Obstetric Protocols (supplementary)-Downloaded on 27-02-2009 from OG departmental website, obtained during IV

rotation OG 2008/2009

-Similar arrangement to previous version

-A Reminder from Prof. Tam: Materials included are only meant for reference, and

may be idiosyncratic and not the ideal management

-Some references and citations were re-included

-Prepared by medic 2010 Rashid Lui (I deleted all the parts that were redundant, but if

you find anything missing or you want all the original downloads, feel free to find

me.)

Table of Contents

APH............................................................2

Preterm labour...............................................3

Maternal medicine..........................................8

Fetal medicine.............................................34

Labour.......................................................38

Drugs........................................................43

Misc..........................................................55

CUHK medic 2010 1

APH

APH of unknown origin Updated:7/14/2008

Diagnosis and Management of Antepartum Haemorrhage of Unknown Origin

Rule out other causes: placenta praevia, abruptio placentae, genital tract lesions

Document the amount of bleeding by history and speculum examination.

Perform CTG if >= 26 weeks.

Consider induction of labour or caesarean delivery if CTG is abnormal.

If gestation < 34 weeks of gestation:

o Perform TVS cervical length assessment, and give corticosteroid if cevical

length <15mm, or manage as a case of threatened / preterm labour when

there are uterine contractions.

Discharge if no more vaginal bleeding or abdominal pain for 2 days.

Remark:

o No need for routine weekly CTG assessment or induction of labour in cases

with history of APH of unknown origin.

CUHK medic 2010 2

Preterm labour

TVS cervical length

Updated:7/14/2008

Indications

To assess the immediate risk of preterm delivery when patients present with

symptoms of threatened preterm labour

To predict, in long term, the chance of preterm delivery in asymptomatic patients

present at antenatal clinic at 20-24 weeks of gestation

Method of assessment

Patient must empty bladder before scan

Use 5-MHz transvaginal transducer

Put TVS probe 3 cm proximal to the cervix to avoid any cervical distortion of its

position or shape

Obtain a good sagittal view of the cervix, with the echogenic endocervical mucosa

along the length of the canal

Magnify the view as much as possible

Measure the length of the straight line between the internal os and the external os

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Interpretation of Result

For cases present with threatened preterm labour:

o a positive result (cervical length <15mm) indicates indicates 37% chance of

delivery within 7 days and hence corticosteroid and tocolytic may be

indicated

o a negatiave result indicates 99% chance that delivery would not occur within

7 days and hence corticosteroid and tocolytic are not necessary

References

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

cervical length in threatened preterm labor. Ultrasound Obstet Gynecol. 2003

Jun;21(6):552-5.

Cervicovaginal fibronectin test Updated:7/14/2008

Introduction

Fetal fibronectin (fFN) is an extracellular matrix protein found in the decidua basalis

next to the placental intervillous space. It acts like a ‘glue’ attaching the fetal

membranes to the uterine decidua.

Mechanical or inflammatory mediated damage to the placenta or membranes may

result in its release into the cervico-vaginal fluid.

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

the end of term pregnancy; however, it is not normally present from 22 to 37 weeks,

and hence its presence is associated with an increased risk of preterm birth.

Indication of cervico-vaginal fibronectin test

To assess the immediate risk of preterm delivery when patients present with

symptoms of threatened preterm labour

Method of assessment

The test must be done before any digital examination of the vagina and cervix

After insertion of speculum into the vagina, a Dacron polyester swab is put into the

posterior vaginal fornix, and roll across to absorb fluid

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The Dacron swab is then inserted into a collection tube for bedside monoclonal

antibody assay (available in Ward 7E)

Remark: blood and amniotic fluid in the vagina will give false positive result and

hence the test should not be done in case of APH or ROM

Interpretation of Result

For cases present with threatened preterm labour:

o a positive result (fibronectin level >=50ng/ml) indicates 24% chance of

delivery within 7 days and hence corticosteroid and tocolytic may be

indicated

o a negatiave result indicates 98% chance that delivery would not occur within

7 days and hence corticosteroid and tocolytic are not necessary

References

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

cervical length and fetal fibronectin testing in threatened preterm labor. Ultrasound

Obstet Gynecol. 2006 Apr;27(4):368-72.

Preterm labour

Updated:7/14/2008

Definition of preterm labour

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

Onset of labour can be diagnosed when there are the cervix started to dilate or has

totally effaced, associated with regular painful uterine contractions

Onset of labour is suspected (threatened preterm labour) when there are uterine

contractions plus one of more of the following:

o Show of mucus

o rupture of membranes

o shortening of cervical length as measured by transvaginal scan

o cervicovaginal fibronectin test is positive

Initial assessment

Inform on-call Medical Officer

Ascertain gestation

Look for causes of preterm labour eg.

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o Abruptio placentae or APH

o Chorioamnionitis (check for rupture of memrbanes and take HVS)

o Urinary tract infection (check MSU)

o Polyhydramnios

o Multiple pregnancy or fetal anomalies

Depending on the gestation and clinical presentation, TVS cervical length,

cervicovaginal fibronectin test result, decide the use of corticosteroid, tocolytic agent,

time and mode of delivery with Mid-1 or above

Management of threatened / preterm labour before 34 weeks

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

To labour ward, NPO, X-match, iv access

Continous fetal monitoring when gestation >= 26 week

Invite Neonatalogists to counsel the patient

Give corticosteroid and tocolytic agent in the following conditions:

o preterm labour (cevix is dilated or effaced)

o threatened preterm labour with cervical length <15mm, or +ve cervicovaginal

fibronectin test

Withhold corticosteroid and tocolytic agent if the above conditions are not fulfilled.

However, when uterine contractions persist, reassess TVS cervical length to make

decision accordingly.

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

clinical situation

Management of preterm after 34 weeks

Allow delivery and manage as for term pregnancy

No need for corticosteroid or tocolytic agent,

Management of threatened / preterm labour with special conditions

Extreme prematuirty less than 26 weeks

Discuss with patient:

o Prognosis (together with Neonatalogists)

o Different modes of fetal monitoring (continuous vs intermittent ascultation)

o Different modes of delivery (classical CS and vaginal delivery) in case of fetal

malpresentation and fetal distress

Antepartum Haemorrhage

Rule out abruption which requires immediate delivery

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Tocolytic agent s may be used to suppress labour in mild case of APH. Atosiban is the

preferred choice.

Prolonged rupture of membranes

Labour that starts after prolonged ROM may be a result of evolving chorioamnionitis.

Use of tocolytic agents to suppress labour should only be considered with strong

indications (e.g. extreme prematurity, for completion of corticosteroid), and should be

decided by specialists

Drugs for the mothers

Entonox for labour pain relief

Pethidine for labour pain relief

syntometrine or syntocinon iv or im injection for management in the third stage of

labour.

Sodium citrate

o Purpose:

premedication prior to emergency caesarean section

o Regimen:

30ml of 0.3M po once

Panadol

o Purpose:

for post-delivery pain relief

o Regimen:

500mg po QID prn

Potassium permaganate (KMnO4), Zinc oxide, hirudoid, sitz bath

o Purpose:

for local treatment of perineal wound

o Regimen:

local application bd

Drugs for the newborns

Vitamin K 1 for routine prophylaxis against neonatal haemorrhagic disease.

Naloxone (Narcan) for treatment of neonatal respiratory depression as antidote to

maternal narcotic effect.

Hepatitis B immunoglobin (hyperhep) to reduce the risk of vertical transmission of

hepatitis B.

Hepatitis B vaccine, polop and BCG vaccine

o Purpose:

for routine newborn immunization

o Regimen:

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hepatitis B vaccine 0.5ml imi

polio 0.25ml po

BCG vaccine

Zinc oxide, Drapolene cream, Penatan cream. For treatment and prevention of nappy

rash, Apply cream after every nappy change. Drapolene: contain benzalkonium

chloride 0.01% and cetrimide 0.2% in a water miscible base

Maternal medicine

Ovarian cyst

Updated:11/10/2004

Antenatal management

Perform USG to assess the size and characteristics of the cyst

Look for any symptoms related to complications of the cysts

Confirm gestation

Management will depend on the nature of the cysts, presence of any symptoms and

gestation as stated below.

Simple unilocular ovarian cysts

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

o Most likely physiological cyst that will resolve spontaneously by 16 weeks.

o Adopt conservative management during antenatal course unless the patient

develops complication.

Before 16 weeks of gestation and size > 6cm:

o Unlikely to be physiological cyst.

o Counsel patient on the pros and cons of operation on ovarian cysts during

pregnancy.

o Surgery should be preferably performed at around 14 weeks of gestation

unless complication arises, earlier if the cyst is larger.

o Contact endoscopy team for arrangement of operation.

Between 16 - 20 weeks of gestation:

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o Unlikely to be physiological cyst.

o Counsel patient on the pros and cons of operation on ovarian cysts during

pregnancy.

o Contact endoscopy team for arrangement of operation.

After 20 weeks of gestation:

o Unlikely to be physiological cyst.

o Adopt conservative management during antenatal course unless the patient

has symptoms.

Ovarian cysts with ultrasonic features of benign pathological cysts

Before 20 weeks of gestation:

o Counsel patient on the pros and cons of operation on ovarian cysts during

pregnancy.

o Surgery should preferably be performed around 14 weeks unless

complication arises, earlier if the cyst is larger.

o Contact endoscopy team for arrangement of operation.

After 20 weeks of gestation:

o Adopt conservative management during antenatal course unless the patient

develops complication.

Ovarian cysts with ultrasonic features suggestive of malignancy

Contact oncology team for assessment.

Intrapartum management

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

section.

However, operation on ovarian cysts can be performed opportunistically during

caesarean section.

Acute complications during pregnancy

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

haemorrhage, arrange surgical treatment.

No indication of Caeserean delivery at the same time unless:

o there is other obstetric indication, or

o the gravid uterus causes surgical difficulty (should be decided by Mid-call 2).

Postnatal management

For ovarian cysts in which conservative management is adopted during antenatal

period:

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o Arrange an ultrasound examination of pelvis at radiology department to be

performed 3 months after delivery.

o Arrange a follow-up appointment at Pelvic Mass Clinic in the cluster at 4

months after delivery to review the report of ultrasound examination. (Need to

state the reason of the arrangement of a gynaecology follow-up on the

inpatient record)

For patients with ovarian cysts removed at caesarean section:

o Arrange a routine follow-up appointment at general gynaecology clinic in the

cluster for review of pathology report. (Please state the reason for gynaecology

follow-up on the in-patient record).

o

Fibroid

Updated:5/23/2005

Antenatal management

Counsel the patient:

o It is a bengin lesion and would not cause any risk to the mother and the fetus

in most of the cases

o Small chance of red degeneration that may lead to abdominal pain

o May cause fetal malpresentation if the fibroid is situated at the lower pole of

the uterus

No need to arrange serial ultrasound examination routinely throughout the antenatal

period, unless there is difficulty in monitoring fetal growth by fundal height

measurement.

For fibroid locating at the lower pole of the uterus, arrange follow-up at 37 weeks of

gestation (+/- USG) to assess the fetal presentation and engagement and decide

mode of delivery:

Allow vaginal delivery unless the uterine fibroid is situating at the lower segment AND

affect engagment of fetal head or cause malpresentation.

Intrapartum management

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

the same time.

After delivery, no need for routine prophylactic syntocinon infusion unless the uterine

fibroid larger than 5 cm. Give syntocinon infusion (40 units in 500 ml of cystalloid

solution over 4 hours) if it is required.

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Postnatal follow up

For patients who are asymptomatic before the pregnancy (no menorrhagia or

pressure symptoms):

o It is not necessary to give gynaecology follow-up after delivery

o Advise patient to seek medical advice when she has symptoms

For patients who has symptoms before the pregnancy:

o Arrange a follow-up appointment at Pelvic Mass Clinic in 6 months with

pictorial chart given to patient to document the menstrual pattern

o It may be necessary to postpone the follow-up appointment if the patient

would have long period of breast feeding and remains amenorrhoea.

Bacterial vaginosis Updated:7/14/2008

Diagnostic Test

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

normal vaginal flora

intermediate

indicative of bacterial vaginosis

Indications of Treatment

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

o For symptomatic relief, or

o For asymptomatic pregnant woman before 20 weeks of gestation

risk of preterm delivery significantly reduced if treated before 20

weeks but not after 20 weeks

Routine treatment of sex partners is not necessary

Treatment regimen

Clindamycin 300 mg bd po * 7 days; or

Metronidazole 400 mg tds po * 7 days:

o Metronidazole can be used throughout pregnancy as multiple studies and

meta-analyses have not demonstrated an association between metronidazole

use during pregnancy and teratogenic or mutagenic effects in newborns

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o Advise against drinking alcohol during metronidazole treatment and up to 24

hours afterwards

Screening

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

Discussion / Justification

Risk of preterm delivery before 37 weeks significantly reduced RR 0.63 (95% CI: 0.48 – 0.84)

if patients who have bacterial vaginosis receive treatment before 20 weeks. However, studies

do not show any benefits when treatment is started after 20 weeks

Haematuria

Updated:5/7/2001

Routine antenatal screening

Urine hemostix for all NEW obstetric cases

If positive, perform urine culture to exclude infection

If persistent haematuria (haematuria persists in two visits):

Refer to renal physician with special referral form

Perform

o urine cytology,

o RFT and

o 24 hour urine for protein and creatinine clearance.

If all other investigations are normal, patient can have routine AN care.

If the renal function is abnormal, refer to Medical OBS.

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

Sample of referral letter:

o I would like to refer the above lady for your further assessment whom we

detected persistent microscopic hematuria during antenatal check-up.

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o She is now _______________ weeks pregnant. Her EDC is

___________________

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Cardiac arrest Updated:5/7/2001

Cardiopulmonary resuscitation for cardiac arrest in obstetric patients

Nursing staff start cardiopulmonary resuscitation before doctors arrive, and mark the

time of all events:

1st nurse

Secure airway

Apply Ambu bag with 100% O2

2nd nurse

Call Junior obs and gynae on call M.O.s and midcall 1 using emergency code

9996/7/8/9

Call resuscitation team 2468

Call labour ward

Display uterus to left side by:

o Putting the wooden board underneath the patient"s back

o wedging the board to tilt the patient to left lateral position at about 30 degrees

Apply ECG electrodes to the chest

Perform external cardiac massage

3rd nurse or nursing Officer

Deploy nurses from other wards.

Assist in resuscitation +/- Perimortem Caesarean section

Other labour ward nurses

Inform paediatrician, NNU

Inform house officers, midcall 2 and consultant

Inform anaesthetist on call

Assist MO in the perimortem Caesarean section

Assist resuscitation of the baby

Prepare Caesarean section set for suturing

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

1st Medical officer who arrives

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Enquire the duration of cardiac arrest from nursing staff

Check the patient"s carotid pulse and ECG tracing when nurse withholds cardiac

massage

Decide to proceed with perimortem Caesarean section if the duration of cardiac arrest

is greater than 4 minutes without response to CPR

Instruct the nurse to stop cardiac massage during perimortem Caesarean section

2nd doctor (medical officer or intern) who arrives

Establish IV line

Prepare for defibrillation in case of Ventricular fibrillation (300 J from the start)

Mid-call doctors

Assist in the CPR or the rest of the caesarean section

Decision on Perimortem Caesarean section

Avoid undue delay

Aim to deliver within 4 minutes of cardiac arrest which will optimise neonatal outcome

and facilitate maternal CPR

Liaise with anaesthetist for ICU transfer if resuscitation is successful and after

completion of Perimortem Caesarean section

Perimortem CS

Updated:5/7/2001

Indication

Obstetric patients with sudden cardiac arrest

Procedure

Put on the gloves and mask

Skip unnecessary steps: scrubbing, draping of operation site, bladder catheterization

Antiseptic is not required

Midline subumbilical incision and classical Caesarean section

Antibiotic cover with 1.2 gram IV Augmentin if patient responded to resuscitation

Close the wound

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DM-antenatal managementUpdated:10/11/2007

Initial management of pre-existing IGT/DM

In patient management is preferred

Early admission to start diet control and h’stix monitoring

Stop any oral hypoglycaemic drug and change to insulin

Check HbA1c and investigate for diabetic complications

Arrange morphology scan at second trimester

Refer to ophthalmologist for retinal assessment

Initial management of newly diagnosed GDM

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

Outpatient management is preferred for most GDM

Refer DM education class to see dietitian for DM diet and DM education

Start outpatient H’stix monitoring

Follow up in Thursday medical obstetric clinic

Routine growth scan is not necessary

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

Early admission to start diet control and h’stix monitoring

Check HbA1c and investigate for diabetic complications

Fetal growth scan

Start insulin as indicated

Diet control:

Pregnancy 1st trimester 2nd trimester

singleton 1500kcal/day 1800kcal/day

multiple 1500kcal/day 2000kcal/day

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Reference for glycaemic control

H'stix Normal Borderline Abnormal

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

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

Subsequent Outpatient management for DM/GDM

GDM/DM on diet control

H'stix monitoring one to two days per week (4 times/day: Fasting, PB, PL, PS)

Check compliance and revise dietary plan if glycaemic control is borderline

Admit to consider insulin if glycaemic control is persistently borderline or abnormal

Uncomplicated GDM not requiring insulin can be followed up by midwives diabetic

clinic (MCDM) on Thursday morning

GDM/DM on insulin

H'stix monitoring two to five days per week (4 times/day: Fasting, PB, PL, PS)

Adjust insulin dosage if persistently borderline or abnormal glycaemic control

Admit if glycaemic control is difficult

Growth scan every 4 weeks

CTG weekly from 36 weeks for GDM/DM on insulin

Indications for blood sugar series

Routine blood sugar series is not necessary for all GDM cases

Blood sugar series would be used as a reference for the commencement of insulin,

the final insulin dosage for individual cases and when the h’stix result is in doubt

Timing of delivery

GDM on diet with good control: await spontaneous labour and induction at 41 weeks

gestation

GDM requiring insulin or pre-existing DM/IGT with normal H'sitx: consider induction at

40 weeks

GDM or pre-existing DM/IGT with poor glycaemic control and/or any complication:

consider induction at 38 weeks or earlier if indicated

Mode of delivery

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Discuss elective caesarean delivery if the EFW > 4 kg

Take precaution of shoulder dystocia if mother with a macrosomic fetus (AC > 97

centile) undergoes vaginal delivery:

Doctor standby at fetal head delivery

Mid-call doctor assess before instrumental delivery

Measurement of blood pressure in pregnancy

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

labour)

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

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

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

from those using mercury sphygmomanometry in pregnancy

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

sphygomanometer at the time of diagnosis

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

using mercury sphygmomanometer

References:

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

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

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

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

A, March 2006.

Diagnostic Criteria

Diagnostic criteria for hypertension in pregnancy

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

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

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Diagnostic criteria for significant proteinuria in pregnancy

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

diagnosis of significant proteinuria unless the clinical urgency dictates immediate

delivery)

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

proteinuria / 24 hours can be used as an alternative

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

by 24 hour urine or spot urine protein to creatinine ratio

Urinary tract infection should be excluded by MSU

References:

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

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

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

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

the NHLBI Working Group on Research on Hypertension During Pregnancy.

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

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

A, March 2006.

Classification

Classification of hypertensive disorder in pregnancy

Gestational hypertension

o De novo hypertension without proteinuria onset after 20 weeks gestation

Pre-eclampsia/eclampsia

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

proteinuria after 20 weeks

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

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

diagnosis of pre-eclampsia should be considered

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

Chronic hypertension

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

Essential hypertension: hypertension without an apparent cause

Secondary hypertension: hypertension associated with renal,

renovascular and endocrine disorders and aortic coarctation.

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

be re-classified as chronic hypertension

Pre-eclampsia superimposed on chronic hypertension

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

hypertension

De novo proteinuria occurs after 20 weeks gestation

A sudden increase in the magnitude of hypertension or sudden increase

in proteinuria in women who have proteinuria early in gestation

Appearance of thrombocytopenia <100, and /or raised ALT

N.B. ‘White-coat’ hypertension

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

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

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

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

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

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References:

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

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

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

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

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

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

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

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

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

Severe pre-eclampsia

Diagnostic criteria of severe pre-eclampsia

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

with significant proteinuria, or

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

impending eclampsia, such as

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

papilloedema

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

(ALT > 70)

o Haematological: thrombocytopenia < 100, disseminated intravascular coagulation;

haemolysis

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

an indication of earlier delivery

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

o Fetal growth restriction or features of utero-placental insufficiency

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

is indicated for the prophylaxis of eclampsia

Early onset pre-eclampsia

Pre-eclampsia with onset 34 weeks

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

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

resulted in preterm delivery

References:

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

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

trial. Lancet 2002;359:1877-90.

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

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

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

A, March 2006.

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Peripartum management of Pre-eclampsia

General management in pre-eclampsia

Manage patient in the labour ward

NPO

IV fluid: Hartmann solution at 80 ml/hr

Use infusion pump for syntocinon infusion and adjust maintenance fluid accordingly

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

Monitor BP/P every 15 minutes

Monitor hourly urine output

Continuous fetal heart monitoring

Advise on epidural anaesthesia for pain relief if no contraindication

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

Special management in severe pre-eclampsia

MgSO4

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

delivery

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

into 20 ml)

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

saline into 50 ml)

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

o Monitoring while on MgSO4

Hourly urine output

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

on regional anaesthesia)

Check respiratory rate hourly

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Continuous SaO2

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

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

impairment

o Caution

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

neuromuscular disease or respiratory depression

Antihypertensive

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

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

syndrome

o IV Labetalol

First line for intrapartum BP control

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

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

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

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

Stop labetalol if maternal heart rate falls below 70/min

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

o IVI Hydralazine

Second line for intrapartum BP control if labetalol fails or is

contraindicated

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

(maximum cumulative bolus dose: 20 mg)

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

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

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

mg/hr)

Consider other alternative antihypertensive if hydrallazine fails to control

CUHK medic 2010 24

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

Caution: Maternal hypotension may occur with bolus or infusion regimen

o Oral nifedipine

Nifedipine should only be given as oral and preferably used in

postpartum

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

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

maintenance in postpartum

o Oral labetalol

Start at 200 mg bd for BP control in postpartum

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

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

fluid overload

o Stop MgSO4

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

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

fluid replacement

Management of magnesium toxicity

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

may be symptoms and signs of toxicity

Absence of deep tendon reflexes

o Stop MgSO4

o Check for respiratory depression

o Continue cardiac monitoring

o Check urgent serum Mg level

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

Respiratory depression (respiratory rate < 10/min)

o Stop MgSO4

o Give O2 via mask to maintain SaO2 > 95%

CUHK medic 2010 25

o Continue cardiac monitoring

o Check urgent serum Mg level

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

o Consult anaesthetist for the need of respiratory support

Serum Mg level and toxcity

Serum level (mmol/l)

Normal pregnancy 1

Therapeutic 2-4

Loss of patellar reflex 5

Prolonged AV conduction 6

Respiratory failure 7.5

Cardiac arrest 12

References

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

A, March 2006.

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

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

RCOG Press; 2003 p.133-147.

Management for eclampsia

General measure

o Call for help

o Lie patient in left lateral position

o Maintain airway and give 100% O2

o Documentation of the event and duration of convulsion

Anti-convulsant

o Diazepam is used to terminate any ongoing convulsion

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

o MgSO4 is used to prevent further recurrent convulsion

CUHK medic 2010 26

If eclampsia occurs before commencement of MgSO4, start loading dose

infusion over 5 min

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

over 5 min

If eclampsia occurs during MgSO4 maintenance infusion, additional 2

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

into 10 ml) given over 5 minutes

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

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

bolus has been given

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

Reference

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

A, March 2006.

CUHK medic 2010 27

Postpartum management for pre-eclampsia

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

Oral antihypertensive can be used as to control BP if indicated

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

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

o Consult physician for refractory case

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

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

follow up.

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

proteinuria by urine albustix

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

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

postnatal follow up

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

syndrome

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

Flow chart for management of eclampsia

CUHK medic 2010 28

CUHK medic 2010 29

Antibiotic for heart diseases Updated: 2007

Intrapartum antibiotic prophylaxis is indicated in:

Prosthetic cardiac valve

Previous infective endocarditis

Congenital heart disease (CHD) limited to the following conditions:

o Unrepaired cyanotic CHD, including palliative shunts and conduits

o Completely repaired congenital heart defect with prosthetic material or

device, whether placed by surgery or by catheter intervention, during the

first 6 months after the procedure

o Repaired CHD with residual defects at the site or adjacent to the site of a

prosthetic patch or prosthetic device (which inhibit endothelialization)

Cardiac transplantation recipients who develop cardiac valvulopathy

Antibiotic Regimen

No allergy Allergy to ampicillin

At onset of labour/ rupture of

membranes Ampicillin 2.0g ivi Vancomycin 1.0g iv infusion

Intrapartum Ampicillin 500mg ivi Q6H Vancomycin 1.0g iv infusion Q12H

Postpartum Not required Not required

Remarks

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

section is very low so that antibiotic cover is not indicated for the above cardiac

conditions

Vancomycin infusion guideline

o reconstitute in 20 ml water, and dilute with 200 ml NS

o infuse over at least 100 min

Consult physician

o for the vancomycin dosage in case of severe renal impairment

o for opinion if patient allergic to both ampicillin and vancomycin

Discussion / Justification AHA has reviewed the topic and updated the guideline on antibiotic

prophylaxis in May 2007. Reference: AHA Prevention of Infective Endocarditis. A guideline

from the American Heart Association Rheumatic fever, endocarditis, and Kawasaki disease

committee, council on cardiovascular disease in the young, and the council on clinical

cardiology, council on cardiovascular surgery and anesthesia, and the quality of care and

outcomes research interdisciplinary working group. Circulation. published online, Apr 19,

CUHK medic 2010 30

2007.

Management of acute VTE

General management

VTE should be suspected in women at risk

ECG abnormalities are frequently transient and the commonest abnormality is sinus

tachycardia

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

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

could be unreliable

Perform USG Doppler lower limbs in suspected DVT

Perform spiral CT in suspected PE

Perform USG Doppler lower limbs if PE confirmed

Spiral CT has higher sensitivity & specificity and lower radiation to the fetus than V/Q

scan, but it increases the life time risk of breast cancer

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

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

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

A positive test is not useful in the diagnosis, only a negative test can make the

diagnosis of VTE less likely

Thrombophilia screening

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

while Protein C, protein S, antithrombin III when anticoagulant has been stopped

for at least 2 wk and at least 6 weeks postpartum

Initial treatment of DVT

Both above knee or below knee DVT require anticoagulant treatment

Encourage mobilisation with graduated elastic compression stockings

CUHK medic 2010 31

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

Start therapeutic dose of LMWH

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

Use the nearest dose as charted:

Early pregnancy weight Initial dose of SC enoxaparin

< 50 kg 40 mg Q12 hr

50 - 69 kg 60 mg Q12 hr

70 - 89 kg 80 mg Q12 hr

90 kg 100 mg Q12 hr

Routine anti-Xa level and platelet count monitoring while on LMWH treatment is not required

except in

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

renal impairment

recurrence on treatment

For antenatal above knee DVT

Arrange USG Doppler of lower limbs at 2-4 weeks after the initial treatment to assess

interval changes and repeat later if indicated

Initial treatment of PE

Mild PE Therapeutic dose of LMWH as for DVT

Severe PE Consult physician or cardiologist for the need of IVI heparin

Massive PE Consult ICU and cardiothoracic surgeon for the need of embolectomy

Anticoagulant regimen and duration

Antenatal VTE

Anticoagulation should be continued throughout pregnancy till at least 6 weeks

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

Postnatal VTE

CUHK medic 2010 32

Start warfarin 2 days after delivery if there is no excessive bleeding and stop

enoxaparin when INR reach the target range

Severe/ massive PE

Regimen as decided by physician or cardiologist

Intrapartum management

Spontaneous labour or ROM

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

admit for assessment

Withhold enoxaparin during labour till delivery

Elective induction

Stop enoxaparin 1 day prior to induction

Elective CS

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

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

Anaesthetic plan & regional analgesia/anaesthesia

Consult anaesthetist regarding to regional analgesia or anaesthesia during labour and

caesarean section

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

enoxaparin

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

Enoxaparin should not be given for at least 4 hours after the epidural catheter has been

removed (or at least 6 hours if procedure has been traumatic)

Postpartum management

Vaginal delivery

Resume therapeutic enoxaparin after delivery if there is no excessive bleeding

CUHK medic 2010 33

Early mobilisation with graduated elastic compression stockings

CS

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

excessive bleeding

Resume to full therapeutic enoxaparin by 12 hours later

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

Duration of anticoagulant:

Below knee DVT: continue till 6 weeks postnatal

Above knee DVT or PE: continue for at least 6 weeks postnatal and until at least 3

months of anticoagulant therapy has been completed

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

and anti-thrombin III) at least 6 weeks postpartum and when anticoagulant has been

stopped for at least 4 wk

All patients with above knee DVT or PE should be referred to physician for long term follow up

Breast feeding is not contraindicated for either warfarin or LMWH use

Patient should be counseled to avoid COC pills

Reference

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

Guideline No. 28 (2nd ed) 2007.

CUHK medic 2010 34

Fetal medicine

Choroid plexus cyst Updated:11/20/2008

Definition

Cyst in choroid plexus >=5mm in diameter

Clinical significance

Present in 1 – 3 % of normal fetuses

Usually resolve by 24 weeks

Although it is regarded as one of the soft markers for fetal aneuploidies, isolated

choroid plexus cyst does not increase the risk of fetal aneuploidies

Clinical management

If other structural abnormality is not detected and morphology scan is complete and

normal, no need to report

If other structural abnormality is not detected but morphology scan is incomplete,

arrange repeat scan in 1 – 2 weeks to complete morphology scan (USGP or USGM)

If other structural abnormality is detected : refer patient to Fetal Medicine Team for

further management (USG9 appointment in W7EA session)

References

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

choroid plexus cysts in an unselected population: results of a multicenter study.

Ultrasound Obstet Gynaecol 1998; 12: 391-7.

RC Reinsch. Choroid plexus cysts-association with trisomy: Prospective review of

16,059 patients. AJOG 1997; 176: 1381-3.

JK Gupta, M Cave, RJ Lilford, TA Farrell, HC Irving, G Mason, CM Hau. Clinical

significance of fetal choroid plexus cyst. Lancet 1995; 346: 724-9.

CUHK medic 2010 35

Soft marker - provisional

Updated:11/20/2008

Second Trimester Sonographic Soft Markers for Trisomy 21

Strong markers

Nasal hypoplasia

Measure nasal bone in mid sagittal plane of facial profile

=< 2.5 mm

Nuchal edema

Measure nuchal fold in an angled transverse plane including cavum septum

pellucidum, cerebral peduncles and cerbellar hemisphere, from outer skin line to

outer occipital bone line

>= 6 mm

Echogenic bowel

Echogenicity of bowel as echogenic as adjacent iliac crest bone and does not fade

out before the adjacent iliac crest bone upon reducing the gain

Weak markers

Short humerus

Humerus length < 2.5th percentile (-2SD)

Short femur

Femur length < 2.5th percentile (-2SD)

Markers with disputed association with aneuploidies

Echogenic intracardiac focus

Echogenic spot in ventricle as echogenic as adjacent rib bone and does not fade out

before the adjacent rib bone upon reducing the gain

Pyelectasis

Measure anteroposterior width of renal pelvis in transverse plane from inner margin to

inner margin of the pelvis

>= 4 mm

Markers that need to be dealt with in their own right

CUHK medic 2010 36

Nuchal edema

Pyelectasis

Echogenic bowel

Short humerus

Short femur

Management of soft markers on mid trimester scan

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

If any one of the strong markers is detected, refer patient to Fetal Medicine Team for

further management (USG9 appointment in W7EA session)

Isolated weak marker or isolated marker with disputed association with aneuploidy

(Short humerus, Short femur, Echogenic intracardiac focus, Pyelectasis)

If strong marker is not detected and morphology scan is complete and normal, no

need to report the presence of a soft marker. But if the marker needs to be dealt with

in its own right, manage according to the individual marker concerned as stipulated in

3.

If strong marker is not detected but morphology scan is incomplete, arrange repeat

scan in 1 – 2 weeks to complete morphology scan (USGP or USGM)

If any one of the strong markers is detected, refer patient to Fetal Medicine Team for

further management (USG9 appointment in W7EA session)

Markers that need to be dealt with in their own right

Pyelectasis

Mild pyelectasis (AP width 4 – 7 mm)

o Book follow up scan (USGA) at 28 – 34 weeks

o Consult Paediatrician after delivery

Hydronephrosis (AP width >= 8 mm)

o Refer patient to Fetal Medicine Team for further management (USG9)

Short humerus / Short femur

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

session)

Anti-D Immunoglobulin Updated:10/31/2002

CUHK medic 2010 37

Indications

For prophylaxis for non-sensitized Rhesus D negative mothers.

Timing of administration

See Rhesus D negative

Regimen

For all gestations and all sensitizing events:

250ug (1250iu) imi

should be given as soon as possible after the event and always within 72 hours.

Beyond that, anti-D Ig should still be given within 10 days of the event

no need for routine Kleihauer test after a sensitizing event

no need to repeat anti-D Ig injection if it has been given within prior 4 weeks for

another sensitizing event.

CUHK medic 2010 38

Labour

Third stage of labour

Updated:10/29/2008

Routine management of third stage of labour

Give oxytocic agent prophylaxis on delivery of baby

For low risk cases:

o syntometrine im 1 ampoule im (will not be available by the end of 2008)

o syntocinon when syntometrine is contraindicated or unavailable

5 units iv bolus over 1-2 minutes

May need to give slower injection over at least 5 minutes if

patient has cardiac disease or particularly at risk of

hypotension

10 units im is an alternative to iv, when iv access is not available

For high risk cases such as parity >=4, mulitple pregnancy, co-existing fibroids,

polyhydramnios, placenta praevia, abruptio placentae:

o syntocinon infusion 40 units in 500ml crystalloid Q4H, or

o Carbetoicin 100mcg im

Deliver the placenta:

o Attempt controlled cord traction when there is signs of separation:

lengthening of cord

gush of blood

contracted uterus with rising of its fundus to umbilical level

o Empty urinary bladder if placenta is separated but retained.

o Do not apply fundal pressure and cord traction at the same time as uterine

inversion may occur.

o Examine placenta for completeness and any abnormalities.

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

haemorrhage.

Take cord blood for blood gas assay (arterial and venous), thyroid function and

G6PD.

Give newborns injection:

CUHK medic 2010 39

o vitamin K 1 to all newborns.

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

mother.

Postnatal discharge

Updated:11/6/2004

Time of discharge

Usual length of stay after term delivery (calculated from the time of birth of the baby):

o Uncomplicated labour and vaginal delivery (included instrumental):

3 days for parity 1 patients,

2 days for patients of parity 2 or above

o Complicated labour and vaginal delivery: 3 days or more

o Caesarean section: 4 days or more

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

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

o Uncomplicated vaginal delivery

o Patient should have been observed for at least 24 hours after birth

o Midwife has assessed the following:

Patient is mobile with adequate pain control.

Bladder and bowel functions are adequate.

No problem in feeding baby.

Stable emotion.

Advice on perineal care has been given.

Advice on postnatal follow-up and health check for both the mother

and the baby has been given.

Patient is accessible to medical and social support including MCH,

postnatal ward hotline, postnatal clinic at Li Ka Shing Outpatient

Clinic, community nursing service, medical social worker when

needed.

Patient can be contacted for follow-up.

o Doctor or intern has assessed the following:

Perineal wound is normal.

No postpartum haemorrhage or ongoing bleeding.

CUHK medic 2010 40

No fever (> 38 degrees for two or more readings of at least one hour

apart) within 24 hours before discharge.

Rh immunoglobulin has been given if indicated.

No intrapartum or postpartum complications that require inpatient

medical treatment or observation.

Follow up plan has been drawn for any antepartum, intrapartum or

postpartum problems or complications.

Contraceptive advice has been given.

For cases not fulfilling the above criteria: Decision should be made by a medical

officer on individual basis (or agreed by a medical officer after assessment by an

intern). If patient insists early discharge against medical advice, she should sign the

"Discharge with acknowledgement of medical advice" (DAMA).

Consultation

Anaesthetic consultation Updated:7/30/2002

Patients with the following list of disorders require assessment by the obstetric

anaesthetic team.

Schedule admission of these patients at early third trimester(or earlier if indicated) for

consultation or liaise with anaesthetist to see as outpatient.

Cardiac disorders

Cyanotic heart disease or complex heart disease

Valvular heart diseases:

o Moderate to severe mitral regurgitation

o Mitral stenosis

o Pulmonary stenosis / regurgitation

o Aortic stenosis / regurgitation

o Hypertrophic obstructive cardiomyopathy

Cardiomyopathy

Cardiac arrhythmia which either requires treatment or increases peripartum risk

Pulmonary hypertension

Coronary heart disease

Pacemaker in-situ

Respiratory disorders

Severe asthma

Previous tracheostomy or other problem with the major airway

Previous pneumonectomy

CUHK medic 2010 41

Skeletal disorders

Chest deformity e.g. scoliosis, kyphosis

Rheumatoid arthritis with risk of cervical joint subluxation

Miscellaneous

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

regional anaesthesia:

Intracranial space occupying lesions

Increased intracranial pressure

Refusal of blood transfusion e.g. Jehovah's witness

Cross match problems

Bleeding tendency (e.g. thrombocytopenia < 50, Von Willebrand's disease)

Patient currently put on anticoagulant or aspirin

Past history of anaesthetic problems

Any other moderate or severe systemic disturbance due to medical or surgical

disease, or systemic disturbance which poses a constant threat to life and is

incapacitating.

Neonatologist consultation

Updated:11/28/2008

Indications for neonatalogists to standby at delivery in PWH

Multiple gestation

Premature labour (<34 weeks)

Estimated fetal weight < 2 kg

Vaginal breech delivery

Difficult delivery e.g. shoulder dystocia

Suspected fetal distress (non-reassuring fetal heart rate patterns)

Moderate or thick meconium-stained / blood stained amniotic fluid

Oligohydramnios or no liquor

Suspected intrauterine infection / chorioamnionitis

Prolapsed cord

Fetuses with known or suspected malformation that might require immediate medical

attention at birth, e.g. exomphalos, hydrocephalus, diaphragmatic hernia

Abruptio placenta

Placenta previa

Severe hypertension of the mother requiring i.v. sedation / eclampsia

Other conditions in which the obstetrician anticipates adverse neonatal outcome

CUHK medic 2010 42

Conditions required neonatal medical officer"s assessment after delivery

Fetal conditions

o Congenital malformations

o Respiratory depression at birth

Maternal disorders:

o endocrine diseases, e.g. diabetes mellitus, thyrotoxicosis

o autoimmune diseases, e.g. systemic lupus erythematous, myasthenia gravis,

immune thrombocytopenic purpura

o infectious risk e.g. syphilis, Group B streptococcus carrier

o medical diseases on drugs that may affect the baby, e.g. anti-epileptic, anti-

psychotic

o substance abuse

o Unattended delivery

o Other conditions as instructed by obstetricians

Conditions requiring notification of NNU upon admission to labour ward

Gestation of 35 weeks or less

Severe IUGR or severe oligohydramnios

Major congenital disorders which may require special neonatal care or immediate

surgery

Multiple pregnancy

Other conditions as instructed by obstetricians

CUHK medic 2010 43

Drugs

Steroid cover

Updated:5/23/2005

Indications for steroid cover during labour, delivery and surgery

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

or have received this dose in the last three months.

Dosage of various kinds of steroid that is equivalent to 10mg prednisolone:

Dexamethasone or Betamethasone 1.5mg

Methylprednisolone 8mg

Hydrocortisone 40mg

Cortisone acetate 50mg

Steroid cover is not indicated when:

o oral daily prednisolone intake is 10mg or less or the last dose of steroid is

more than 3 months ago.

o short course of steroids for 1 - 2 week.

Regimen

Labour and intrapartum caesarean section

Give usual dose of steroid before labour

Give 25mg ivi hydrocortisone Q6H at onset of labour till delivery

Resume usual steroid dose post-delivery

In case of complicated instrumental delivery or emergency caesarean section,

continue IV hydrocortisone 25 mg Q6H till 24 hour after delivery or longer till oral

intake is resumed

Minor sugery

For example: cervical cerclage, fetoscopic surgery, first trimester surgical TOP,

operation for ectopic pregnancy.

Give usual dose of steroid pre-operatively

Give stat 25mg ivi hydrocortisone on-call to OT

After uneventful surgery, resume usual steroid dose on resumption of oral intake

CUHK medic 2010 44

Intermediate surgery

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

cholecystectomy, ovarian cystectomy complicating pregnancy

Give usual dose of steroid pre-operatively

Give stat 25mg ivi hydrocortisone on-call to OT

then 25mg ivi hydrocortisone Q6H for 24 hours post-operatively or longer till oral

intake is resumed

After uneventful surgery, resume usual steroid dose on resumption of oral intake

Major surgery or complications

For example: internal iliac artery ligation, uterine artery embolization or caesarean

hysterectomy; septicaemia; DIC

Increase to IVI hydrocortisone dose to 50 mg Q6H and gradually wean off at 48-72

hrs post-op/post-delivery

Maintain this regimen until light diet started and usual steroid dose is resumed

Corticosteroid Updated:7/14/2008

For enhancement of fetal lung maturity:

Dexamethasone

Betamethasone

For Maternal indications:

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

steroid treatment

Dexamethasone Updated:7/3/2008

Indication

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

Regimen

6mg im/iv Q12H for 4 doses

Contraindications

chorioamnionitis

active TB

Special precautions

CUHK medic 2010 45

Poorly controlled diabetes mellitus

Repeat dexamethasone

It should not be routinely given, but can be considered in cases in which the ongoing

risk of preterm delivery remain high

Decision should be made by a specialist

No more than 3 courses in total should be given

The repeat course should not be given in less than 1 week interval

Should not be given in case of PPROM

Nevirapine

Updated:11/6/2002

Nature

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

Indication

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

babies.

Not routinely given, but individualized treatment.

Regimen

Intrapartum maternal therapy:

o 200mg po single dose 1 hour prior to Caesarean section or at the onset of

labour

Neonatal therapy:

o To be decided by paediatrician.

Contra-indication

Hypersensitivity

Toxicity

Rash

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

CUHK medic 2010 46

Discussion / Justification

If the mother has not been treated with antenatal Zidovudine, a two-dose

intrapartum/newborn Nevirapine is superior to Zidovudine alone by 47% and as

effective as Zidovudine + Lamivudine in reducing vertical transmission rate.

Due to the high frequency of nevirapine-resistant mutations of the HIV-1 virus,

Lamivudine + Zidovudine is the preferred regimen to Nevirapine for intrapartum

treatment for HIV +ve mothers who have not received antenatal Zidovudine therapy.

The addition of intrapartum Nevirapine to Zidovudine for patients who have received

full antenatal Zidovudine has not been shown to be of benefit.

References

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

Nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission. A

randomized trial. PACTG 316. JAMA 2002;288(2):189-198.

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

Zidovudine combination for prevention of maternal-infant transmission of

HIV-1. JAMA. 2001;25:285(16):2083-93.

Lamivudine

Updated:11/6/2002

Lamivudine therapy

Nature

A nucleoside reverse transcriptase inhibitor of retrovirus including HIV.

Indication

To reduce the risk of vertical transmission of HIV from HIV-positive mothers who have

not received antenatal Zidovudine therapy.

Not routinely given, but individualized treatment.

Regimen

Intrapartum maternal therapy

o orally 150mg every 12 hours till delivery

o combined with oral Zidovudine

Neonatal therapy by paediatrician

Discussion / Justification

CUHK medic 2010 47

If the mother has not been treated with antenatal Zidovudine,Lamivudine +

Zidovudine is preferred to Nevirapine for the intrapartum treatment for HIV +ve

mothers who had not received antenatal Zidovudine therap, due to the high frequency

of nevirapine-resistant mutations of the HIV-1 virus.

Early observational study suggested Lamivudine might provide additional benefit to

Zidovudine in reducing HIV vertical transmision rate.

However, Lamivudine is associated with high frequency of Lamivudine-resistant

mutations of the virus and there is insufficient data to recommend routine addition of

Lamivudine to Zidovudine for patients who have received full antenatal Zidovudine

therapy.

References

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

combination for prevention of maternal-infant transmission of HIV-1. JAMA. 2001 Apr

25;285(16):2083-93.

The Petra Study Team. Efficacy of three short-course regimens of zidovudine and

lamivudine in preventing early and late transmission of HIV-1 from mother to child in

Tanzania, South Africa, and Uganda (Petra study): a randomised, double-blind,

placebo-controlled trial. Lancet 2002;359:1178-86.

Zidovudine

Updated:11/1/2002

Zidovudine therapy

Nature

A nucleoside reverse transcriptase inhibitor of retrovirus including HIV.

Indication

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

babies

Regimen

Antenatal maternal therapy:

o 300mg b.d. orally

o Specialist from QEH(SMS)/DH(SPP) may give the dosage differently in order

to improve compliance

Intrapartum maternal therapy

o If patient had antenatal Zidovudine therapy

CUHK medic 2010 48

2mg/kg iv loading dose over 30-60min, then 1mg/kg per hour iv till

clamping of cord

o If patient had not received antenatal Zidovudine therapy

300mg oral therapy for loading following by 300mg q3h till delivery

Combined with Lamivudine

Neonatal therapy

o Give Zidovudine syrup 2mg/kg po 4 doses/day for 6 weeks

o or if not tolerate orally,give iv 1.5mg/kg over 30min Q6H

o start therapy within 8 to 12 hours of birth

o if no intrapartum therapy was given, start therapy immediately after delivery

Monitoring of Zidovudine therapy

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

o baseline CBP, LFT, CPK then

o CBP Q2weeks for 1 month, then Q4 weeks

o LFT, CPK Q4 weeks

o Consider discontinuation if:

Hb<8g/dl

Platelet<100x109/L

WCC<75x109/L

o ALT/AST >5X normal

Discussion / Justification

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

transmission and should be recommended because it is found to be safe to both the

mother and the baby on the 5-year follow-up studies from the PACTG 076 trial.

If the mother has not been treated with antenatal Zidovudine, a two-dose

intrapartum/newborn Nevirapine is superior to Zidovudine alone by 47% and as

effective as Zidovudine + Lamivudine in reducing vertical transmission rate.

Singel agent nevirapine is associated with high frequency of nevirapine-resistant

mutations of the HIV-1 virus

The addition of Nevirapine to standard Zidovudine therapy has not been shown to be

of benefit

References

Conner EM, Sperling RS, Gelber R et al. AIDS Clinical Trials Group (ACTG) 076.

Reduction of maternal-infant transmission of HIV type 1 with zidovudine treatment. N

Engl J Med 1994; 331: 1173-80

CUHK medic 2010 49

Culnane M, Fowler M, Lee S et al. Lack of long-term effects of in utero exposure to

zidovudine among uninfected children born to HIV-infected women. JAMA 1999;

281(2): 151-157

Hanson IC, Antonelli TA, Sperling RS et al. Lack of tumours in infants with perinatal

HIV-1 exposure and fetal/neonatal exposure to zidovudine. J Acquir Immune Defic

Syndr Hum Retroviraol 1999; 20: 463-467

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

Nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission. A

randomized trial. PACTG 316. JAMA 2002;288(2):189-198.

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

Zidovudine combination for prevention of maternal-infant transmission of

HIV-1. JAMA. 2001 Apr 25;285(16):2083-93.

Oxytocic agent

Updated:8/13/2008

Drugs

Oxytocin deviatives

o Syntocinon

o Syntometrine

o Carbetocin

Prostaglandins deviatives

o PGE2

o Hemabate

o Misoprostol

o Cervagem

Indications

Rippening of cervix: PGE2

Induction or augmentation of labour: syntocinon

Prophylaxis and treatment of postpartum haemorrhage: syntocinon, syntometrine,

hemabate

For termination of pregnancy or treatment of abortion: misoprostol, cervagem

Syntocinon

Updated:10/29/200

8

Indications

CUHK medic 2010 50

Induction of labour

Augmentation of labour

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

Regimen

For induction and augmentation of labour:

o Start infusion using either infusion drip set or syringe pump (see table 1), and

titrate the infusion rate accordingly.

o Maintain the infusion rate if adequate contractions (3 to 4 contractions per 10

minutes) are achieved, till the next cervical assessment.

o Inform medical officer if more than 20 mu/min of oxytocin is required to

achieve optimal uterine contractions.

For intrapartum managment third stage of labour:

o iv bolus 5 units over 1-2 minutes, or

o im bolus 10 units if no iv access available and in absolute emergency

(unlicensed route)

patients with cardiac disease or those particularly at risk of

hypotension should have the iv bolus 5 units given slower i.e. over 5

minutes

o iv infusion 40 units in 500ml crystalloid solution Q4H once

Table 1. Syntocinon Infusion

Time after

starting

Oxytocin dosage

(milliunits per

minutes)

Infusion rate for 10 units in

500ml of Hartmann

solution (ml/hour)

Infusion rate for 5 units in

50 ml of Hartmann

solution (ml/hour)

0 1 3 0.6

30 2 6 1.2

60 4 12 2.4

90 8 24 4.8

120 12 36 7.2

150 16 48 9.6

180 20 60 12.0

210 24 72 14.4

240 28 84 16.8

270 32 96 19.2

CUHK medic 2010 51

Remark

Midwives can adminster syntocinon bolus injection at third stage of labour according

to departmental standing order.

References: Thomas TA and Cooper GM. Maternal deaths from

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

Confidential Enquiries into Maternal Deaths in the United Kingdom.

Br J Anaesth 2002;89:499-508. FDA website:

http://www.drugs.com/pro/syntocinon.html

Carbetocin - provisional

Updated:8/13/2008

Pharmacology

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

Indication

first line prophylaxis against postpartum haemorrhage in high risk cases during the

third stage of labour.

Contraindications

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

hepatic or renal disease

Regime

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

Misoprostol

Updated:1/8/2009

Nature of Misoprostol (Cytotec)

A PGE-1 analogue of the prostaglandin group

Indications

First line treatment for first and second trimester miscarriages to evacuate the uterus

First line treatment for second trimester medical induced abortion

CUHK medic 2010 52

First line treatment for cervical ripening prior to mechanical cervical dilatation for first

trimester suction termination of pregnancy

Caution

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

Adverse reactions

Uterine rupture

Side effects

GI upset, vomiting, diarrhoea, pyrexia

Route of administration

Oral or vaginal

Regimen

For medical evacuation of the uterus for first trimester miscarriage, single dose of

800micrograms vaginally.

For medical evacuation of the uterus for second trimester abortion (spontaneous or

induced), 400micrograms every 3 hours vaginally for 5 doses. May repeat the course

if necessary. If 2 courses fail, consider change to gemeprost.

For cervical ripening prior to mechanical cervical dilatation for first trimester suction

termination of pregnancy, 200micrograms single dose vaginally 3 hours before the

procedure

Discussion / Justification

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

Vaginal route of Misoprostol is more effective than oral Misoprostol in second

trimester induced abortion

For cervical priming, oral Misoprostol is better than vaginal Gemeprost with greater

baseline cervical dilatation and easier dilatation.

For cervical priming, 200mcg vaginally is as effective as 400mcg vaginally

For cervical priming, vaginal Misoprostol is more effective if given 2-4hrs prior to

surgery than oral Misoprostol given 8-12 hrs prior to surgery.

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

Misoprostol compared with vaginal Gemeprost in termination of

CUHK medic 2010 53

second trimester of pregnancy. Contraception 1998;58:207-210. Gilbert A, Reid R. A randomized trial oral versus vaginal administration of Misoprostol for the

purpose of mid-trimester TOP. ANZJOG 2001;41(4):407-410. Ngai SW, Au Yeung KC, Lao T

et al. Oral Misoprostol versus vaginal Gemeprost for cervical dilatation prior to vacuum

aspiration in women in the sixth to twelfth week of gestation. Contraception 1995;51:347-350.

Ngai SW, Chan YM, Tang OS et al. The use of Misoprostol for pre-operative cervical

dilatation prior to vacuum aspiration: a randomized trial. Human Reprod 1999;14:2139-2142.

Lawrie A, Penney G, Templeton A. A randomized comparison of oral and vaginal Misoprostol

for cervicla priming before suction termination of pregnancy. BJOG 1996;103(11):1117-9.

Carbonell JL, Velazco A, Rodriguez Y et al. Oral versus vaginal Misoprostol for cervical

priming in first-trimester abortion: a randomized trial. Eur J Contraception Reprod Health Care

2001;6(3):134-140

Sulprostone

Updated:6/22/2002

Indication

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

death when other treatment has failed

Decide treatment by FHKAM and senior call

Contraindications

Asthma

Cardiac disease

Hepatic or renal failure

Regimen

Add 500mcg to 250ml of NS for infusion

Infuse at 100mcg per hour

May infuse continuously for 10 hours

Never exceed infusion rate of 500mcg per hour

Maximum totol dosage of 1500mcg

Side effects

Nausea, vomiting, diarrhoea, headache, fever

CUHK medic 2010 54

Warfarin

Updated:10/11/2007

Indication

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

antenatally with the exception of metabllic valve replacement)

Regimen

Baseline INR before commencement

Start loading dose 5 mg daily at both Day 1 and day 2

Check INR from Day 3 onwards

Titrate the warfarin dosage to reach the target INR

The sliding scale is a reference for warfarin dose at day 3 and day 4 while further

dosage will be adjusted according to the response to previous dose

Please consult specialist in medical medicine or physician for the management in all

cases on warfarin

It is preferred to start warfarin at evening and blood taking for INR at morning)

INR Warfarin dosage

<=1.5 5 mg

> 1.5 - 2.0 4 mg

> 2.0 - 2.5 3 mg

> 2.5 - 3.0 2 mg

> 3.0 - 3.5 1.5 mg

> 3.5 omit warfarin for 1 day

CUHK medic 2010 55

Misc

CS wound complication Updated:6/22/2002

Management of wound dehescience and wound infection

Initial assessment

Inform medical officer and Midcall-1 in charge of the case and the principal surgeon

for the operation.

Initial wound assessment should be performed by a senior midwife, an intern and the

medical officer in charge.

Record the size and depth of the wound, the presence or absence of

haematoma/pus/necrotic tissue/cavity and surrounding cellulitis.

Take a wound swab for culture and sensitivity.

Care of the wound

Irrigate wound with normal saline and dress the wound one to three times daily.

Frequency of dressing is to be decided by the Medical officer in charge. Usually once

daily dressing would reduce disturbance of the wound and promote healing.

Liaise with midwife for the best type of dressing.

Antibiotic treatment

Empirical treatment of Augmentin 375mgtds should be started while awaiting for

swab culture result.

Patients allergic to penicillin should use erythromycin 500mg qid.

Augmentin has good coverage for Group B strep, most G-negative oragnisms, most

anaerobes and also Staph. aureus (methicillin-sensitive), although sensitivity of these

organisms to Augmentin is not always tested e.g. Staph. aureus

If in doubt of the sensitivity of the cultured organism to Augmentin, please consult

microbiologist before changing the already-started antibiotic regimen.

Antibiotics should continue for at least 7-10 days.

Resuturing of the wound

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

CUHK medic 2010 56

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

local anaesthesia

Re-suturing should be performed either in the main Gynaecological operation theatre

(under GA) or the ward treatment room under aseptic technique (under LA).

Surgeons should be properly gowned up.

Removal of the new sutures should be performed at least 7-10 days after re-suturing.

Patient can be managed as out-patient after re-suturing and followed up in the ward

for the removal of sutures.

In case of a second wound dehiscence, Midcall 1 is to be involved to take personal

care of this complicated patient.

Discussion / Justification

Management of wound dehescience and wound infection

Initial assessment

Inform medical officer and Midcall-1 in charge of the case and the principal surgeon

for the operation.

Initial wound assessment should be performed by a senior midwife, an intern and the

medical officer in charge.

Record the size and depth of the wound, the presence or absence of

haematoma/pus/necrotic tissue/cavity and surrounding cellulitis.

Take a wound swab for culture and sensitivity.

Care of the wound

Irrigate wound with normal saline and dress the wound one to three times daily.

Frequency of dressing is to be decided by the Medical officer in charge. Usually once

daily dressing would reduce disturbance of the wound and promote healing.

Alginate should be used if packing is needed for wounds with lots of discharge.

Antibiotic treatment

Empirical treatment of Augmentin 375mgtds should be started while awaiting for

swab culture result.

Patients allergic to penicillin should use erythromycin 500mg qid.

Augmentin has good coverage for Group B strep, most G-negative oragnisms, most

anaerobes and also Staph. aureus (methicillin-sensitive), although sensitivity of these

organisms to Augmentin is not always tested e.g. Staph. aureus

If in doubt of the sensitivity of the cultured organism to Augmentin, please consult

microbiologist before changing the already-started antibiotic regimen.

CUHK medic 2010 57

Antibiotics should continue for at least 7-10 days.

Resuturing of the wound

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

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

local anaesthesia

Re-suturing should be performed either in the main Gynaecological operation theatre

(under GA) or the ward treatment room under aseptic technique (under LA).

Surgeons should be properly gowned up.

Removal of the new sutures should be performed at least 7-10 days after re-suturing.

Patient can be managed as out-patient after re-suturing and followed up in the ward

for the removal of sutures.

In case of a second wound dehiscence, Midcall 1 is to be involved to take personal

care of this complicated patient.

CUHK medic 2010 58