• High risk for pre-eclampsia: Start on low dose aspirin (150mg) from 12 weeks
• Label the foetuses: Right/left, top/bottom, draw a sketch

Late booker ultrasound:

• Determine the gender, number, and location of placentae
• Measure separating membrane
o DCDA: discordant/same gender, two placental masses, membrane
measuring>2mm
o MCDA: same gender, single placenta, membrane measuring <2mm
o If unclear manage as unknown chorionicity
Book at High-Risk Clinic: Suspected MCDA, MCMA, uncertain chorioncity, higher order
multiples, suspected fetal anomalies, sIUGR, or other obstetric or medical conditions

DCDA Twins
1. 20-22wks:
• Detailed anatomy
• Amniotic fluid volume (DVP/MVP)
• Cervical length if prior history/suspicion of PTB – if CL <25mm consider
Progesterone.
• Follow up every 4wks: Assess growth, amniotic fluid volume & Doppler,
• Elective delivery at 38 weeks. Induction of labor if leading twin is cephalic
o Continuous CTG monitoring of both fetuses in labour
o IOL with mechanical means ± Prandin 1mg or Prepidil gel 0.5mg 6hrly x3
doses
o C/section is reserved for obstetric indication

MCDA Twins
• Follow up every 2 weeks from16 weeks gestation due to increased risk of
complications, i.e TTTS, TAPS, TRAP (acardiac fetus), selective IUGR & conjoined
twins
• Delivery: 36- 37+6 Weeks; Mode of delivery as above.

MCMA Twins
• Book at high-risk clinic
• Require close surveillance due increased perinatal mortality
• Delivery: 32-34 weeks, after a course of steroids
• Mode of delivery: Caesarean section

82
Some complications & management
Preterm labour: No intervention has shown to prevent PTB
Management:
• Tocolysis + corticosteroids (same dose as for singleton pregnancies)
• MgSO4 for neuroprotection before <32wks

Discordant growth/ selective growth restriction

• Defined as 20% difference in fetal weight between fetuses
• Formula: [EFW (large twin)- EFW (smaller twin)/ EFW (larger twin) x100
• Management: Book at High-Risk clinic
o Classification: Type I (Positive UA dopplers), II (Absent or reversed end-
diastolic velocities (ARED) and III (Intermittent AREDV; iAREDV).
o Delivery: Type I 34-36 weeks and Type II – III: 32 weeks

Single fetal demise

• MCDA twins have a increased rate of stillbirth
• Neurological abnormality in surviving twin is greater in MCDA (18%) than DCDA
(1%)
• Immediate delivery of the surviving twin does not improve outcome, especially
before 34 weeks gest
• Timing of delivery should be based on condition of mother and surviving fetus
• Management: Book at High-Risk clinic
o Deliver at 36 weeks

Complication of monochorionic placentation

• TTTS results from A-V anastomosis
• Usually presents in the 2nd trimester from 16 weeks

Quintero staging for TTTS

Stage 1: Polyhydramnios oligohydramnios sequence: DVP > 8cm in the recipient & < 2cm in
the donor
Stage 2: Bladder in the donor not visible on ultrasound
Stage 3: Abnormal umbilical doppler flow (absent or reversed)
Stage 4: hydrops in one or both twin
Stage 5: Death in one or both twin

Management: Book at High-Risk Clinic and stage using the Quintero system
• Deliver: 34 – 36 weeks

83
[2]

84
[2]

References:
1. Multiple Fetal Pregnancy. [Homepage on the internet] Available from:
https://slidetodoc.com/multiple-fetal-pregnancy-elahe-zarean-incidence-and-epidemiology/
2. FIGO Working Group on Good Clinical Practice in Maternal–Fetal Medicine. Good
clinical practice advice: Management of twin pregnancy. Int J Gynecol Obstet 2019; 144:
330–337.
3. Kilby MD, Bricker L on behalf of the Royal College of Obstetricians and Gynaecologists.
Management of monochorionic twin pregnancy. BJOG 2016; 124:e1–e45.

85
Management of Labour

Diagnosis of Labour
Labour is a clinical diagnosis and is made when regular painful uterine contractions is present
with one or more of the following features are present:
• Cervical dilatation and progressive cervical changes (effacement and dilatation)
• A show
• Ruptured membranes

The presence of uterine contractions in the absence of cervical changes or any of the above
does not meet the criteria for the diagnosis of labour and should be assessed as false labour/
threatened labour..

Assessment of contractions:
• Clinical observations
• Manual palpation
• Tocograph

An adequate contraction includes:

• 3 to 5 contractions in 10 min
• Cervical dilatation
• Caput succedaneum of the fetal scalp

Risk assessment
All patients who are diagnosed to be in labour, should be assessed as either low or high risk.
Low risk patients should deliver in midwife obstetric units or in primary settings, i.e: district
hospitals. All high-risk patients should be referred to the appropriate level for delivery, i.e:
WCH/ KSH complex.

High Risk includes the following (this list is not exhausted):

Maternal Fetal
1. Hypertension, pre-eclampsia, 1. Multiple pregnancy
eclampsia 2. Malpresentation
2. Diabetes mellitus 3. Prematurity
3. Maternal cardiac disease 4. Post maturity
4. Previous caesarean section or 5. Meconium-stained liquor
scarred uterus 6. Oligohydramnios
5. Antepartum hemorrhage 7. Fetal growth restriction
6. Poor obstetric history 8. Polyhydramnios
7. Induction of labor 9. Non - reassuring fetal condition
8. Grand multipara (fetal distress)
9. Advanced maternal age (> 35yo)

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Intrapartum fetal monitoring
Low risk pregnancy: Intermittent auscultation using handheld foetal doppler or fetoscope or
intermittent CTG
High risk pregnancy: Continuous CTG

Stages of labour

First stage
Latent phase
From 0 to 4cm dilatation, this mainly involves effacement slow cervical dilatation, variable
duration.

Active phase
Refers to the interval between 5cm and full dilatation (10cm). If the rate is slower, the cause
should be searched for as per the “RULE of the 4 Ps” and manage accordingly.

Observations during the first stage of labour

Observations Low risk High risk

Fetal heart rate During and after contractions Continuous electronic
½ hrly, intermittent monitoring (CTG)
auscultation
Pelvic examination 6-hourly (Latent phase) & 6-hourly (Latent phase) &
4-hourly (Active phase) 4-hourly (Active phase)
Contractions 2-hourly (Latent phase) & 2-hourly (Latent phase) &
2-hourly (Active phase) 2-hourly (Active phase)
Maternal pulse 2-hourly 2-hourly
Urine output and temp 4 hourly 4 hourly
Drugs and IVI fluids When given When given

Second stage
From full dilatation ends with the delivery of the foetus. Divided into two phases:
• First phase from full dilatation up to the decent of the head of the presenting part to
the pelvic floor: Propulsive phase
• Second phase from head on perineum/ maternal bearing down until delivery This
usually coincides with the urge to push (the Ferguson reflex): Expulsive phase

Recommended time to allow for delivery once the patient is fully dilated:
• Nulliparous: Propulsive phase: 3-hour & Expulsive phase 45 minutes, in case of
epidural, 2 hours is appropriate, provided the fetal condition is reassuring.
o Diagnose delay in the active second stage when it has lasted 2 hours
• Multiparous: Propulsive phase: 2-hour & Expulsive phase 30 minutes. In case of
epidural 1 hour can be allowed provided the fetal condition is reassuring.
o Diagnose delay in the active second stage when it has lasted 1 hour

87
Foetal monitoring during the second stage of labour:
Low risk pregnancy: intermittent auscultation every 5 minutes, or after every contraction,
whichever comes first
High risk pregnancy: Continuous CTG

NB: If failure to progress during the 2nd stage: implement the “RULE of the 4 Ps” and
manage accordingly

Third stage
Delivery of the placenta and foetal membranes. The third stage of labour must always be
managed actively, controlled cord traction. Mismanagement of this stage may lead to serious
postpartum haemorrhage. Uterotonic of choice: Oxytocin 10IU IMI stat.

References:
1. WHO recommendations: Intrapartum care for a positive childbirth experience
2. Wright A, Nassar AH, Visser G, et al. FIGO good clinical practice paper:
management of the second stage of labor. Int J Gynecol Obstet 2020; 152(2): 172–
181.

88
Postpartum haemorrhage (PPH)

Definition: blood loss ³ 500ml post vaginal delivery & 1000mls post caesarean section or
blood loss that is enough to cause symptoms of shock.
Classification
Primary PPH: blood loss within the first 24 hours after delivery.
Secondary PPH: blood loss 24 hours – 6 weeks after delivery.

Aetiology and risk factors

The causes of PPH as related to abnormalities of one or more of four basic processes – ‘the
four Ts’: tone, trauma, tissue and thrombin. The most common cause of PPH is uterine atony.

Risk factor The four Ts

Abruptio placentae Tone, Thrombin (DIC)
Multiple pregnancy Tone
Multifibrod uterus Tone
Previous PPH Tone
Fetal macrosomia Tone
Failure to progress in 1st or 2nd stage Tone
Prolonged 3rd stage of labour Tone
Chorioamnionitis Tone
General anesthesia Tone
Pre-eclampsia Thrombin
Retained placenta Tissue
Placenta accreta spectrum Tissue
Episiotomy Trauma
Perineal laceration Trauma
Assisted delivery Trauma

Prevention
• Treat anaemia during pregnancy
• Active management of the 3rd stage of labour
• Controlled cord traction & oxytocin 10IU imi stat after a normal vaginal deliver
• At caesarean section: oxytocin 2.5IU ivi bolus, the 7.5IU in 1L Ringer’s lactate or
Normal saline, run at 125ml/h (15mU/min)
• Early detection of PPH: colour coded early warning monitoring charts

Management
The key to managing PPH is to identify the cause, i.e.: 4 T’s. PPH is a sign of a problem not a
diagnosis.
Immediate management
• Call for help
• CAB of resuscitation if necessary
• Empty the bladder, rub the uterus
• Insert 2 large IV canula
• Infusion of oxytocin 20 - 40IU in 1 litre Ringer’s lactate or normal saline
• Bloods: Crossmatch, FBC, UKE, LFTs
• Continuous monitoring: BP, pulse, urine output
• Tranexamic acid 1g ivi stat

89
Algorithm for management of PPH after vaginal delivery

Uterine atony
• Massage uterus and expel clots
• Continuous oxytocin infusion
• Misoprostol 800µg sublingual stat
• Ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated
in women with hypertension).

If ongoing bleeding:
• Intrauterine balloon tamponade (Ellavi, Condom balloon, Bakri balloon) is an
appropriate first line ‘surgical’ intervention for most women where uterine atony is
the only or main cause of haemorrhage.
• A ‘positive test’ (control of PPH following inflation of the balloon) indicates that
laparotomy is not required, whereas a ‘negative test’ (continued PPH following
inflation of the balloon) is an indication to proceed to laparotomy.
At laparotomy:
• Explore for retained products and deep laceration
• Haemostatic suturing: B-Lynch, Hayman
• Stepwise uterine devascularisation and internal iliac artery ligation
o Stepwise uterine devascularisation describes the successive ligation of (i) one
uterine artery, (ii) both uterine arteries, (iii) low uterine arteries, (iv) one ovarian
artery and (v) both ovarian arteries and internal iliac artery in the management of
PPH.
• Hysterectomy: Early recourse to hysterectomy is recommended, especially where
bleeding is associated with placenta accreta or uterine rupture. Subtotal hysterectomy
is the operation of choice in many instances of PPH requiring hysterectomy, unless
there is trauma to the cervix or a morbidly adherent placenta in the lower segment.

Trauma
• Suture lacerations of perineum, vagina or cervix
• If ongoing bleeding: Consider an examination under anaesthesia and laparotomy as
above.

Tissue
• Evacuation of uterus
• Digital exploration
• Ovum forceps and largest curette

Thrombin
• Give blood products: packed RCC, FFPs, Cryoprecipitate, Platelets
• Formular protocol, RCC: FFP, 1:1
• PT/APTT greater than 1.5 times normal demonstrate that severe and established
haemostatic impairment has occurred
• FFP results in relatively small increments in fibrinogen level, and to increase the level
rapidly, cryoprecipitate or fibrinogen concentrate are required
• Platelets should be transfused when the platelet count is less than 75 X 109/l based on
laboratory monitoring.

90
Bleeding at caesarean section
Identify the cause
Atonic uterus: Manage as above

Tears:
Lateral tears: Uterine artery ligation (identify the ureters)
Inferior tears: Secure apex and repair the tear
Uterus rupture: Repair or subtotal hysterectomy
Placental site bleeding:
• Mattress suture
• Compression suture
• Stepwise devascularisation
• Balloon tamponade
• Subtotal hysterectomy

Bleeding after caesarean section

Diagnosis:
Revealed PPH: Excessive PV bleeding
Concealed PPH: pallor, dropping BP, tachycardia and abdominal distension

Identify the cause

Atonic uterus: Manage as above, if ongoing bleeding book s relook laparotomy
Concealed PPH: Book relook laparotomy, identify the cause and if unable control the
bleeding or patient critical proceed to a lifesaving subtotal hysterectomy.

References:
1. Postpartum Haemorrhage, Prevention and Management (Green-top Guideline No.
52). London: RCOG; 2016.
2. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on
mortality, hysterectomy, and other morbidities in women with post-partum
haemorrhage (WOMAN): an international, randomised, double-blind, placebo-
controlled trial. Lancet 2017 May 27;389(10084):2105-2116.

91
Managing Maternal Sepsis

Definitions:
Sepsis: is a life-threatening condition that arises when the body’s response to infection causes
injury to its own tissues and organs.
Maternal sepsis: is a life-threatening condition that arises when the body’s response to
infection causes injury to its own tissues and organs during pregnancy, childbirth, post-
abortion, or the postpartum period.
• Puerperal sepsis WHO definition: an infection of the genital tract occurring at any
time between the rupture of membranes or labour and the 42nd day post-partum; in
which, two or more of the following are present: pelvic pain, fever, abnormal vaginal
discharge, and delay in the reduction of the size of the uterus.
Septic shock: persisting hypotension requiring vasopressors to maintain MAP >65 mmHg or
a serum lactate level >2 mmol/L despite adequate volume resuscitation.
Multiple organ dysfunction syndrome (MODS) describes a state where potentially
reversible physiologic dysfunction is seen in ³ 2 organ systems.

Symptoms and signs

Fever, Tachycardia (>110/min), Tachypnoea (>24bpm), Clammy or mottled skin,
Hypotension or shock, Oliguria/ anuria, Pain at site of infection, Oozing wound, Altered
mental status

General considerations
1. Severe uterine infection may be present < 24 hours especially if amniotic fluid
infection syndrome preceded delivery (i.e: chorioamnionitis).
2. Endometritis may be present without pyrexia.
3. qSOFA: SCORE ≥ 2 Increased mortality & admission to ICU

[1]

Risk Factors for genital tract infection

The following are risk factors:
• Caesarean section, prolonged labour, prolonged rupture of membranes, pre- term
labour, retained products, immuno-suppression.

Prevention
Patients with pre-labour rupture of membranes and with prolonged rupture of membranes
must receive antibiotics, and vaginal examinations should be performed only once they are in
labour.
Therapeutic antibiotics must be given to all patients at high risk for infection.

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Special investigations
The following special investigations are needed to assess organ function:
• ABG: Metabolic acidosis, lactate, increased base deficit
• Bloods: FBC, LFTs, UKE, Clotting profile, Blood cultures/ ± Urine MCS, Counsel
for HIV
• Imaging: Chest X-ray

The results of these investigations will diagnose any existing organ dysfunction

Differential diagnosis:
Meningitis, Pneumonia, Mastitis, Endometritis, Episiotomy septic wound, Caesarean section
septic wound, Acute pyelonephritis, Retained products of conception, Acute appendicitis,
Ovarian vein thrombosis, Deep venous thrombosis

Management

• Sepsis bundle” “HOUR-1 BUNDLE”

• Urgent assessment and treatment, including initial fluid resuscitation
• Purse source control
• Obtaining further laboratory results
• Precise measurements of hemodynamic status
• Make clinical diagnosis ➙ systematic approach

Initial resuscitation Sepsis 6 ‘Hour-1 bundles’

o Recognize severe sepsis and septic shock
o CAB of resuscitation if necessary
o Adequate hydration (IV fluids) ➙ normotensive
o 30ml/kg bolus if hypotension, (SBP < 100mmHg or lactate > 4mmol/l)
o Obtain relevant cultures (i.e. blood, urine, sputum)
o Broad spectrum IV antibiotics within 1st hour
o Face Mask oxygen (O2), intubate if hypoxic (PaO2 < 60mmHg)
o Catheter: monitor urine output (aim > 25ml/h)
o Lactate, repeat if > 2mmol/l
o Cool down patient to decrease temperature
o Source identification and site control - consider surgical management if
appropriate

Give 3 Take3
Fluids Cultures
O2 Bloods: FBC, UKE, CRP, LFT, INR
Antibiotics Urine output

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Haemodynamic management
• Treat hypotension ± ⇡ s-lactate [> 4 mmol/L]
o Initial 30 ml/kg crystalloids
o Vasopressors if not responding to fluid resus
i. MAP < 65mmHg/ lactate > 2mmol/L

o Adrenalin infusion
i. 10mg/200ml NaCl - Start at 5ml/h, max 20ml/h
ii. Low dose: 0.05 – 0.1mcg/kg/minute
iii. High dose: > 0.1mcg/kg/minute
• Continuous support
o FMO2
o Glucose monitoring
o Transfuse RBCs if Hb < 7g/dL

Antibiotic therapy: Empiric therapy, Tazocin 4.5g q6h provides one of the broadest ranges of
treatment for severe sepsis

Search and eliminate source of sepsis

• Big 5
o CNS: AVPU
o CVS: Tachycardia; shock
o Resp: Tachypnoea, SaO2<90%
o Hepatic & GIT: Abnormal liver enzymes, glucose, bowel sounds, acute abdomen
o Renal: Decreased urine output, ⇡ urea and creatinine
• Forgotten 4
o Haematological: Hb, Plt, WCC, INR, PTT, Fibrinogen
o Immunological: HIV status, temperature
o Endocrine: Glucose reduced, TSH, Mastitis
o Musculo-sketetal: DVT, Thrombophlebitis
• Core 1: Uterine size, abdominal tenderness
1. Core 2: Genital system, cervix open, foul-smelling discharge, Speculum

Indications for a hysterectomy:

• Necrotic cervix uterus
• Septic shock
• 2 or mor organ systems affected: Hepatic, Haematological, Renal, Respiratory (ARDS)

Septic caesarean section wounds must be wholly opened to assess if the sheath is intact,
opened sheath requires a relook laparotomy.

References:
1. quick SEPSIS RELATED ORGAN FAILURE ASSESSMENT. Homepage on the
internet: Available from: https://qsofa.org [Accessed 10 February 2022]
2. Sepsis in Pregnancy, Bacterial (Green-top Guideline No. 64a). London: RCOG; 2012.
3. Bacterial Sepsis following Pregnancy (Green-top Guideline No. 64b). London:
RCOG; 2012.
4. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International
Guidelines for Management of Sepsis and Septic Shock 2021. Crit. Care Med. 2021
November; 49 (11). Pe1063-e1143.

94
Postpartum Contraception

Aim: To prevent unintended and closely spaced pregnancies after childbirth

Importance:
• Worldwide 9 out of 10 women want to avoid pregnancy for 2 years after giving birth
but only a few are using contraception
• Can prevent >1/3 maternal deaths
• Can prevent 1 in 10 deaths among babies
(Best practise, 2015)

WHO, Medical Eligibility criteria

Timing contraception initiation:

• Best practice is to start before the patient leaves the facility after delivery
• If started within 4 weeks of delivery- no need to check pregnancy
• After 4 weeks and if menstrual cycle has returned – check for pregnancy
• If no pregnancy test available:
• Exclude signs of pregnancy
WHO criteria:
• Within 7 days of start of normal menstruation
• No sexual intercourse since the start of the last normal menstruation
• Exclusively/nearly fully (85%) breastfed + amenorrhoeic + < 6 months postpartum

Most effective Effective methods - Less effective • Least effective

methods – failure rate failure rates of > methods - failure methods - failure of >
of < 1/1000 users 3/1000 users rates of > 12/1000 18/1000 users
users
Intrauterine devices Progesterone only Male condoms Coitus interruptus
Contraceptive injectables Female condoms Fertility awareness-
Implants Hormonal based methods
Sterilisation contraceptive pills Emergency
(POP, COC’s) contraception
Lactation
amenorrhoea

95
Recommendations for breastfeeding women (Use MEC criteria)

Recommendation for non-breastfeeding women

Emergency contraception (ECP)

Refers to contraceptive methods used to prevent pregnancy in the 1st few days after an
unprotected intercourse.
Effectiveness varies according to type of ECP chosen, day of the menstrual cycle, length of
time between unprotected intercourse and initiation of ECPs.
NB effectiveness is reduced after 96 hours

96
Hormonal:
• Ulipristal acetate (UPA), 30 mg taken as a single dose
• Levonorgestrel (LNG-ECP) taken as a single dose of 1.5 mg, or alternatively, LNG
taken in 2 doses of 0.75 mg each, 12 hours apart.
• Yuzpe method: COCs, taken as a split dose, one dose of 0.1mg of ethinyl oestradiol +
0.50 mg of LNG, followed by a 2nd dose 12 hours later.
Non-hormonal:
Copper-IUD: can be inserted up to 120 (5 days) after intercourse (can be left in-situ for
continuation: LARC)

Reference:

1. Medical eligibility criteria for contraceptive use. WHO Library Cataloguing-in-

Publication Data. World Health Organization 2015.
2. Emergency contraception. World Health Organization. Homepage on the internet:
Available from: https://www.who.int/news-room/fact-sheets/detail/emergency-
contraception [accessed 29 December 2021].

97
Peri-operative care

Definition: The period before a surgical procedure is called the pre-operative period and the
period after surgery is called the post-operative period.
Patients must be prepared for both periods as surgery, the hours and days before and after a
surgery, can be incredibly stressful.

Pre-operative preparation

For the surgical consent to be valid 3 conditions must be met:

1. Disclosure: Information sharing about the diagnosis and proposed surgery by the
Doctor
2. Capacity to give consent (mental and age)
3. Voluntary: No coercion by the Doctor

Informed Consent: indicates that prior to surgery the patient has been informed by the
surgeon and the patient understands the following:
1) Her diagnosis
2) The nature of the surgery/procedure.
3) Why the surgery/procedure is being done.
4) The risks and benefits of the surgery/procedure.
5) The risks and benefits of not having the surgery/procedure performed.
6) What outcome she/he can expect.
7) What the post-operative period and the recovery period will be like.
8) Alternatives management to the surgery/procedure as well as their risks and benefits.

All of this should be discussed with the patient and the patient will then sign a surgical
consent form.
If a patient is mentally incapable (Minor ≤17yrs or mentally retarded) to sign for themselves,
a next of kin should be contacted for consent.
Failure to reach a next of kin prior to an emergency surgical procedure, the medical
superintended should be contacted for consent.

Pre-operative checklist
• Patient name and Date of birth
• Positive identification of the patient by two witnesses Verification of an identity band
that correctly identifies the patient
• Name of the surgery to be performed
• Vital signs, height and weight (BMI)
• Contact lenses, dentures, and hearing aids removed (if applicable) Jewellery removed
• Chronic illnesses and Allergies
• Previous surgeries
• Language and religion (some Jehovah Witness do not receive blood products)
• Intravenous line
• Urinary catheter
• Pre-operative medications, eg, names, doses, times administered.
• Verification that the patient has been NPO for the length of time ordered by the
surgeon

98
 • Laboratory test results: FBC & UKE on all patients
• Chest X-ray: All smokers, chronic lung disease, or if ≥45 years, BMI ≥ 40kg/m2
• ECG: Chronic hypertension, Diabetes mellitus, Cardiac disease, BMI ≥ 40kg/m2

Post-operative care

Areas of Concern:

Vital signs
Frequency: ICU every 15min, High care 15min for the first hour then hourly, general ward:
15min for the first hour, 30 minutes for the second hour, hourly for ± 4 hours then every
4hours
Slight deviations of pulse and blood pressure may be normal after surgery, but these should
still be reported

Mental status
Drowsiness is expected after surgery. This can be minimal, or it may be significant.
However, excessive drowsiness or drowsiness that is not improving is not normal and the
senior doctor should be informed

Pain

Aside from asking the patient about pain you should look for objective information and non-
verbal cues that indicate the presence of pain
Use numerical pain scale (1-10 scale), with 1 being minor pain and 10 being the worst pain
they have ever felt or facial pain scale
For management see the ERAS recommendations below

Venous thromboembolism (VTE) prophylaxis

Start LMWH (Clexane) prophylaxis 6 hours after surgery (0.5mg/kg s/c dly)

Surgical dressing

A surgical dressing is a sterile cover applied over the incision.

Day 0-1: Examine if the dressing is clean and dry, if soaked in blood remove it, exclude
active bleeding and re-apply a new dressing
Day 2: Remove all surgical dressing and educate the patient on wound care (Also Mobilise
and remove all patient lines if there is no contra-indication)
Obese patients with a transverse abdominal incision may need gauze or a sanitary pad to be
placed under the abdominal panniculus to keep the surgical dressing dry.

Bleeding
A slight amount of bleeding can be expected at the surgical incision site. Bleeding that stains
through the dressing is much less common and should be reported. Do not forget to exclude
vaginal bleeding

99
Red flags of Intra-abdominal bleeding
• Patients complain of thirst and weakness
• Drowsiness, pale and cold extremities
• Tachycardia, hypotension
• Tachypnoea, dyspnoea
• Severe abdominal pains
• Abdominal distension

If any of the above are present the senior doctor must be informed

Urinary retention

Remove the catheter day 1 post op.

Urinary retention is defined as a failure to void for up to 8hours after the removal of a urinary
catheter and a documented bladder volume of > 600 mL (Fluid drained after re-insertion of a
urinary catheter)
All cases of urinary retention must be reported

Nausea and vomiting

Nausea and vomiting are very common post-operative problems. In the great majority of
cases, they are mild and temporary and can be easily treated with an anti-emetic such as
Metoclopramide (Maxolon) 10mg q8h IVI or Ondansetron (Zofran) 8mg q12h po.

Paralytic ileus

Paralytic ileus is the condition where the motor activity of the bowel is impaired, usually not
associated with a mechanical cause. Treatment is conservative, as the condition is mostly
self-limiting. Management includes parenteral infusion with crystalloids, NG tube, keep
NPO, monitor input & output, prokinetic drugs such as macrolides (Erythromycin 500mg q4h
po) and antiemetics, e.g: Maxolon 10mg q8h IVI.

Infection

Despite the careful use of sterile technique, post-operative infections cannot be eliminated.
There will always be patients who develop a post-operative infection and for some patients
the risk is high (Elderly, Obese, Smokers, Immuno-comprised, Diabetic etc)

Signs and Symptoms of Post-Operative Infection

• Confusion, Tachycardia, Tachypnoea and/or Dyspnoea
• Fever
• Dysuria
• Hypotension
• Wound site purulent discharge
• Inflammation and tenderness around the wound

If any of the above is/are present the consultant should be notified

100
Enhanced Recovery After Surgery (ERAS): 2019 Recommendations
• Patients should be encouraged to eat a light meal up until 6 hours and consume clear
fluids including oral carbohydrate drinks up until 2 hours, before the initiation of
anaesthesia.
• Patients with delayed gastric emptying (Including pregnant women) should fast
overnight or 8 hours before surgery
• Level I evidence demonstrating a lower surgical site infection rate associated with
chlorhexidine-alcohol skin preparation compared with povidone-iodine
• Greater emphasis on non-opioid medications, preserves or improves patient
experience and functional recovery after surgery: Acetaminophen & NSAIDs have
better outcomes
o Pelfargan/Panado 1g q6h ivi/po + Brufen 400mg q8h po + local
o Incisional injection of bupivacaine and Transversus abdominis plane blocks
• Diet: No NGT, emphasize early feeding, clear fluids on the day of surgery if possible
and chewing gum 4 hours post-op
• Bowel function: Drinking coffee, euvolemia, opioid-sparing analgesia and early
feeding are safe, inexpensive and appear effective in decreasing the time to return of
bowel function.
• Early mobilization: Patients should be encouraged to mobilize within 24hours of
surgery
• Venous Thromboembolism Prophylaxis: Patients at increased risk of VTE should
receive dual mechanical prophylaxis (stockings) during theatre and chemoprophylaxis
LMWH (clexane)
• Improved post-operative education for patients before discharge is required
• Antibiotics prophylaxis
Procedure Antibiotic Stat Dose (SD within 60 minutes
before procedure)
Hysterectomy: Cefazolin 2g, 3g > 120 kg
TVH, TAH, TLH *Repeat if 3 hours intraoperative
Uterine Evacuation Doxycycline 200mg
Colporrhaphy Cefazolin 2g, 3g > 120 kg
Caesarean section Cefazolin 2g, 3g > 120 kg
Vaginal sling placement Cefazolin 2g, 3g > 120 kg

Laparotomy without entry Consider Cefazolin

into bowel or vagina
Cervix: LLETZ, biopsy, NOT RECOMMENDED
Hysteroscopy, EM sample

References:
1. Nelson G, Altman A, Nick A, et al. Guidelines for perioperative care in
gynaecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society
recommendations—2019 update. Int J Gynecol Cancer 2019;0:1–18.
doi:10.1136/ijgc-2019-000356
2. Wilson RD, Caughey AB, Wood SL, et al. Guidelines for Antenatal and Preoperative
care in Caesarean Delivery: Enhanced Recovery After Surgery Society
Recommendations (Part 1). AJOG. 2018 December; 219 (6): 523.e1-523.e15.

101
3. Caughey AB, Wood SL, Macones GA, et al. Guidelines for intraoperative care in
cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part
2). AJOG. 2021 May; 224 (5): 553-554.
4. Macones GA, Caughey AB, Wood SL, et al. Guidelines for postoperative care in
cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society
recommendations (part 3). AJOG. 2019 September; 221 (3): 247.e1-247.e9

102
Evidence-Based Caesarean Section

Definition: Delivery of the baby through surgical incisions made in the abdomen and the
uterus
Surgeons should communicate the urgency of the caesarean section to nursing,
anaesthesia, and paediatric staff
• Category 1 (Emergency C-Section): Immediate threat to the life of the women or
foetus (perform delivery as soon as possible, at least within 30 minutes of decision)
• Category 2 (Urgent c-section): Maternal or foetal compromise which is not
immediately life-threatening (perform delivery as soon as possible, but goal at least
within 75 minutes of decision)
• Category 3 (Elective c-section): No maternal or foetal compromise
• Category 4: Delivery timed to suit staff or patient needs
Preoperative fasting
Allow clear fluids up to 2 hours prior to caesarean section, 6 hours for a light meal, and ≥ 8
hours after heavy meals including fried or fatty foods
Completion of WHO Surgical Safety Checklist
Preoperative bathing
Bathe or shower night prior to surgery or on the day of surgery using plain soap or
antimicrobial soap
Hair removal
Routine hair removal should not be performed. If deemed necessary to obtain appropriate
surgical exposure, do hair clipping (NB shaving with razor increases the risk of SSIs)
Before induction of anaesthesia
Nurse and anaesthetist should confirm the patient's identity, procedure to be performed, and
that consent has been obtained; the anaesthesia machine and medications have been checked;
the pulse oximeter has been placed on the patient and has been confirmed to be functioning;
patient allergies have been confirmed; patient’s airway has been evaluated; and placement of
two large-bore IVs has been performed if anticipated blood loss is > 500 mL
Antibiotic prophylaxis
Appropriate antibiotic prophylaxis within 60 minutes, a cephalosporin (1st, 2nd, or 3rd
generation) before skin incision
Abdominal skin preparation
Apply an alcohol-based chlorhexidine solution prior to incision
Pre-anaesthetic medications
Administer histamine type-2 (H2) receptor blockers and antacids to reduce the risk of
aspiration pneumonitis (IV Ranitidine 50mg)
Anti-emetics to help prevent nausea and vomiting which can increase the risk of aspiration
(IV Ondansetron 40mg)
Urinary catheter placement
Helps in easy recognition of bladder injuries if they occurred, remove 12 hours post
operatively

Intraoperative techniques
Skin incision
Use either the Joel-Cohen or Pfannenstiel incision, a vertical midline incision may be
reserved for patients with prior extensive history of abdominal surgery, for situations where
concomitant caesarean section hysterectomy is planned or is anticipated, for caesarean
section performed under local anaesthesia, or for other situations where improved intra-
abdominal access is required.

103
Bladder flap
Not mandatory to routinely create bladder flaps prior to making the uterine incision
Hysterotomy site and type
Transverse incision in the lower uterine segment should be routinely performed
Low vertical, mid-segment, or classical incision within the contractile portion of the uterus
should be reserved for special circumstances such as preterm delivery without well-
developed lower uterine segment; foetal transverse, back down presentation; or concern for
placenta accreta spectrum
Delivery of the placenta
Deliver the placenta by gentle cord traction
Uterine exteriorization
Uterine exteriorization provides sufficient exposure but can also be repaired without
exteriorization. Decision is left to the discretion of the surgeon
Hysterotomy closure
Do a double-layered closure of the hysterotomy
Peritoneum closure
Closure of the peritoneum is not recommended
Subcutaneous tissue closure
Reapproximation of the tissue layer in women with >2 cm of subcutaneous tissue, should be
performed
Skin closure
Recommend closure with subcuticular suture. For WHC- Interrupted nylon sutures is
recommended due to delayed presentation of wound sepsis associated with subcuticular
suture.
Before patient leaves the operating room
Provisions for a postoperative debriefing including confirmation of the procedure actually
performed, specimen labelling, and any anticipated concerns for patient recovery.
Removal of urinary catheter
Should be removed 12 hours postpartum. If the patient is unable to void in 6 hours, consider
replacing the catheter for an additional 12-24 hours.
NB remove after ≥14 days in mothers who had obstructed labour
Early mobilization
Ambulation should start soon after return of motor function
Resumption of oral feeding
Allow sips within 60 minutes of admission to the post-anaesthesia care unit; and if tolerating
fluids, advance to regular diet within 4 hours
Postoperative antibiotic prophylaxis prolongation
Not recommended for clean operations but continue antibiotics in mothers who had
obstructed labour and chorioamnionitis
Thromboprophylaxis
Routinely use of pneumatic compression devices to reduce the risk of venous
thromboembolism for all women undergoing CS, which should remain in place until the
patient is fully ambulatory
Consider addition of pharmaceutical prophylaxis for high-risk women, such as those with a
history of thromboembolism or with a high-risk thrombophilia
Wound dressing
Remove the dressing at 24–48 hours with daily examination of the incision
Patient discharge
Discharge 2-4 days after delivery if the patient has recovered well postoperatively

104
Reference:

1. Caesarean section NICE guidelines (NG 192). 31 March 2021. Available from:
www.nice.org.uk/guidance/ng192

105
 Appendix A

Windhoek Hospitals Complex Induction of labor checklist

Date: ………………………… Time: …………………..

Name of patient: ………………………………………………… Hosp. No: …………………

• Age: …………… years; Gravida: ………….. Para: ……….. Others: ……………………

• Gestational age: …………………….. By: ………………………… EFW: ………………

• History of any allergies, medical condition, special need: Yes No

• High Risk Review: Yes No

• Indication for Induction Reviewed: Yes No

………………………………………………………………………………………………

• Method used for the patient: ……………………………………………………………….

• Type of IOL: Indicated Elective

• Consent form signed by the patient and her attendant: Yes No

• Fetal Heart Rate Assessment: Yes No CTG interpretation: ……………….

Pre-Induction Modified Bishop’s Score:

Score Bishop Score
Cervix Modifiers
0 1 2 3
Dilatation Closed 1-2 3-4 5 Add 1 point for:
• Preeclampsia
Length >4 3-4 1-2 0 • Each previous NVD
Consistency Firm Medium Soft - Subtract 1 point for:
• Late-term
Position Posterior Midline Anterior - pregnancy
• Nulliparity
Station -3 -2 -1, 0 ³ +1 • PPROM

Total Score of the patient: ………..…..; (Favourable Score: 6-13 & Unfavourable Score: 0-5)

Signature of the Doctor: ……………………………….; Date and time: ………..……………

Name of the Doctor: ……………………………………………………………………………

106
 Appendix B

FIGO Misoprostol Recommended Dose Regimens

107
 Appendix C

Windhoek Hospitals Complex Augmentation of labor chart

Date: ………………………… Time: …………………..

Name of patient: ………………………………………………… Hosp. No: …………………

• Age: …………… years; Gravida: ………….. Para: ……….. Others: ……………………

• Gestational age: …………………….. By: ………………………… EFW: ………………

• History of any allergies, medical condition, special need: Yes No

• Indication for AOL Reviewed: Yes No

………………………………………………………………………………………………

• Regimen used for the patient: ………………………………………………………………

• Consent form signed by the patient and her attendant: Yes No

Dosage regimens for augmentation

Time since Oxytocin CTG INTERPTREATION
AOL dose(mU/min) Regimen flow rate
(min) CTG Category Signature
1
2
4
6
8
10
12
14
16
18
20*

*Maximum dose

Signature of the Doctor: ……………………………….; Date and time: ………..……………

Name of the Doctor: ……………………………………………………………………………

108
Windhoek Hospitals Complex Appendix D

TRIAL OF LABOUR AFTER CAESAREAN DELIVERY CHECK LIST FORM

Patient Name: …………………………………………. Hospital No.: …………………….

fDATE:
CONTRAINDICATIONS FOR TOLAC TICK WHEN
DISCUSSED
Contraindications include: previous uterine rupture; history of classical caesarean
section; previous myomectomy, contraindications to vaginal birth which apply
regardless of history of caesarean (e.g. placenta praevia), complex caesarean scar
(e.g. inverted T or J)
LIKELIHOOD OF TOLAC TOLAC RATE
1 previous caesarean section, no previous vaginal birth 72 -75%
1 previous caesarean section, at least 1 previous NVD 85 -90%
Induced labour, no previous vaginal birth, BMI greater Any, ± 40%
than 30, previous caesarean for dystocia
MATERNAL RISKS OF PLANNED TOLAC vs ERCS
RISK TOLAC ERCS
Uterine rupture 0.5% (1/200) <0.02% (1/1000)
*If uterine rupture occurs, 14–33% risk of hysterectomy and 6.2% risk of perinatal death
Future pregnancies Nill Increased likelihood of placenta praevia/ morbidly
adherent placenta
Maternal mortality 0.004% (1/25 000) 0.013% (1/7600)
FETAL RISKS TOLAC vs ERCS
RISK TOLAC ERCS
Stillbirth beyond 39+0 0.1% (1/1000) N/A
weeks awaiting labour
HIE 0.08% (1/1250) <0.01% (< 1/10 000)
Perinatal mortality 0.13% (1/770) 0.05% (1/2000)
INTRAPARTUM CARE RECOMMENDATIONS
EFW Known, preferably < 3800g
Continuous CTG
IVI line access
Hb known and type and screen done
Urinary catheter
Close monitoring of progress in labour: 1cm/2 hours in active labour
Analgesia
Consent signed
The cervicograph ALERT line becomes the ACTION line
DOCTOR: SIGNATURE:

The clinical features associated with uterine scar rupture include:

• Abnormal CTG, Severe abdominal pain, especially if persisting between contractions
• Acute onset scar tenderness, Abnormal vaginal bleeding, Hematuria
• Cessation of previously efficient uterine activity, Maternal tachycardia, hypotension, fainting or
shock, Loss of station of the presenting part
• Change in abdominal contour and inability to pick up fetal heart rate at the old transducer site

109
 Appendix E

Timing of Delivery at or after 34 Weeks Gestational Age

Term pregnancy classification

Early-term 37 +0–38 +6 weeks
Full-term 39 +0– 40 +6 weeks
Late-term 41 +0– 41 +6 weeks
Post-term > 42 +0 weeks
Neonatal risks of preterm and early-term are well documented therefore nonindicated
delivery before 39 weeks of gestation is discouraged.

Condition Suggested Specific timing

Placental/ Uterine Conditions

Previous C/S * 1 - 2 39 +0 weeks
> Previous C/S * 2 37 +0 – 38 +6 weeks
Placenta previa 36 +0 weeks
Placenta Accreta Spectrum 34 +0 weeks
Vasa previa 34 +0 weeks
Prior classical caesarean delivery 36 +0–37 +0weeks
Prior myomectomy 37 +7–38 +6 weeks
Previous uterine rupture 36 +7–37 +0 weeks

Fetal Conditions
Oligohydramnios (isolated or otherwise uncomplicated) 36 +0 –37+6 weeks
Polyhydramnios (mild, idiopathic) 39 +0 weeks
Growth restriction (singleton) See FGR section

Multiple gestations—uncomplicated
DCDA 38 +0 weeks
MCDA 36 +0 – 37 +6 weeks
MCMA 32 +0–34 +0 weeks
Triplet and HOMG Individualize

DCDA twins with isolated FGR 36 +0–37 +6 weeks

MCDA twins with isolated FGR 32 +0 –34 +6 weeks

Alloimmunization
At-risk pregnancy not requiring intrauterine transfusion 37 +0–38 +6 weeks
Requiring intrauterine transfusion Individualize

110
Maternal conditions

Hypertensive disorders of pregnancy

Chronic hypertension 38 +0 weeks
Chronic hypertension: difficult to control (requiring frequent 36 +0 –37 +6 weeks
medication adjustments)

Gestational hypertension 38 +0 weeks

Preeclampsia without severe features 34 +0 weeks
Preeclampsia with severe features, unstable or complicated, Soon after maternal
after fetal viability (includes superimposed, uncontrolled BP stabilization and steroids mature
and HELLP)
Preeclampsia with or without severe features, before viability Counsel the couple on medical
TOP
Diabetes Mellitus in Pregnancy
Pre-existing & GDM (Uncomplicated) 38 +0 weeks
Complicated pre-existing & GDM (e.g: Macrosomia, poorly Individualize
controlled)

HIV 39 +0 weeks by elective

Viral load > 1,000 copies/mL with antiretroviral therapy caesarean section or an
emergency at any GA

Obstetric Conditions

Preterm PROM 34 +0 weeks

PROM (37 0/7 weeks of gestation and beyond) Immediate IOL at diagnosis
Previous stillbirth 38 +0 weeks

111
 Appendix F

Windhoek Hospital Complex In-patient Diabetes Glucose control chart

Patient Name: Hosp. No.:

A- Actrapid Test glucose 30 minutes before each meal, 2 hours after meal,
B- Protaphane 22h00 and 02h00.
Supplement Actrapid according to blood glucose before meals
as per sliding scale.
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Date
Fasting glucose level
Before Time
Value
Breakfast Insulin A
After Time
Value
Before Time
Value
Lunch Insulin A
After Time
Value
Before Time
Value
Dinner Insulin A
After Time
Value
Bedtime Time
Value
Insulin B
Night 02h00 Value

Sliding scale Target venous plasma glucose levels (FIGO)

If blood glucose is Add on Actrapid dose Time Desired Level (mmol/l)
4.5 – 6.4 mmol/l 2IU Fasting 3.3 – 5.3
6.5 – 8.4 mmol/l 4IU Pre-prandial 3.3 – 5.6
8.5 – 10.4 mmol/l 6IU 1-hour post prandial £ 7.8
10.5 – 12.4 mmol/l 8IU 2-hour post prandial £ 6.7
³ 12.5 mmol/l 10IU + Call Dr on call 2am 3.3 - 5

Total insulin requirements (FIGO) DOSING:

st
1 trimester 0.7 – 0.8 IU/kg Basal dose: 2/5 of the total dose
Bolus doses: 3/5 of the total doses in 3 divided
2nd trimester 0.8 – 1 IU/kg doses 30min before meals
rd
3 trimester 0.9 – 1.2 IU/kg

112
 Appendix G

Cardiac disease ANC record

PREGNANCY DETAILS DELIVERY PLAN

Name: Obstetrician:

EDD: Cardilogist:

Cardiac lesion: Anaesthaetist:

Echocardiogram: Mode of delivery:

Medications: Others:

Date GA Shortness Palpitations Other BP Pulse Pulse Murmur Lung Oedema Presentation FH urine Next Signature
Of breath symptoms RYTHM bases visit

113
 Appendix H

Acute severe hypertension pathway (BP ³160/110)

Time (Min) Nifedipine PO (mg) Labetalol IV (mg) Hydralazine IV (mg)

0 10 20 5-10
10 Check BP BP ³160/110 Check BP
40
20 BP ³160/110 BP ³160/110 BP ³160/110
20 80 10
30 Check BP BP ³160/110 Check BP
Hydralazine 10
40 BP ³160/110 Check BP BP ³160/110
20 Labetalol 40
50 BP ³160/110 BP ³160/110 BP ³160/110
Labetalol 20, inform inform consultant inform consultant
consultant

114
 Appendix I

Emergency treatment algorithm for Eclamptic seizures

Time Intervention
(Min)
0-5 1. Airway: lateral decubitus position, oxygen, suction
2. IV access
3. Avoid maternal injury: elevate and pad bed rails
Prevent recurrent seizures:
1. MgSO4 4g in 200ml IVI over 15 – 20 min
Continue with maintenance: 1g/hr
10 - 15 Control of severe hypertension
15 – 20 Obtain PET bloods: Hb, Plts, AST, ALT, Urea, Creatinine
Assess fetal status: FHB
Recurrent seizure: Stable
MgSO4 2g over 3 – 5 minutes 1. Prepare for delivery
Refractory seizure: Lorazepam 4mg 2. Assess the need to transfer to
Consider need for intubation Acute care or ICU

115
 Appendix J

Surgical site infection management algorithm

Operation

Fever within Fever > 4days after

48 hrs-4days
surgery

Unlikely to be wound
infection Wound examn
Erythema normal
±induration or
fluctuations
Look for other
Systemic illness
No systemic causes of fever
illness
Open the wound
Look for other causes of fever:
Diff dx: Physiological, DVT,
Remove stiches, drain the pus
and assess the sheath.
Do BC, FBC, UKE, CRP, AST,
ALT

Start antibiotics:
Tazocin 4.5g q6h IV

Sheath intact: Wound

dressing with Drawtex Sheath Dehiscence: Book
Dressing for relook exploartive
laparotomy

Reference:

1.Ekanem EE, Oniya O. Surgocal site infection in obstetrics and gynaecology. TOG.
February 2021. 23; (2): 124 – 137.

116
 Appendix K

CTG Interpretation algorithm

Reference:

1.Fetal heart traces flow chart. SASOG guidelines. 2019. Available from:
https://sasog.co.za/wp-content/uploads/2021/10/FOETAL-HEART-TRACES-FLOW-
CHART.pdf

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NOTES:

118