O&G HO Guide @thechayondeducation

PATIENT ADMISSION CENTRE (PAC)

(HRPZ HOUSEMAN GUIDE)
©The Chayond Education, 2020

The present guidelines supersede the existed documents shared and revised accordingly. To ensure proper
management for patient’s safety, please follow your local hospital guidelines. Additional recommendations will be
forthcoming. Feel free to follow my IG: @thechayondeducation

A. FULLY CLERKING TEMPLATE

B. APPROACH TO COMMON SIGNS AND SYMPTOMS IN PAC
a) Leaking liquor
b) Contraction pain
c) Reduced fetal movement
d) PV bleeding
e) Show
f) PV discharge

C. COMMON ANTENATAL ISSUES

a) Pre-existing DM
b) GDM
c) Anemia
d) Essential/secondary HPT
e) Preeclampsia
f) Hyperthyroidism
g) Placenta previa
h) Rhesus negative
i) Epilepsy
j) Fibroids
k) SLE and APLS
l) Multiple pregnancy
m) History of UTI
n) SGA
o) Bronchial asthma
p) 1 previous scar
q) Subfertility
r) 1st child of 2nd / 3rd union
s) Multiple pregnancy
t) History of perinatal death
u) Single parent/PMC
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D. COMMON PLAN IN PAC

a) Latent phase of labor
b) Active phase of labor
c) PROM
d) PPROM
e) SGA with oligohydramnios
f) Reduced FM
g) Hyperthyroidism
h) Anemia
i) Threatened preterm labor
j) Intermediate APH
k) Vagina candidiasis
l) GDM on Insulin
m) Gestational HPT
n) IOL
o) Preterm labor
p) Bleeding previa
q) GDM on diet control unlikely PROM
r) Suspicious CTG
s) UTI in pregnancy
t) Placenta previa

E. DISCUSSION
a) Hypertensive disorder in pregnancy
b) Anemia in pregnancy
c) Diabetes in pregnancy
d) Hyperthyroidism in pregnancy
e) Placenta previa
f) Rhesus negative in pregnancy
g) Epilepsy in pregnancy
h) Fibroids in pregnancy
i) SLE and APLS in pregnancy
j) Multiple pregnancy
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A. FULL CLERKING TEMPLATE

<Full Clerking>
s/b Dr ________ (MO/Specialist)

13/01/22 Miss Sameera, 31 years old, G2P1 at 40 weeks + 2 days POA/POG

0345H LMP: 04/04/2021 (sure of date, regular menses, not on contraception)
EDD: 11/01/2022 (Verified by scan at 12 weeks, subsequent scans follow EDD), or
REDD: 20/02/2022 (benefited first scan, given REDD 11 weeks POG)

Referred case from/Electively admitted for/IOL for (must get consent from both wife and husband)/
Leaking less than 18 hours/Contraction pain (Elaborate thoroughly according to chief complaint)

Antenatally (Summarized),
1) GDM on T. Metformin 500 mg BD Gestation Definition
- MOGTT × 1 @24 weeks: 5.2/7.6 Term 37 – 40 weeks
- HbA1c: 6.2% Preterm <37 weeks
- Started on T. Metformin _____ Viable 24 weeks
- BSP optimized, AFI, EFW EDD 40 weeks
2) Anemia in Pregnancy EDD + 9 days Post date
- Latest Hb
- On T. Iberet I/I OD
- Anemic workout done/not done
3) Placenta previa

Booking done at 12 weeks POA at KKIA Pandan Indah

BP:
PR:
BMI:
MBG:
Hb: 12.4 (blood group)
Infective screening:
Urine albumin:
Urine sugar:

Dating scan Detail scan

Done 8 – 13 weeks Previous history of perinatal death, syndromic
CRL is used to determine or congenital malformation
gestational age GDM mother on s/c Insulin

Latest TAS done at 36 weeks

Singleton, cephalic, FH+ (shown to mother)
Placenta at ____
BPD: ____ mm (35 w + 6 d)
AC: ____ mm (35 w + 6 d)
HC: ____ mm (35 w + 6 d)
FL: ____ mm (35 w + 6 d)
EFW:
AFI: ≥ 25 (Poly)
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Past Obstetric History

Gynae History
Past Medical
Past Surgical
Allergy History
Family History
Social History

Currently, contraction
no leaking
no show
good fetal movement (do not mention during APOL)

On examination, alert, pink

BP TIPS!
PR
RR Other miscellaneous physical examination
should be done accordingly
T
SpO2 Eg: Relevant thyroid examination for mother
with hypo/hyperthyroidism
Lungs:
CVS:
Per abdomen: Soft, non-tender
Uterus at termed
Singleton (multiple poles felt if twin), cephalic (leading twin cephalic)
Head 4/5th
EFW 3.2 – 3.4 kg

SSE (Sterile Speculum Examination) or PSE (Per Speculum Examination) – (if leaking)
- Cervix tubular healthy
- Os not opened
- No pooling of liquor
- Cough impulse negative (only done if no pooling)

VE
- VVNAD (varicosities, vesicles)
- Cervix 1 cm, mid-anterior, soft
- Os 5 cm
- Station -2 (Largest diameter of presenting part in relation to pelvic ischial spines)
- Vertex (head felt)
- Membrane intact/absent
- No cord (elongated, pulsatile)/placenta felt

Transabdominal Scan (TAS)

CTG

Impression: 31 years old, G2P1 at 40 weeks + 2 days POA in active phase of labor

Plan (Refer plan)

- Admit labor room for ARM and delivery
- CTG post ARM
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B. Approach to common signs & symptoms in PAC

1. LEAKING LIQUOR
• Time started of leaking (Eg: 0030H)
• Colorless/Odorless
• Gushing soaked sarung
• Dribbling
• Continuous
• Any precipitated event

2. CONTRACTION PAIN
• Time started of contraction (Eg: 0300H)
• Regular or irregular
• Increasing intensity, frequency in 10 mins
• Radiation: from fundus to suprapubic and back
• If preterm, ask history of
- Trauma
- Abdominal massage
- Resent SI (Semen has prostaglandin causing contraction)
- UTI symptoms, or any vaginal discharge

3. REDUCED FETAL MOVEMENT

• Both in intensity and frequency
• Usually 10 kicks completed at 1200H, but today only 2 kicks from 0900H to 1200H
• No history of trauma, abdominal massage
• Fasting/not fasting (eat when hungry, drink cold water when active or not)
• UTI symptoms
• Currently, satisfied with fetal kicks, already completed 10 kicks today

4. PER VAGINAL BLEEDING (NO VE!)

• Onset: passing out blood clot today 0500H, @30weeks POA Info!
• Amount, color, duration
Painless dark PV bleeding – Vasa previa
• Pattern: intermittent or continuous bleeding
Painless bright red PV bleeding – Placenta previa
• Frequency: how many episodes Painful PV bleeding – Abruptio
• Pain/painless
• Precipitated during doing house chores/sleeping/micturating/walking upstairs
• Severity: syncopal attack, palpitations
• Latest scan at 32 weeks, placenta AUS
• ALSO, explore signs and symptoms of: Threatened miscarriage, abruptio, vasa previa

5. SHOW
• What time
• Mucus + blood associated with abdominal pain
• Size/amount, color?
• Any leaking liquor?

6. VAGINAL DISCHARGE
• Color, smell
• Amount, using pad?
• UTI symptoms?
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C. Common Antenatal Issues

1. Pre-existing Diabetes Mellitus

- Diagnosed since 36 years old
- How was the diagnosis made?
- Current medications
- SMBG monitoring
- HbA1c, BSP
- Pre-pregnancy status (detail scan, latest assessment, preconception counselling)

2. Gestational Diabetes Mellitus

- MOGTT × 1 @24 weeks: 5.2/7.6
- HbA1c: 6.2%, BSP, Urine dipstick/C+S, RP
- Since then, started on T. Metformin _____
- Weight gain, control of the disease Complications of anemia in pregnancy
- Detail scan, AFI, EFW
- Overt DM if fasting ≥ 7 and random/MOGTT ≥ 11 MATERNAL
a. Heart failure
- BP trend, urine for proteinuria, PE prophylaxis?
b. Preterm labor

3. Anemia in Pregnancy FETAL

- Diagnosed at 12 weeks (Hb 9.8) 1. IUGR
- Anemic workout: FBP, Iron study, Hb analysis, DNA analysis
- On T. Zincofer II/II OD/Parenteral iron/Blood transfusion
- Ask about compliance if persistent low Hb despite on optimum treatment given
(stool color, constipation)
- Control: anemic symptoms, Hb trend, blood transfusion/parenteral iron therapy
- Currently treated as IDA/Thalassemia Trait/Hemodilution
- Latest Hb at 36 weeks, 10.9 mg/dL

4. Essential/Secondary Hypertension Hypertension in Pregnancy

- Diagnosed since 38 years old 1. Essential/Secondary HPT
- How was the diagnosis made? 2. Pregnancy-induced HPT
(without significant
- Any investigations done? (especially young hypertension)
proteinuria)
- Since then, on T. Amlodipine 5 mg OD 3. Pre-eclampsia (with
- BP range 134-138/82-88 (pre-pregnancy, antepartum) significant proteinuria)
- Target organ damage
- Pre-pregnancy status (disease status, adjustment/change of antihypertensive medications)
- IE symptoms, PE profile, urine dipstick taken antenatally
Symptoms of IE
5. Pre-eclampsia • Headache
- Presented with symptoms of ___ at ___ weeks, recorded BP • Blurry of vision
- PE profile (FBC, RP, LFT, Uric acid, UFEME, UPCI) • Epigastric pain
- Given IV Labetalol 10 mg & T. Nifedipine 10 mg STAT at ED • Nausea, vomiting
- Started on IV MgSO4 4g loading dose
Complications of high BP in pregnancy
- On IV MgSO4 5cc/hour, with 2 hourly toxicity monitoring
- Latest scan: IUGR (parameters, doppler scan) A. MATERNAL
- No IE symptoms • Placenta abruptio
• Eclampsia
• HELLP syndrome
• TOD

B. FETAL
• IUGR (Uterus smaller than
date)
O&G HO Guide @thechayondeducation

6. Hyperthyroidism in Pregnancy
- When was it diagnosed? Presentation – Hyperemesis gravidarum?
- Ix: TFT trend, Antibodies for Graves’ disease, neck USG, FNAC?
- On Carbimazole, PTU (any detail scan?)
- Control of the disease: symptoms/laboratory
- Pre-pregnancy and antenatal status (any change in medication?)
- If suboptimal control, ask compliance to medication, UTI symptoms
- Growth parameter: IUGR
- BP & PR trend, any IE symptoms
- Carbimazole: sore throat and fever, FBC – Agranulocytosis

7. Placenta Previa
- Low lying (<28 weeks) or placenta previa (>28 weeks)
- When confirmed to have PP?
- How was the diagnosis being made? – routine scan or PV bleeding
- Current exact diagnosis? Type of PP, anterior/posterior, cm from Os, presentation
- Explore risk factors of PP: Previous LSCS, previous uterine surgery (eg: myomectomy)
- Management given – outpatient or inpatient (expected management – McAfee regime)
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8. Rhesus Negative in Pregnancy

- Explore the case: sensitize or non-sensitized
- Ask for any sensitizing event

Sensitized case Non-sensitized

Husband Rh status Husband Rh status
• If Rh Negative (no further test required) • If Rh Negative (no further test
required)
• If Rh positive,
Suggest for non-invasive fetal karyotyping to determine fetal Rh • If Rh positive,
status Enquire for any antenatal sensitizing
↓ event?
If fetal Rh ֎ Threatened miscarriage
֎ Chorionic venous
sampling/amniocentesis/cordocentesis
Rh Negative Rh Positive ֎ Abdominal trauma
(No further test) ֎ ECV
֎ APH

If yes, any Anti-D prophylaxis after

event?
Non-invasive fetal karyotyping to determine fetal Rh
status. If Rhesus positive, need to measure maternal anti-D If no, for routine anti-D prophylaxis
titer 4 weekly until 28 weeks, then 2 weekly until delivery (2 doses at 28 and 32 weeks
respectively, 1 dose at postnatal
If Anti-D titer >4 IU/ml, to refer Fetal Medicine period)
Specialist.
• Periodic Coomb’s test
Anti-D titer between 4 – 15 is associated with moderate
risk of hemolytic disease of fetus and newborn (HDFN)

Consider Fetal MCA Doppler ultrasound

- Booking should have taken

֎ Blood group + Rh confirmed
֎ Indirect Coomb’s test
֎ Maternal antibody titre
֎ Husband Rh
֎ Fetal Karyotyping

9. Epilepsy in Pregnancy
- When was the diagnosis made?
- Presentation: unprovoked seizure?
- Investigation done: EEG, lumbar puncture
- Risk factors: family history, neurocutaneous syndrome
- Medications: how long? How many AED?
- Control: seizure free for how long? Fitting episode during pregnancy?
(If patient experienced seizure weeks prior to labor, ELLSCS is recommended)
- Pre-pregnancy: any change in medication?
- Investigations taken in pregnancy (treatment effects to pregnancy): Maternal serum AFP,
AFP in amniotic fluid, ultrasound
O&G HO Guide @thechayondeducation

10. Fibroids in Pregnancy

- When diagnosis made?
- Presentation: HMB, incidental findings
- Investigations: ATS – results, type, number of fibroids
- Treatment given? myomectomy
- Progression of condition: pre-pregnancy until now
- Effects of fibroids to pregnancy and vice versa

Fibroids to pregnancy Pregnancy to fibroids

MATERNAL RED DEGENERATION OF
• Symptoms of early miscarriage during early pregnancy FIBROIDS
• Symptoms of early labor • Abdominal pain
• Symptoms of placenta abruption • Any admission
• Placenta previa
• Pressure symptoms

FETAL
• Fetal anomalies: limb reduction defects
• Dolichocephaly, torticollis
• Malpresentation

11. SLE & Antiphospholipid Syndrome in Pregnancy

- When diagnosis made?
- Presentation at diagnosis?
- Investigations: anti-dsDNA, antiphospholipid antibody
- Current treatment
- Last acute disease/thrombotic event (prior pregnancy)
- Complications: any end-organ damage such as renal impairment
- Any preconception counselling done: is this a well-prepared pregnancy, what is the risk
stratification made by doctor?
- At booking (Extra things: PE profile, antiphospholipid antibody, anti-Ro, anti-La which
associated with increased risk of neonatal congenital heart block, anti-dsDNA, complement
level. Additional treatment: continue hydroxychloroquine, aspirin from 12 weeks gestation)
- Explore the complications of disease to pregnancy and vice versa
DISEASE TO PREGNANCY
Maternal Fetal
• Risk of miscarriage (especially APLS) • Congenital anomalies (detailed scan @18w)
• Hypertension/PE • IUGR (Doppler?)
• Placenta abruptio • Neonatal congenital heart block (in anti-
• Preterm labor Ro/anti-La +ve case)
• Thrombotic event (APLS)
TREATMENT TO PREGNANCY PREGNANCY TO DISEASE
*Associated with medications • SLE flare
• Congenital fetal malformation
• NTD
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12. Multiple Pregnancy

- At which week the diagnosis was made?
- Findings in USG: twin-peak (lambda) sign or T-sign
- Chorionicity (IMPORTANT!)
- Monitoring necessary for monochorionic twin:
a) 11 – 13+6 weeks: NT scan, triple test
b) 18 – 20+6 weeks: detailed scan for anomaly
c) Ultrasound every 2 weekly from 20 weeks: AFI of each pocket, umbilical artery
pulsatile index, EFW and difference in EFW
- Explore complications of multiple pregnancy

MATERNAL FETAL
• Hyperemesis gravidarum • Twin-to-twin transfusion syndrome (if
• Risk of miscarriage monochorionic twin) – ultrasound 2 weekly
• Anemia
• Risk of preeclampsia
• Preterm labor

13. History of UTI at ___ weeks

- Complaint of increased urinary frequency and incomplete voiding
- Completed C. Cephalexin 500 mg TDS x 1/52
- UFEME
- Urine C+S

14. Small Gestational Age

- 1st noticed at __ weeks
- Mother short stature: 153 cm height
- Latest scan at 37 weeks, EFW, AFI
- Growth chart growing at 50th centile (look at AC first – soft tissue affected first)
- Normal doppler waveform
- Plot growth chart

15. Bronchial Asthma in Pregnancy

- Diagnosed since 3 years old
- On MDI Salbutamol PRN
- No history of ICU/Hospitalization
- Symptoms controlled
- Last attack (If within 1 month of labor, need to give steroid to prevent bronchospasm)

16. 1 previous scar

- Previous pregnancy due to?
- Uneventful?
- Counselled for TOLAC at 34 weeks, keen for TOLAC
(TOLAC is the first step toward a VBAC)

17. Subfertility
- 2nd / 3rd union
- Voluntary subfertility for 3 years using Implanon
- Involuntary subfertility for 5 years
- Ever/never been investigated
- Embark into spontaneous conception (if involuntary and long waiting time, precious
pregnancy, offer LSCS)
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18. 1st child with 2nd / 3rd union

- LCB was 2017
- Married in August 2021
- Divorced previous spouse
- All 3 children stay together with patient

19. Multiple pregnancy

- Diagnosed by scan at 28 weeks
- Under HRPZ follow up
- Detail scan at 30 weeks, growing normal fetuses
- Latest scan at 32 weeks in HRPZ
a. Leading twin cephalic, EFW, DVP
b. Second twin cephalic, EFW, DVP

20. History of perinatal death in 2018

- Passed away at 4 months of age
- Down syndrome baby with Hirschsprung’s disease
- Done detail scan in current pregnancy, normal

21. Single parent/Pre-marital Conception

- With boyfriend
- Not planned for marriage
- Claim had multiple sexual partners, not sure boyfriend had multiple partners or not
- Plan to give child for adoption post delivery
- Infective screening – HIV, Syphilis, Hep B, C non-reactive
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D. Common plan in PAC

1. Latent phase of labor

• Admit ANW
• Monitor vital signs 4 hourly
• Time contraction
• FHR and FKC monitoring
• NR in 4 hours at ____ H if contraction 2:10
• NR in 4 hours at ____ H if contraction 1:10, VE when contraction persistent 2:10

2. Active phase of labor

• T/O to labor room for ARM and delivery

3. PROM (HVS, LVS, FBC, CRP, UFEME and Urine C+S)

• Admit ANW
• Monitor vital signs
• Strict pad charting, to inform if change in color or foul smelling
• Watch out for chorioamnionitis
• To start IV Benzylpenicillin 3g STAT and 1.5g 4 hourly if PROM >18H
• Trace all investigations taken
• If allergic to penicillin, for IV Clindamycin 900mg TDS (countersign by specialist). Other option IV
Cefazolin 1g TDS x 2/7 + T. EES 1g STAT change to T. Cephalexin 500 mg QID x 5/7 (If low risk –
pharmacy 2472), or IV Cephazolin 2g loading dose, then IV Cephazolin 1g TDS

4. PPROM (HVS, LVS, FBC, CRP, UFEME and Urine C+S)

• Admit ANW
• Monitor vital signs
• Strict pad charting, to inform if change in color or foul smelling
• Watch out for chorioamnionitis
• Start T. EES 400 mg BD x 10/7
• Start IM Dexamethasone 12 mg STAT and 12 hourly apart
• Trace all investigations taken

5. SGA with Oligohydramnios

• Admit ANW
• Monitor vital signs 4 hourly
• Strict FHR and FKC monitoring
• For BISHOP score and IOL coming morning
• Plot growth chart

6. Reduced fetal movement

• Admit ANW
• Monitor vital signs
• Time contraction
• Strict FHR and FKC monitoring

7. Hyperthyroidism in pregnancy (TFT)

• Watch out for thyroid storm
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8. Anemia in pregnancy (FBC)

• Delay or avoid episiotomy. If episiotomy done, for rapid proper repair of episiotomy wound
• For active management of 3rd stage

9. Epilepsy in Pregnancy
• Watch out for epilepsy in labor
• Watch out for bleeding tendency
• Continue patient’s regular AED in labor
• For epidural

10. Fibroids in Pregnancy

• For continuous CTG
• Watch out for scar dehiscence (previous myomectomy)
• Extended use of Iv Pitocin (12 – 24 hours post-delivery)
• For IM Ergometrine during 3rd stage of labor

11. Threatened preterm labor (HVS, LVS, urine FEME, FBC)

• Admit ANW
• Monitor vital signs
• Time contraction
• FHR and FKC monitoring
• Start IM Dexamethasone 12 mg STAT and 12 hourly apart
(reconsider with your superior if mother has GDM)
• KIV Tocolysis with _____

12. Intermediate APH (FBC, GSH)

• Admit ANW
• Monitor vital signs
• FHR and FKC monitoring
• Pad charting, to inform if increase in PV bleeding
• Active management of 3rd stage: with Duratocin

13. Vaginal Candidiasis

• Admit ANW
• Monitor vital signs
• FHR and FKC monitoring
• For Clotrimazole (Canesten) pessary 500 mg STAT

14. GDM on s/c Insulin (FBC, RP)

• Admit ANW
• Monitor vital signs
• Time contraction
• FHR and FKC monitoring
• GM OD
• For intrapartum insulin sliding scale if GM ≥ 7
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15. Gestational Hypertension (PE Profile)

• Admit ANW
• Monitor vital signs
• Time contraction
• FHR and FKC monitoring
• Watch out for IE symptoms
• Strict I/O charting
• Strictly keep DBP 90 – 100 mmHg
• To inform if BP persistently high >160/100 mmHg
• KIV for early delivery if BP persistently high

16. IOL (FBC, GSH)

• Admit ANW
• Monitor vital signs
• Time contraction
• FHR and FKC monitoring
• For BISHOP score and IOL cm with Prostin/Foley’s

17. Preterm labor (FBC/GSH, HVS, LVS, Urine FEME, Urine C+S)
• T/O Labor room for delivery
• Monitor vital signs
• Time contraction
• Start IM Dexamethasone 12 mg STAT and 12 hourly apart
• To inform Paeds to book ventilator
• Not for ARM, next review when patient complained of bearing down
• Not for tocolysis (Preterm labor/threatened labor with leaking)

18. Bleeding previa (FBC, GSH)

• T/O to LR
• CTG
• Monitor vital signs
• Time contraction
• Strict pad charting, to inform if increase PV bleed
• Start IM Dexamethasone 12 mg STAT and 12 hours apart
• To book ventilator
• KIV for LSCS if increase in contractions and PV bleed
• Keep NBM
• IV drips 2 pints NS + 2 pints D5% over 24 hours

19. GDM on diet control unlikely PROM

• Allow discharge
• Continue local clinic follow up
• For IOL at 40 weeks if still not delivered

20. Suspicious CTG

• Show CTG to MO and do ARM at PAC (Noted MSL or CL)
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21. UTI in pregnancy (HVS, LVS, UFEME, Urine C+S)

• Allow discharge
• Trace HVS, LVS, Urine FEME, Urine C&S taken
• For T. Cephalexin 500 mg TDS x 1/52
• For Ural sachet I/I TDS x 3

22. Placenta previa (major PP – Type 2 posterior and above) (GSH)

• Admit antenatal ward
• Daily CTG
• Monitor vital signs 4 hourly
• Time contraction ½ hourly. To inform if having strong contraction pain
• To book ventilator (if preterm)
• Strict pad charting, to inform if increase PV bleed
• FKC and FHR monitoring in ward
• FBC and GSH on admission. To trace FBC and inform if abnormal
• Watch out for anemic symptoms
• For TAS 2 weekly to look for placenta migration
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COMMON DISCUSSION

A. HYPERTENSION IN PREGNANCY

1. Definition
• PIH/Gestational hypertension: SBP ≥140 and/or DBP ≥90 after 20 weeks on 2 occasions at least 4
hours apart, diagnosed after 20 weeks of gestation without significant proteinuria
• Essential/Chronic hypertension is diagnosed before 20 weeks of gestation
• Preeclampsia: PIH + significant proteinuria

2. What may contribute to proteinuria besides pre-eclampsia?

• UTI
• Preexisting renal disease

3. Pathogenesis of preeclampsia
• Abnormal trophoblastic invasion
• In normal pregnancy, uterine spiral arteries undergo extensive remodeling as they are invaded by
trophoblasts: trophoblastic cells replace endothelial and muscular lining of spiral arterioles to enlarge
their diameters for better circulation to the developing fetus
• Incomplete trophoblastic invasion: myometrial portion of spiral arterioles were not adequately invaded
by trophoblasts; they retain their endothelial lining and musculoelastic tissue with narrow diameter
• Impaired placental blood flow may result inadequate perfusion leads to release of placental debris

4. What is HELLP syndrome? What classification do we used for it?

• H (Hemolysis), EL (Elevated liver enzymes), LP (Low platelets)
• Mississippi criteria

5. Late onset IUGR?

• AC affected more than HC

6. Examples of antihypertensive agents used in pregnancy

Name Mechanism Daily dose Half-life Side effects

Methyldopa α2 adrenergic receptor 250 – 1000 mg in 1.8 hours Postpartum depression,
agonist (central- 2 – 3 divided drowsiness, lupus like
acting): stimulates doses syndrome, blood
brain to decrease dyscrasias, liver
activity of sympathetic dysfunction
nervous system
Labetalol α and β adrenergic 200 – 800 mg in 4 hours Complete heart block,
receptor antagonist 2 – 3 divided pulmonary oedema,
doses bronchoconstriction

* Conventional antihypertensive medications are not used in pregnancy as those may cause IUGR,
oligohydramnios, fetal renal failure
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B. ANEMIA IN PREGNANCY

1. Definition of anemia in pregnancy according to semester

• 1st trimester: Hb <11 g/dL
• 2nd and 3rd trimester: Hb <10.5 g/dL
• Postpartum: <10 g/dL

2. Severity of anemia
• Mild: 9.5 – 10.5
• Moderate: 8.0 – 9.4
• Severe: 6.9 – 7.9
• Very severe: <6.9

3. How do you manage patient who came for antenatal checkup with persistent low Hb despite on oral iron
supplement?
• Assess whether the patient requires parenteral iron therapy or blood transfusion
• Find out the cause of persistent anemia
- Compliance issue (nausea, vomiting)
- Possible thalassemia trait: FBP, iron study, serum electrophoresis

4. Iron deficiency anemia

• Serum iron – low
• Transferrin – elevated
• Ferritin – low
• TIBC – elevated

5. What do you understand about physiological anemia in pregnancy?

• Mechanism: expansion in plasma volume is greater than the increase in red cell mass, causing
hemodilution

6. Choice of contraception postnatally for anemic patient

• Mirena: methods that have the effect of reducing menstrual blood loss
• COC is not suitable for immediate postpartum

7. Oral iron supplement

• OFMIZ

Name Iron content (mg) Side effects: nausea,

Obimin 30
vomiting,
Folic acid 60
constipation,
Maltofer 100
diarrhea, abdominal
Iberet folic 105
cramping
Zincofer 115

8. Parenteral Iron
• 2nd trimester onwards
• Adverse reactions: allergy, urticarial, chest pain, dyspnoea
• Not to be given to Thalassemia (incl Trait) patient
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9. Blood Transfusion
• Moderate to severe anemia near term
• Severe or symptomatic anemia at any gestational age

10. Complications of anemia in pregnancy

MATERNAL
a. Heart failure
b. Preterm labor
FETAL
a. IUGR
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C. DIABETES IN PREGNANCY

1. How do you instruct patient prior MOGTT?

2. Preconception counselling for DM

• Purpose: To prepare patients with pre-existing DM optimally before embarking pregnancy to reduce
risk of fetal congenital malformation and pregnancy morbidity
• Advice to lose weight if obese
• Exercise not less than 150 mins per week
• Keep blood pressure <130/80
• Keep HbA1c <6.5%
• Screen for microvascular complications: nephropathy, retinopathy
• Cardiovascular risk assessment

3. Why do we repeat MGTT at 24 – 28 weeks even when he first is normal?

• This period is the most diabetogenic period in pregnancy
• If one is tested normal for MGTT during this period, it is most likely the pregnancy will not be
associated with GDM later

4. HbA1c in pregnancy
• HbA1c reflects the blood sugar control over the past 3 months. High HbA1c during booking may
signify overt DM but cannot diagnose GDM

5. Metformin Vs Insulin
• Metformin: should be started within 1 – 2 weeks when blood glucose target is not achieved by
diet/exercise
• Insulin: when metformin is contraindicated, blood glucose target not achieved by metformin, FBS ≥7
at diagnosis, or when complications happened like macrosomic, polyhydramnios

6. What is the correlation between anemia and HbA1c in pregnancy?

• HbA1c measures the percentage of hemoglobin that are glycosylated. In anemia, the number of red
cells is reduced following dilutional effect in pregnancy, which may potentially cause a false positive
result

7. Examples of fetal anomalies associated with pre-existing DM

• CVS: Transposition of great arteries, VSD, ASD, CoA, cardiomyopathy
• GIT: duodenal atresia, anorectal atresia
• Renal: renal agenesis, ureteric abnormality
• Neurological: anencephaly, spina bifida, holoprosencephaly
• MSK: caudal regression syndrome, sacral agenesis, limb defects

8. Abnormalities in infant of diabetic mother

• RDS
• Polycythemia
• Hypoglycemia
• Hypocalcemia, hypomagnesemia
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D. HYPERTHYROIDISM IN PREGNANCY

1. Pregnancy and hyperthyroidism

Graves’ disease tends to worsen in the first trimester and improves in second and third trimesters

2. Antenatal antithyroid medication

Antithyroid medication Dose Side Teratogenic effects

effects
PTU – 1st trimester (preferred 450 mg – 600 mg x 4 Rash, Aplasia cutis, upper airway atresia,
in newly diagnosed cases, if – 6 weeks, then 50 – urticarial esophageal and other GI atresia,
patient is already on 150 mg abdominal wall defect, VSD, fetal
carbimazole prior pregnancy, hypothyroidism
resume consumption)
Carbimazole – 2nd trimester 45 – 60 mg x 4 – 6 *Fetal hyperthyroidism in case of
weeks, Graves’ disease: autoantibodies can
then 5 – 15 mg ross placenta into fetal circulation

3. Management of thyroid storm in labor

Supportive treatment – tepid sponging

Medications (START ALL MEDICATIONS SIMULTANEOUSLY)
• PTU 150 – 200 mg 6 hourly (preferred) OR Carbimazole 15 – 20 mg 6 hourly
• IV Propanolol 1 – 2 mg 4 – 6 hourly
• Oral Potassium Iodide 5 drops 6 hourly OR Oral Lugol’s iodine 5 – 10 drops 6 hourly (inhibit release
of thyroid hormones)
• IV Dexamethasone 2 mg 6 hourly OR OV Hydrocortisone 200 mg 6 hourly

4. What are your differential diagnoses when patient presented with excessive nausea and vomiting in early
pregnancy?
• Hyperemesis gravidarum
• Hyperthyroidism
• Multiple pregnancy
• Gestational trophoblastic disease

5. Definition of hyperemesis gravidarum

Triad of weight loss >5% of pre-pregnancy weight, dehydration, and electrolyte imbalance
Management:
• IV 6 pint NS/24 hours
• Pyridoxine
• Thiamine supplement
• Antiemetic: phenothiazine, H1 receptor antagonist
• Thromboprophylaxis with LMWH
• Avoid iron-containing preparation
• Monitor urine output, BUSE
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E. PLACENTA PREVIA

1. Definition of placenta previa

• After 28 weeks

2. Types of Placenta Previa

• Minor: Type 1 anterior & posterior, type 2 anterior
• Major: Type 2 posterior, Type 3, Type 4 anterior & posterior

3. USG findings of accreta?

• Thinning and loss of retroplacental hypoechoeic zone
• Interruption of the hyperechoiec border between uterine serosa and bladder
• Presence of mass-like tissue with same echogenicity to that of placenta in myometrium
• Lacunar lake sign: prominent vessels within placenta or myometrium

4. Timing of delivery
• For major PP, via LSCS at 37 weeks

F. RHESUS NEGATIVE MOTHER (AUTOSOMAL RECESSIVE)

1. Clinical significance
• The probability of the production of anti-D is high when D positive red cells are transfused to a D
negative individual.
• The anti-D antibody can cause hemolytic transfusion reaction and may lead to severe morbidity and
mortality
• Anti-D antibodies are IgG subclass which can cross the placenta and cause severe hemolytic disease of
fetus and newborn

2. What does a positive indirect Coomb’s test tell you?

• Indirect Coomb’s test measures the presence of anti-D antibody in the maternal serum
• If indirect Coomb’s test is positive, it means the mother has been sensitized
• It is done by mixing maternal serum with Rh positive RBCs. The anti-D antibody will target the Rh
positive RBSs, forming antibody-antigen complexes. Anti-human Ig (Coomb’s reagent) will then be
added into the mixture and agglutination happens

3. What is Kleihauer test?

• Kleihauer test measure the amount of fetal RBCs that have entered the maternal circulation n
• Purpose: to decide the dose of rhogam need to be given after sensitizing events like PPH

4. Potential sensitizing events

• Invasive prenatal diagnostic and in-utero therapeutic procedures
• Antepartum hemorrhage
• ECV
• Ectopic pregnancy
• Evacuation of molar pregnancy
• IUD and stillbirth
• Miscarriage & threatened miscarriage
• Therapeutic termination of pregnancy
• Delivery (SVD, instrumental, or LSCS)
• Abdominal trauma
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G. EPILEPSY IN PREGNANCY

1. Effects of the disease and treatment to the pregnancy and vice versa
• Disease to pregnancy: not so much effect
• Treatment to pregnancy: Risk of teratogenicity from AED: NTD, cardiac, facial and limb
malformations
1 AED = 4 – 8 % of fetal malformation, >1 AED = 15% of fetal malformation,

Teratogenic effects Investigation to detect/monitor Sensitivity

Neural tube defect Serum AFP in maternal blood 80% at 16 weeks
AFP in amniotic fluid >80% but reserved when ultrasound
cannot reliably exclude NTD
Ultrasound 94% at 16 to 18 weeks
Cardiac, facial, and Ultrasound 20 – 24 weeks
limb anomalies

2. Examples of AED and its teratogenic effects

Antiepileptic Drugs (AED) Teratogenic effects

Phenytoin* Cleft lip and palate, cardiac defects, craniofacial defects, digital
hypoplasia
Valproate* NTD, cardiac defects, urogenital malformations
Carbamazepine* NTD
Ethosuximide Cleft palate
Barbiturates
Vigabatrin
Lamotrigine Orofacial cleft
Topiramate Cleft lip and palate, hypospadias
Levetiracetam No increased risk, also safe for BF
*Highly teratogenic

3. Abnormal AFP level in pregnancy

• Raised AFP
- NTD: spina bifida, anencephaly
- Abnormal wall defects: gastrochisis, omphalocele
• Low AFP
- Down syndrome

H. FIBROIDS IN PREGNANCY

1. If patient presented to you with contraction pain at 33 weeks, how do you manage?
• Confirm gestational age: review history, physical examination, and ultrasound
• Counsel patient regarding risk of fetal prematurity, plan of management
• Management:
- Assess maternal and fetal wellbeing
- Identify any indication where labor should not be suppressed
- IM Dexamethasone 12 mg BD 12 hours apart (for preterm labor 24 – 36 weeks) + tocolysis

2. Treatment for red degeneration of fibroids in pregnancy

• Pain relief with ibuprofen antenatally
• May require admission
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3. Mode of delivery
• Vaginal delivery except for cervical fibroids

I. SLE AND APLS IN PREGNANCY

1. Symptoms of SLE flare

• Joint pain, skin rash, increased fatigue, fever, lupus nephritis (increasing oedema)
• Investigations: thrombocytopenia, renal impairment, raised anti-dsDNA, low complement

2. How do you differentiate PE and lupus nephritis?

Preeclampsia Lupus nephritis

• Urinalysis: proteinuria only • Urinalysis: proteinuria, urine
• Complement usually normal sediments (cellular casts)
• More prominent thrombocytopenia, • Low levels of complement +
elevated liver enzymes and uric acid increased level of anti-dsDNA

3. Examples of APL antibodies

• Anticardiolipin antibodies
• Lupus anticoagulant
• Anti-beta 2 glycoprotein 1 antibodies

4. SLE medications contraindicated in pregnancy?

• Cyclophosphamide
• Methotrexate
• Mycophenolate mofetil

5. Which type of patient you will expect a higher risk of SLE flare during pregnancy?
• Those have acute disease during six months prior pregnancy
• Those with history of lupus nephritis
• Those who discontinue hydroxychloroquine
• Primigravida

6. Explain how APLS can cause PE?

• APLS is a prothrombotic disorder which leads to thrombus formation
• Microthrombi occlude the small vessels at the placenta bed, causing placenta ischemia and release of
cellular debris which further impedes the placenta perfusion

7. Besides APLS, what are the other causes of recurrent miscarriages?

Cause First trimester loss Second trimester loss

Genetic factor: aneuploidy √ √
Immunological cause: √ √
APLS
Anatomical cause:
Uterine abnormality √ √
Cervical insufficiency √
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8. How do you manage SLE vs APLS antenatally?

SLE APLS
• Aspirin from 12 weeks to reduce risk of PE • Preferred treatment: combination of heparin +
aspirin → reduces pregnancy loss by 54%
• Medication during pregnancy
• In women with multiple episodes of thrombotic
1. Continued in pregnancy: events, they are considered high risk group and
hydroxychloroquine, low dose aspirin may necessitate the use of warfarin starting from
from 12 weeks as prophylaxis for second trimester, or even in all trimesters →
preeclampsia teratogenic effects of warfarin should be clearly
2. Used if needed: NSAID, prednisolone, explained (1 – 2 % teratogenicity in 1st trimester,
azathioprine, cyclosporine, tacrolimus, later complications include ongoing risk of fetal
antihypertensives loss, hemorrhage)
3. Used with cautious: biological agents
4. Contraindicated: cyclophosphamide, • Management of acute thrombosis: LMWH
mycophenolate, mofetil, methotrexate,
leflunomide • Regular frequent follow up: fetal growth
assessment at least monthly from 20 weeks,
• Treatment of acute flare, depends on which organ uterine artery Doppler at 18 – 22 weeks to predict
system is involved poor outcome, serial umbilical artery Doppler 2-
4 weekly after 24 – 26 weeks

J. MULTIPLE PREGNANCY

1. Timing and mode of delivery for twin pregnancy

• Uncomplicated monochorionic: 36 – 37 weeks by CS due to risk of cord prolapse

• Complicated monochorionic: delivery by 34 weeks
• Dichorionic: 37 – 38 weeks, can allow SVD

*But in case the woman has one previous scar, CS is recommended as there is a risk of scar dehiscence
during ECV/IPV for second twin

2. How do you know the heart sounds are from 2 different fetuses?

• Difference in FHR for at least 10 bpm suggests two distinct fetal heart rates

3. Types of twins and pathogenesis

• Mnemonic: MorBID
- Morula: 1 – 3 days (DCDA twin)
- Blastocyst: 4 – 8 days (MCDA twin)
- Implanted blastocyst: 9 – 12 days (MCMA twin)
- Embryonic Disc: 13 and beyond (conjoined twin)

4. How does TTTS happen?

• TTTS only occurs in monochorionic twins

• It is a result of blood shunting from one twin (donor) to another twin (recipient) through vascular
anastomosis, most commonly artery-to-vein anastomosis in the shared placenta bed
• The donor twin manifests as oligohydramnios while the recipient twin developed polyhydramnios.
Both twins are at risk of hydrops fetalis
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5. What is the treatment for TTTS?

• Laser ablation of vascular connections