Gynaecological Conditions

Contraception

A method or a system, which allows intercourse and yet prevents conception, is called a contraceptive method. This contraception may be temporary when the effect lasts only till the couple uses the method but the fertility returns after the use is discontinued. The permanent contraceptive methods are surgical and are aimed to achieve sterility after the surgical procedure.

A couple in the reproductive age group, who desires contraception should be provided information about all the available methods of contraception and should be counselled & helped so as to choose a method most suitable for that couple. Various contraceptive methods available are:

I. Temporary methods

1. Hormonal contraceptives
   - Combined oral contraceptive pills.
   - Injectable hormonal contraceptives (DMPA and NET-EN).
2. Non hormonal contraceptive pills
   - Centchroman.
3. Intrauterine contraceptive device
   - CuT 200B.
   - Multiload 280 and Multiload 375.
   - CuT 380A.
4. Barrier methods
   - Male condoms.
   - Vaginal diaphragms with spermicidal jelly.
   - Contraceptive sponge.

II. Permanent methods

1. Female sterilization
   - Postpartum sterilization.
   - Interval ligation (laparoscopic or minilap ligation).
   - Ligation concurrent with MTP.
2. Male sterilization
   - Vasectomy (traditional or non scalpel).

I. Temporary methods

A. (i) Combined oral contraceptive pills
Any of the low dose combined oral contraceptive pill containing 30 mcg Ethinyl estradiol and a Progestin (0.3 mg Norgestrel or 0.15 mg Norgestrel or 0.15 mg Desogestrel) can be prescribed. One tablet to be taken daily with meals at consistent time. It should be started during first seven days of the menstrual cycle or at any other time when it is reasonably certain that she is not pregnant. If started after first 7 days of menstrual cycle, back up method (abstinence or barrier method) should be used for 7 days. Pills should be taken for three weeks followed by 1 week of pill-free interval during which placebo tablets are to be taken if pack contains 28 tablets.

In women >40 years of age very low dose pills containing Ethinyl estradiol 20 mcg and desogestrel 0.15 mg can be used. After age 50 years, if woman on oral pills, check FSH during 5 – 7 days of pill free interval. If FSH >30 IU/l change to HRT regimens.

Contraindications

Combined oral contraceptive pills are contraindicated in cases with current or history of

• thromboembolic disease, cerebrovascular disease, coronary artery disease.
• complicated valvular heart disease
• acute liver disease.
• current or past breast cancer.
• undiagnosed vaginal bleeding.
• pregnancy.
• heavy smokers over 35 years of age.
• migraine with neurological symptoms.
• diabetes >20 years or with vascular disease.
• current gall bladder disease.
• uncontrolled hypertension (BP >160/100).

Should not be taken during first 6 months postpartum if breast feeding and first 3 weeks postpartum in non-breast feeding females. Pills can be started immediately after spontaneous or induced abortion. Can be used with caution in cases with controlled hypertension, diabetes, migraine without neurological symptoms, non-smokers with age more than 35 years of age without any other medical illness.

Follow up – First follow up should be within 3 months and then annually.

Follow up involves history, blood pressure, urinalysis, breast examination, liver palpation & pelvic examination.

Patient education

Common side effects are nausea, vomiting, GI upset, breast changes, weight gain, acne, breakthrough bleeding, amenorrhea, rash, vaginal candidiasis. Side effects decrease usually after 2 – 3 months of use.

• Report immediately to the clinician in case of symptoms like chest pain, leg pain, severe headache, severe stomachache, swelling of one or both legs, visual impairment.
• It is one of the most effective contraceptive methods with failure rate about 0.1%.
• It has non-contraceptive health benefits like regular periods with less pain and bleeding, improves premenstrual symptoms, and decreases functional ovarian cysts, pelvic inflammatory disease, ovarian and endometrial cancer, endometriosis.
• Forgotten pill – if one pill is forgotten, take as soon as remembered and next day take next pill and continue the schedule. Use back up method for 7 days.
• If 2 pills are forgotten take 2 pills and next day again take 2 pills, then continue as per schedule. Use back up method for 7 days.
• If 3 pills are forgotten, discard rest of the pack, use back up method for 7 days and then restart with new pack.
• Should be discontinued at least 4 weeks prior to any planned major surgery.
• Medicines like rifampicin, barbiturates, phenytoin, carbamazepine, primidone, griseofulvin interfere with the effects of oral pills. So use alternative method during their intake.

(ii) Injectable hormonal contraceptives

Highly effective estrogen free long acting contraceptive not linked to coitus.
Can be given in women where estrogens are contraindicated like sickle cell disease, seizure disorders, age>35 years who smoke. Can be given in breast feeding females after first 6 weeks. In non-breast feeding females, injections can be safely given immediately postpartum.
Depot Medroxy Progesterone Acetate – 150 mg injection to be given deep IM every three months. Next injection can be delayed by 2 weeks
Or
Norethisterone enanthate – 200 mg injection to be given deep IM every 2 months. Next injection can be delayed by 1 week.

Absolute contraindications are

• Pregnancy
• unexplained genital bleeding.
• severe coagulation disorder.
• previous sex steroid induced liver adenoma, active liver disease.
• breast feeding during initial 6 weeks.
• current or history of thromboembolic disease, cerebrovascular disease, coronary artery disease.
• current or past breast cancer
• diabetes >20 years or with vascular disease
• uncontrolled hypertension (BP >180/110).

Patient education

• Common side effects are irregular bleeding, breast tenderness, weight gain, depression, headache, dizziness, abdominal pain.
• Beneficial effects and efficacy is same as that of oral contraceptive pills.
• Fertility return is slightly delayed after discontinuation of use.
• Drug interactions are same as with oral hormonal pills.

B. Nonhormonal oral contraceptive pills

Centchroman

30 mg tablet started on first day of periods. Take twice weekly for three months and then continue as once weekly.

Contraindications

Polycystic ovarian disease, cervical intraepithelial neoplasia, severe allergy, recent history of liver disease, and first 6 months of lactation.

Patient education

• It is a non-steroidal contraceptive pill. It has no hormonal effects.
• Failure rate is 1-2%.
• Delayed periods can occur in 6% cases. If delay is >15 days, perform urine pregnancy test.
• If one tablet is missed take as soon as possible & resume scheduled intake. Add back up method till next period. If tablet missed for >7 days, start fresh regimen.

C. Intrauterine contraceptive devices (IUCD)

Any of the following devices can be inserted inside uterus by a trained health personnel. It should be inserted during or shortly after menstruation during the follicular phase of menstruation. After spontaneous or induced abortion IUCD can be inserted immediately. After delivery it should be inserted during 4 – 8 weeks postpartum. It can be inserted within 5 days of unprotected coitus. These devices need to be changed after the duration of their life span.

Follow up – first follow up should be after next period to check for complications and to rule out expulsion. After that follow up annually.

Contraindications

Pregnancy, postpartum >4 weeks, septic abortion, distorted uterine cavity, uterine fibroids, current or within past 3 months PID or STD, increased risk of STD, HIV positive, AIDS, pelvic tuberculosis, unexplained vaginal bleeding, trophoblastic disease, genital tract malignancy, complicated valvular heart disease.

Patient education

• Common side effects are increased menstrual bleeding and dysmenorrhea. These decrease after initial 2-3 months.
• No protection for STDs.
• Failure rates are 0.5 – 3%. Ectopic pregnancy can still occur.
• IUCD can be spontaneously expelled. Therefore monthly palpation of IUCD string is important. If not palpable, report immediately.

D. Barrier methods

These are cheap, over the counter available, coitus dependant methods. Male condoms, vaginal diaphragm, spermicidal jellies, vaginal sponge can be used.

Male condoms

Any of the available condoms can be used. For each act of coitus a new condom is to be used. If during intercourse, condom breaks or if there is spillage or leakage, woman should contact a clinician within 72 hours and emergency contraception should be provided to her.

Contraindications

Only contraindication is in cases with severe allergy to latex rubber.

Vaginal diaphragm

Available in different sizes. Proper size should be checked by a clinician by pelvic examination. Can be inserted 6 hours prior to intercourse. About a tablespoonful of spermicidal cream or jelly should be placed in the dome of diaphragm prior to insertion. Should be left in place for approximately 6 hours (but not >24hours) after coitus. Additional spermicide should be placed in vagina before each additional episode of sexual intercourse. After removal wash with soap and water, rinse and dry.

Follow up – annually to assess proper fitting of diaphragm.

Contraceptive sponge

Contains spermicidal agent Nonoxynol 9. It should be removed at least 6 hrs after sexual intercourse. Maximal wear time is 30 hours.

Patient education

• Barrier methods provide protection against STD’s and PID. Only condom has been proven to prevent HIV infection.
• Other advantages are prevention of diseases like pelvic inflammatory disease, carcinoma cervix, chronic pelvic pain.
• It can be used soon after delivery.
• No hormonal side effects.
• Side effects like vaginal dryness, itching, irritation, allergic reactions can occur.
• Failure rates are very high. Typical failure rates are with condoms 14%, diaphragm with spermicidal jelly 20%, highest with sponge 28%.

II. Permanent contraceptive methods

• Permanent contraception is provided by sterilization operation in male or female partners.
• Male client should be <60 years of age.
• Female client should be >22 years and <45 years of age.
• Client must make informed decision voluntary and must give consent on the consent form for sterilization.

A. Female sterilization

Can be done by laparoscopic ligation in interval ligation and first trimester abortions or tubectomy.

Timing

• Interval sterilization – within 7 days after menstrual period is over.
• Post partum sterilization – after delivery till 7 days but preferably within 48 hours. Later on after 6 weeks postpartum.
• MTP – concurrently.
• Spontaneous abortion – concurrently but under antibiotic cover and in the absence of infection and anaemia

Contraindications

There are no absolute contraindications. Relative contraindications are psychiatric disorder, acute febrile illness, jaundice, Hb< 8 g%, chronic systemic disease, malignancy, bleeding disorder, severe nutritional deficiency. Postpartum sterilization is contraindicated in puerperial sepsis or fever, severe preeclampsia/eclampsia, premature rupture of membrane >24 hours, severe APH or PPH, genital tract trauma.

Post abortal sterilization is contraindicated in sepsis, fever, haemorrhage, severe trauma, uterine perforation, acute haematometra.

Followup – first follow up should be done seven days after the surgery for wound examination. Second follow up is recommended after one month or next menstrual period whichever is earlier. Subsequent follow-ups if client develops any complication or has query.

B. Male sterilization

Contraindications

There are no absolute contraindications. Relative contraindications include psychiatric and physical illness, local genital conditions, including large varicocele, hydrocele, inguinal hernia, filariasis, cryptorchidism, previous scrotal surgery, intra scrotal mass.

Followup – first follow up after 7 days of surgery for wound examination and stitch removal. Second follow up after 3 months with semen analysis.

Subsequent follow up required in cases of any complication or queries.

Patient education

• It is a safe and simple procedure.
• It is a permanent method to prevent future pregnancies.
• It does not affect sexual pleasure, ability or performance.
• It has a small chance of failure even if performed under optimum circumstances.
• After vasectomy it is necessary to use a back up contraceptive method either for 20 ejaculations or for a period of 3 months.
• Sterilization does not provide protection against reproductive tract infections/STDs or HIV/AIDS.
• Failure rates with female sterilization are < 0.5% and male sterilization < 0.1%.

Emergency contraception

Method used to prevent pregnancy after a likely fertile unprotected act of sexual intercourse. Can be used in cases of condom rupture, rape or other circumstances of unprotected sex.
First dose should be taken within 72 hours following unprotected sex and second dose 12 hrs after the first dose. Any of the following can be used:
Levonorgestrel 0.75 mg 1 tablet 12 hourly for 2 doses.
Or
Combined oral contraceptive pills containing 50 mcg Ethinyl estradiol with 0.5 mg Norgestrel 2 tablets 12 hourly for 2 doses.
Low dose combined oral contraceptive pills containing 30 mcg Ethinyl estradiol with 0.3 mg Norgestrel 4 tablets 12 hourly for 2 doses.
Or
Centchroman 50 mg 1 tablet 12 hourly for 2 doses.

Patient education

• Side effects are nausea, vomiting, dizziness, fatigue, headache, lower abdominal pain, breast tenderness, vaginal bleeding.
• It must be used under medical supervision.
• It decreases risk of pregnancy by 70 – 90%. Earlier it is taken, success is more.
• If vomiting occurs within 2 hours of the dose, it must be repeated.
• There are no contraindications for emergency contraception.
• After this use a barrier method for each act of intercourse until next menstrual period.
• If period delayed >5 days, rule out pregnancy.
• Use regular contraceptive method.

References

1. Improving Access to Quality Care in Family Planning Medical Eligibility Criteria for Contraceptive Use, 2nd Edition, World Health Organization, Geneva 2000.
2. Standards for Female and Male Sterilization, Ministry of Health and Family Welfare, Government of India, October 1999.
3. Clinical Gynaecologic Endocrinology & Infertility. Leon Speroff, Robert H. Glass, Nathan G. Kase (eds), 1994.

Menopause

Permanent cessation of menses for 1 year is known as menopause. It usually occurs between 40 to 50 years, mean age being 48 years. Long term consequences due to decreased estrogens can be rise in the risk of ischaemic heart disease due to adverse effects on lipid profile and osteoporosis and pathological fractures.

Treatment

Nonpharmacological

• Balanced diet with fruits, vegetables, semi-skimmed milk adequate in vitamins and minerals. A reduction or avoidance of smoking and alcohol consumption.
• Exercise: walking or swimming for 20-30 min every day.

Pharmacological

1. Tab. Calcium 1000 mg daily.
2. Hormone replacement therapy (HRT). Rule out contraindications to HRT namely present endometrial/breast cancer, acute phase myocardial infarction, undiagnosed breast lump/abnormal vaginal bleeding and acute liver disease. Hypertension and diabetes if present should be controlled before HRT is prescribed.

Estrogen therapy.

1. Single therapy with estrogens in hysterectomized patients.
   Conjugated equine estrogen 0.625 -1.25 mg.
   Or
   Estriol 1-2 mg is given daily 1-25th day every month or daily without any break. If symptoms recur during drug free period then give continuous therapy.
   Or
   Transdermal estradiol patch 50 or 100 mcg/day applied twice a week away from breast, preferably on the shaved skin of buttock, thigh or legs. (Limiting factor is local skin reactions).
   Transdermal estradiol patch is preferred in case of gall bladder disease, hypertriglyceridemia, history of thromboembolism, poorly-controlled hypertension, recent myocardial infarction, vascular diseases, migraine, chronic hepatic dysfunction, malabsorption syndrome.
2. Combined therapy with estrogens and progestin in women with intact uterus.

1. Estrogen therapy as above.
2. Progestogen-Medroxyprogesterone acetate 5 – 10 mg or
   Dihydrogesterone 10 – 20 mg or Norethisterone 2.5 mg) or 200 ml micronized Progesterone is added from 13th to 25th days in cyclic sequential regimen and 1st to 12th of every month in continuous sequential regimen. If withdrawal bleeding is not acceptable then give continuous combined treatment (0.625 mg conjugated equine estrogen + 2.5 mg Medroxy progesterone acetate or 1 mg micronized estrogen + 100 mg micronized progesterone).
   If conventional HRT is contraindicated
   Tab. Tibolone 2.5 mg per day (major side effects are weight gain, oedema, breast tenderness, GIT symptoms and vaginal bleeding).
   In symptomatic elderly women with atrophic vaginitis and other urogenital symptoms do not desire long term HRT:
   Estriol cream daily application of 0.5 g delivering 0.5 mg of estriol for 3 weeks followed by twice weekly application for 3 – 4 weeks.
   Key indicators of response to therapy are improvement in symptoms.
   Follow up at 2-3 months then at 6 monthly intervals. Yearly mammography, Pap’s smear, pelvic USG and serum estradiol are advisable.
   The appropriate duration is lifelong, otherwise at least for 5-6 years. HRT should be started as early as possible after menopause.

Patient education

• Explain the patients that following side effects due to estrogens can occur: fluid retention, breast tenderness, nipple sensitivity, nausea, headache, leg cramps. Side effects due to progestogens are fluid retention, breast tenderness, oedema, headache, acne, premenstrual syndrome, abdominal cramps, vaginal bleeding.
• Explain the patient that the appropriate duration is lifelong, otherwise at least for 5-6 years. HRT should be started as early as possible after menopause.
• Follow up visits at 2 – 3 months then at 6 monthly intervals are necessary.

References

1. Treatment of the Post Menopausal Woman: Basic & clinical aspects. Rogerio A Lobo (ed), Lippincott Williams & Wilkins, 1999.
2. Menopause & Postmenopausal Hormone Therapy. In: Clinical Gynaecologic Endocrinology & Infertility, Leon Speroff, Robert H Glass, Nathan G Kase (eds), 1994, pp 583-650.
3. The Menopause. In: Gynecology. Robert Shaw, Pat Soutter, Stuart Stanton (eds), 1992, pp 341-354.

Dysfunctional Uterine Bleeding (DUB)

It is abnormal uterine bleeding in the absence of organic disease of the genital tract.

Treatment: Acute bleeding (First episode)

A. Severe bleeding (haemodynamically unstable patient)

1. Usual steps taken for any serious haemorrhage should be instituted immediately like IV line, fluid replacement, blood transfusion, oxygen inhalation and monitoring of vitals.
2. Dilatation and Curettage is the quickest way to arrest bleeding except in cases of puberty menorrhagia where medical management is preferred.

B. Less severe bleeding (haemodynamically stable patient)

High dose Progestogens: Norethisterone 10 mg 3 times a day until bleeding stops (not >3 days) followed by Norethisterone 5-10 mg
Or
Medroxyprogesterone acetate 10 mg per day for 21 days. Withdrawal bleeding will occur after 2-4 days of stopping the drug and will stop in 4-5 days.
Or
Combined oral contraceptive pills (OCs) containing 50 mcg ethinyl estradiol 1 pill 2 times a day for 7 – 10 days followed by progestins for 7-10 days, will be followed by withdrawal bleeding.

C. If bleeding is not controlled with progestogens, patient is having heavy bleeding for many days, endometrial curettage yields minimal tissue, or when the patient has been on progestogen medication (OC’s or Depot MPA) and the endometrium is shallow and atrophic.

Treatment schedules of high dose estrogens, depending on the severity of the bleeding the following can be used.

1. Conjugated estrogen 25 mg IV every 4 hr till bleeding abates or for 12 h. Progestin treatment is started at the same time.
2. Oral treatment conjugated estrogen 1.25 mg or 2 mg estradiol valerate given orally every 4 h for maximum of 24 h followed by single daily dose for 7-10 days.

All treatments must be followed by progestin coverage (10 mg MPA daily) along with estrogen for 7 days.

Monitoring

Clinical monitoring by vital charting and observation of blood loss per vaginum.

Treatment of Chronic DUB (Not actively bleeding)

1. Iron therapy: elemental iron maximum 60 mg 3 times a day depending on the degree of anaemia.

A. Anovulatory DUB

1. If contraception is desired: OCPs for 3 – 6 cycles Or Norethisterone 5-10 mg.
2. Medroxyprogesterone acetate (MPA) 10 mg 16-25th day of the cycle for 3-6 cycles.
3. In cases of endometrial hyperplasia without atypia on histology Norethisterone acetate 5 mg or MPA 10 mg 5-25th day of cycle for 3-9 cycles followed by repeat endometrial biopsy.
4. If fertility desired: ovulation induction is advised.

B. Ovulatory DUB

NSAIDS: Mefenamic acid 500 mg 3 times a day for 3 -5 days during periods.
Or
Oral combined contraceptive pills if contraception is desired.
If the above treatment is not effective in first cycle patient should be referred for tertiary care by a gynaecologist. Following treatment can be considered as an alternative to surgery:
Tab. Danazol 200 mg daily for 3 months.

Follow up

Follow up is done after 1, 3, 6 months of therapy. Treatment is stopped after 3-6 months. If symptoms recur medical treatment is to be continued or surgery can be offered.

Role of surgery

Endometrial curettage

• Acute bleeding in haemodynamically unstable patient to quickly control the bleeding.
• In acute episode if bleeding doesn’t decrease significantly in 12-24 hours with medical treatment, then reevaluation is mandatory and surgical curettage should be done.
• If age is >35 years – premenstrual dilatation and curettage for endometrial histology is a must to rule out endometrial pathology.

Definitive therapy

If medical therapy is not effective then endometrial ablation or hysterectomy is to be performed.

Patient education

• In majority of patients, medical management cures the problem.
• Common side effects of high dose estrogens are: nausea, vomiting, headache, depression, and fluid retention. Contraindicated in liver disease, history of thromboembolic disorder, cardiovascular disease, and estrogen dependant neoplasm.
• Common side effects of progestogens are depression, fluid retention, fatigue, insomnia, dizziness, nausea, and breast tenderness.
• Common side effects are acne, weight gain, fluid retention, hoarseness of voice.

References

1. Dysfunctional Uterine Bleeding, In: Clinical Gynecologic Endocrinology & Infertility, Leon Speroff, Robert H Glass, Nathan G Kase (eds), 1994, pp 531 – 546.
2. Menstruation & Menstrual Abnormality. In: Gynaecology, Robert Shaw, Pat Soutter, Stuart Stanton (eds), 1992, pp 189-204.

Premenstrual Syndrome (PMS)

It is a cyclic recurrence of physical, psychological or behavioural symptoms that appear after ovulation and resolve after the onset of menstruation. PMS requires treatment when the symptoms are severe enough to interfere with the woman’s life style, relationships & occupational functioning.

Treatment

Non pharmacological

Life-style advice should be offered to all women as first line of treatment.

1. Daily charting of symptoms for two months.
2. Dietary modifications like: increase complex carbohydrate meals, reduce or eliminate, especially in the luteal phase, salts, chocolate, caffeine & alcohol, and several small meals per day.
3. Moderate regular aerobic exercise like brisk walk 1-2 miles per day for 4-5 days/week.
4. Stress management courses/counselling

Pharmacological

1. Tab. Pyridoxine 100 mg/day for 10-14 days (during luteal phase) (maximum daily dose is 150 mg)
   Or
   Tab. Evening primrose oil 500 mg 3 times a day.
2. In case of headache or premenstrual dysmenorrhoea, Non steroidal antiinflammatory drugs – like mefenamic acid 500 mg 3 times a day for duration of symptoms till onset of menstruation.
3. In case of predominantly physical symptoms (bloatedness, irritability swelling, weight gain, breast tenderness),
   Tab. Spironolactone 100 mg/day for
   Or
   Tab. Bromocriptine 1.25 – 5 mg/day in the luteal phase for mastalgia.
   Common side effects are nausea and vomiting. Tablet can be given vaginally if side effects are very severe. If no relief in symptoms with above measures in 2 – 3 cycles and symptoms are predominantly emotional, then the following drugs are used preferably in consultation with a psychiatrist:
   Tab. Fluoxetine 5 – 20 mg/day.
   In non responders to the above therapy, ovulation suppression may be beneficial. Any of the following can be used:
   Low dose combined oral contraceptive pills, 1 pill daily from 5th to 25th day of the cycle.
   Or
   Progestins: Medroxyprogesterone acetate (MPA) 15 – 30 mg/day (10 mg 3 times a day) or Depot MPA 150 mg IM 3 monthly. Irregular bleeding is very common.
   Or
   Tab. Danazol 200-800 mg/day. Side effects like weight gain, facial hair, acne are the usual limiting factors.
   Treatment may be stopped after 3 – 6 cycles and look for return of the symptoms. If symptoms return treatment is required till menopause. If no response to the above treatment refer to a higher centre.

Patient education

• Explain the importance of the life-style modification.

References

1. Clinician’s Approach to the Diagnosis & Management of Premenstrual Syndrome. In: Clinical Obstet Gynaecology, 1992, pp 637-657.
2. Hormonal Manipulations in the Treatment of Premenstrual Syndrome. In: Clinical Obstet Gynaecology, 1992, pp 658-666.
3. Premenstrual Therapy. In: Clinical Obstet Gynaecology, 1998, pp 405-421.
4. Premenstrual Syndrome. In: Gynaecology, Robert Shaw, Pat Soutter, Stuart Stanton (eds), 1992, pp 325-340.

Pelvic Inflammatory Disease (PID)

PID is a spectrum of infections involving female upper genital tract i.e. cervix, uterus, tubes, ovaries and pelvic peritoneum. The disease may have acute or chronic presentation. Most cases of acute PID are the result of polymicrobial infection. The commonest cause is sexually transmitted diseases and other causes are post abortal & puerperal sepsis, operative procedures like dilatation and curettage, endometrial biopsy, insertion of intrauterine device.

Treatment (Acute PID)

The patient can be treated as an outpatient or hospitalized depending on the severity of clinical features.

Outpatient treatment

Patient of mild PID with slight pain & tenderness, without toxic features like high-grade fever, vomiting, abdominal distension can be managed as outdoor patients with the following drug regimens

Pharmacological

Either of the following two regimens can be given.

A. Regimen A

1. Inj. Cefoxitin 2 g IM, plus Probenecid 1 g orally, as a single dose.
   Or
   Inj. Ceftriaxone 250 mg IM as a single dose.
   Or
   Inj. Ceftizoxime or Cefotaxime 500 mg IM as a single dose.
2. Cap. Doxycycline 100 mg 2 times a day for 14 days.

B. Regimen B:

1. Tab. Ofloxacin 400 mg oral 2 times a day for 4 days.
2. Tab. Clindamycin 450 mg oral 4 times a day for 14 days.
   Or
   Tab. Metronidazole 500 mg 2 times a day for 14 days.

Follow up after 2 – 3 days of initiation of therapy patient is reevaluated for clinical response. If poor response, patient is to be admitted for intravenous antibiotics.

Indoor treatment

If diagnosis is uncertain and surgical emergencies such as appendicitis & ectopic pregnancy cannot be ruled out, patient is pregnant, post abortal or puerperal and if the patient is adolescent (among adolescents, compliance with therapy is unpredictable), severe illness or nausea & vomiting, HIV positive, unable to follow or tolerate an out patient regimen and outpatient therapy failed. Bed rest. Hydrotherapy, if febrile. IV fluids in cases of vomiting and dehydration and correction of electrolyte imbalance.
Investigate and obtain haemogram with ESR, LFT, KFT, serum electrolytes, blood culture, endocervical swab culture, ultrasonography if adenexal mass. Monitoring by clinical condition, vital monitoring, signs and symptoms of pelvic abscess and peritonitis.

Pharmacological

Either of the following regimens may be instituted at the earliest without waiting for culture reports.

A. Regimen A:

1. Inj. Cefoxitin 2 g IV every 6 hours.
   Or
   Inj. Cefotetan 2 g IV every 12 hours.
2. Inj.Doxycycline 100 mg IV or orally every 12 hours.
3. Inj. Metronidazole 500 mg IV 8 hourly.

B. Regimen B:

1. Inj. Clindamycin 900 mg IV every 8 hours.
2. Inj. Gentamicin 2 mg/kg IV followed by 1.5 mg/kg every 8 hours.
3. Inj. Diclofenac sodium 75 mg deep IM 8 hourly.
   Or
   Inj. Paracetamol 500 mg IM SOS.
4. Inj. Metronidazole 500 mg IV 8 hourly.

Injectable regimen should be continued for at least 48 hours after the patient demonstrates clinical improvement (becomes afebrile, decrease in lower abdomen and pelvic tenderness, improvement in constitutional symptoms). After this, Doxycycline 100 mg 2 times a day orally or Clindamycin 450 mg oral 4 times a day should be continued for total of 14 days.

Clinical improvement should occur within 3 days of initiation of therapy.

Consider further diagnostic tests/laparoscopy if symptoms do not improve or worsen.

Different procedures may be required in the following situations:

• Colpotomy for drainage of midline pelvic abscess
• Dilatation & evacuation of septic products of conception in post abortal sepsis.
• Laparotomy in cases of pyoperitoneum, resistant peritonitis, intestinal obstruction, ruptured tubo-ovarian abscess, enlarging pelvic mass despite medical therapy,
• Laparoscopy: if diagnosis is uncertain, in cases of no response to treatment, to reconfirm the diagnosis, obtain cultures from cul de sac and fallopian tubes and drain pus if necessary.

Treatment of the sexual male partner

Asymptomatic male partner:
Inj. Ceftriaxone 125 mg IM followed by oral Doxycycline 200 mg 2 times a day for 14 days.

Treatment (Chronic PID)

Chronic PID can also be caused by pelvic tuberculosis (see below). Treatment of chronic PID is surgical. Type of surgery is decided considering pathological lesion, patient’s age, and desire for child bearing. Definitive surgery is total abdominal hysterectomy with bilateral salpingooophorectomy, but in young females conservative surgery is preferred.

Treatment (Pelvic tuberculosis)

Primary treatment is medical therapy with anti tubercular drugs for 6 months. Daily dose of the drugs is:

1. Tab. Isoniazid 5 mg/kg (maximum 300 mg).
2. Cap. Rifampicin 10 mg/kg (maximum 600 mg).
3. Tab. Pyrazinamide 15-30 mg/kg (maximum 2 g).
4. Cap. Ethambutol 15-25 mg/kg (maximum 2.5 g).
   (for details see section on tuberculosis (tuberculosis, Tuberculer, meningitis, others))

All these 4 drugs are given in the initial phase for 2 months followed by INH and rifampicin for 4 months. Indication of surgery are: primary unresponsiveness, persistence or enlargement of adenexal mass after 4 – 6 months of treatment, persistence or recurrence of pelvic pain on treatment. Definitive surgery is total abdominal hysterectomy with bilateral salpingo-oophorectomy.

Patient education

• Emphasize behavioural and contraceptive methods to prevent the acquisition of STDs.
• Patients must be encouraged to complete the recommended antibiotic treatment for the full 14 days.
• Sexual abstinence until complete treatment. Sexual partner of patient diagnosed with PID must be treated to prevent reinfection.

References

1. Guidelines for Treatment of Sexually Transmitted Diseases. Centers for Disease Control and Prevention. In: MMWR Morb Mortal Weekly Rep 1998 Jan 23;
   47(RR-1): 1-111
2. Pelvic Inflammatory Disease. In: Te Linde’s Operative Gynaecology, John A Rock, John D Thompson (eds), 1997, pp 657 – 686.

Vaginal Discharge

Vaginal discharge can occur due to vaginitis alone or cervicitis.

Causative organisms for vaginitis are Trichomonas, Candida albicans, Gardenella vaginalis and for cervicitis are Neisseria gonorrhoeae and Trichomonas vaginalis.

Salient features

• A per-speculum examination is necessary in all patients.

A. Treatment (Cervicitis)

Nonpregnant

1. Inj. Ceftriaxone 250 mg IM as a single dose
   Or
   Tab. Ciprofloxacin 500 mg as a single dose
2. Cap. Doxycycline 100 mg twice a day for 7 Days
   Or
   Cap. Tetracycline 500 mg every 6 hours for 7 days
   Or
   Cap. Azithromycin 1 g OD for 7 days.

In Pregnancy

Tab. Erythromycin 500 mg every 6 hours for 7 days (Tetracycline/Doxycycline are contraindicated).

B. Trichomonal Vaginitis

Generally sexually transmitted, but non-sexual contact and fomite transmission also occurs.

Treatment

Pharmacological

Tab. Metronidazole 2 g as a single dose or 500 mg 2 times a day for 7 days or 400 mg 3 times a day for 7-10 days.
Or
Tab. Tinidazole 2 g as a single dose.
Treatment of partner should be undertaken simultaneously. Mixed infection with candida or gardenella is common, therefore may be managed with respective oral therapies or combined (Clotrimazole + Tinidazole) vaginal pessaries as in vulvovaginal candidiasis.

C. Bacterial Vaginosis

Mode of transmission is probably sexual

Treatment

Same as for trichomonal vaginitis.

D. Vulvovaginal Candidiasis

May be sexually transmitted or as an opportunistic infection from endogenous flora. Predisposing factors include pregnancy, oral contraceptives, diabetes mellitus, use of broad spectrum antibiotics, altered cellular immunity (congenital and acquired e.g. HIV), synthetictight undergarments that promote moist and warm local environment.

Treatment

Nonpharmacological

Treatment is aimed towards controlling predisposing factors.

Pharmacological

1. Vaginal Tab. Nystatin (1,00,000 units), 1-2 tablets intra-vaginally HS for 2 weeks (safe in pregnancy)
   Or
   Vaginal pessary Clotrimazole 100 mg HS for 6 days (Alternatively, 200 mg HS for 3 days or 500 mg once). Creams are also available for both vagina and vulva (Safe during pregnancy).
   Or
   Tab. Ketoconazole 200 mg twice a day 2 times a day orally for 5 days
   (CAUTION: Contraindicated during pregnancy, high doses can cause fulminant hepatitis)
   Or
   Tab. Fluconazole 150 mg orally once and repeat weekly for 3 weeks in chronic cases
   (CAUTION: Contraindicated during pregnancy).

Patient education

• Generally sexually transmitted, but nonsexual contact and fomite transmission also occurs.

Reference

Gynaecology, Robert W Shaw, W Patrick Soutter, Stuart L Stanton, (eds), 2nd Edition, 1997, Churchill Livingstone.

Postpartum Haemorrhage (PPH)

Postpartum haemorrhage is excessive blood loss from the genital tract after delivery of the foetus exceeding 500 ml or affecting the general condition of the mother.

Treatment

Patient should be assessed for general condition, amount of blood loss, whether placenta is expelled or not and condition of uterus whether contracted or atonic.

The following resuscitative measures are instituted immediately:

Nonpharmacological

Same as in APH. Monitor pulse rate, blood pressure, respiratory rate and urine output. While resuscitative measures are underway, a thorough clinical examination is made to ascertain the cause of PPH and definitive treatment is planned accordingly.

Pharmacological

Same as in APH and for details see section on shock.

Atonic PPH

Nonpharmacological

Placental removal with cord traction if already separated, uterine massage and bimanual compression.

Pharmacological

1. Oxytocin Infusion (10-40 units in 500 ml Ringer Lactate/Normal Saline at 125 ml/min).
2. Methyl ergometrine maleate 0.2 mg IV, may be repeated IM after 5-10 min. (CAUTION: Contraindicated in heart disease, hypertension).
3. If bleeding is not controlled 15-Methyl PGF2a 0.25 mg IM/ intramyometrial, may be repeated every 15-90 min up to a maximum of 2 mg. (CAUTION: Contraindicated in bronchial asthma, epilepsy).

Indication for referral:

If patient is still bleeding despite medical therapy and if facilities for transfusion and further management are not available arrange for transfer to a higher center. Intrauterine packing or irrigation with hot saline may be done in the mean time.

Surgical treatment

Patient education

• Higher parity and previous atonic PPH predispose to PPH.
• Hospital delivery is mandatory in women with PPH in a previous pregnancy.

References

1. Postpartum Haemorrhage. In: American College of Obstetricians and Gynaecologists, ACOG Technical Bulletin no. 243. Washington, DC, 1998.
2. The Management of Postpartum Haemorrhage. In: Scottish Obstetrics Guidelines and Audit Project, 1998.
3. Williams Obstetrics. F. Gary Cunningham, Paul. MacDonald, Kenneth J Leveno, et al, (eds), 1997.

Antepartum Haemorrhage (APH)

Antepartum haemorrhage is defined as bleeding from genital tract after 20 weeks of pregnancy and before completion of second stage of labor. It is a major cause of maternal morbidity, mortality and perinatal loss. APH is due to placental cause in as high as 70% cases and in 25-30% of cases cause may remain undetermined.

Table I

Table II

Treatment

All patients of APH should be hospitalized in an well equipped center with facilities for blood transfusion, emergency cesarean section and neonatal care unit.

A. Massive Haemorrhage

Following resuscitative measures are started immediately in massive haemorrhage. Simultaneously prepare the patient for termination of pregnancy by vaginal/cesarean section depending on the cause of bleeding.

Nonpharmacological

1. Establish intravenous line (one or two 14/16 gauge cannula)
   a. Draw 20 ml blood for cross-match, haemogram, coagulation profile.
   b. Start fluid therapy rapidly as described below.
2. Head down tilt, keep the patient warm.
3. Oxygen by mask at 8 liters/minute.
4. Empty bladder (Foley’s catheter for urine output).

Pharmacological

1. IV fluids and blood replacement therapy (For details see section on shock).
2. Definitive treatment is termination of pregnancy by cesarean section in cases of placenta previa and by vaginal/cesarian section in cases of abruptio placentae.

B. Mild APH

Expectant management:
In a case of placenta previa without maternal and foetal compromise, expectant management is planned if pregnancy is less than 37 weeks and patient is not having active bleeding and labor pains.

1. Hospitalize and bed rest with foetal & maternal monitoring.
2. Inj. Dexamethasone 12 mg IM 12 hourly for 2 doses should be given for foetal lung maturity.
3. Definitive treatment is termination of pregnancy in case of following: occurrence of life threatening bleeding, pregnancy > 37 weeks, patient is in labor, in all cases of abruptio placentae, baby is dead, congenitally malformed baby and bleeding recurring or premature rupture of membranes on expectant management leading to maternal or foetal compromise.

1. Indications for cesarean section are: Major degree placenta previa, non vertex presentation, in case of abruptio placentae with live foetus if cervix is unfavourable (labor is likely to be longer than 6 hours), failure to progress after amniotomy and oxytocin infusion and other obstetrical indications for cesarean section.
2. Indications for vaginal delivery in APH are: Minor degree placenta previa with vertex presentation and slight bleeding with favorable cervix and abruptio placentae with favorable cervix and with mild to moderate bleeding.

For induction artificial rupture of membranes followed by oxytocin infusion is done. Oxytocin infusion is continued in the postpartum period to prevent postpartum haemorrhage. In abruptio placenta monitoring is done to detect maternal complication early (pulse, BP, urinary output, BT, CT, clot retraction time).

Patient education

• APH irrespective of type and cause results in increased perinatal morbidity and mortality.
• Incidence of placental abruption and placenta previa are both increased with increasing age and parity.
• Hypertension, cigarette smoking, cocaine abuse etc. predispose to placental abruption.

References

1. Antepartum Haemorrhage. In: Anesthetic and Obstetric Management of High Risk Pregnancy, Datta S (ed), 2nd Edition, 1996, Mosby.
2. Obstetric Haemorrhage. In: Intrapartum Obstetrics, Reptke JP (ed), 1996, Churchill Livingstone, pp 203-222.
3. Williams Obstetrics. F Gary Cunningham, Paul. MacDonald, Kenneth J Leveno, et al, (eds), 1997.

Preterm Labor

Onset of labor pains in a pregnant women after 20 weeks and before 37 weeks of gestation associated with progressive dilatation and effacement of the cervix is known as preterm labor.

Treatment

Nonpharmacological

Hospitalization with complete bed rest, preferably in a centre with neonatal intensive care unit.

Laboratory investigations: haemogram, urine culture, and endocervical swab for culture and sensitivity.

Pharmacological

1. Inj. Pethidine 50 mg + Inj. Promethazine 25 mg IM stat and can be repeated 8 hourly.
2. Immediate tocolysis.
   If membranes are intact and labor is not advanced (cervical dilatation <4cm).
   Inj. Isoxsuprine HCl 10 mg IM every 6 hours in case of mild contraction; Intravenous infusion if strong contractions are established 0.2-0.4 mcg/min in 5% dextrose. Maximum dose is 0.8 mcg/min to be continued at least 2 hours after the contractions cease. Followed by IM therapy for 24 hours.
   (CAUTION: Side effects tachycardia and hypotension, hypokalemia, neonatal tachycardia, hypotension and rarely pulmonary oedema and acute respiratory distress syndrome).
   Or
   Inj. Ritodrine infusion 3 ampoules (150 mg) in 500 ml of 5% dextrose or ringer lactate at 50- 100 mcg/min (5-6 drops/min), increase by 50 mcg every 10 min till contractions cease or side effects appear (maximum dose 350 mcg/min), continue for 12 hour after contractions stop. This is followed by oral treatment – 10 mg every 2 hours for 24 hours then 10-20 mg every 4-6 hours.
   (CAUTION: Contraindications: Poorly controlled diabetes or thyroid disease, sickle cell disease).
   Or
   Inj. Magnesium sulfate 4-6 g as 20% solution bolus over 30 minutes followed by infusion of 4-6 g/h.
   (CAUTION: Contraindicated in patient with myasthenia gravis, cardiac decompensation. Use with caution in renal disease. It can cause flushing, lethargy, headache, muscle weakness, dryness of mouth, nausea and foetal distress, transient non-reactive NST).
   Or
   Cap. Nifedipine 30 mg loading dose followed by 10-20 mg every 4-6
   hours.
   (CAUTION: Do not administer along with magnesium sulfate; contraindicated in maternal hypotension (< 90/50 mmHg), cardiac disease. Use with caution in renal disease; maternal side effects, flushing, headache, nausea, dizziness, hypotension). Monitor pulse, BP, and cessation of the uterine contractions. If pulse
   rate >120/min and BP < 90/50 mmHg stop tocolysis. Monitoring in magnesium sulfate therapy is as outlined in eclampsia. Monitor for onset of choriamnionitis (fever, tachycardia with uterine tenderness).
3. Maintenance therapy
   Tab. Isoxsuprine orally 10 mg 6 hourly or 20 mg 12 hourly (maximum daily dose is 40 to 80 mg/day) to be continued till 34 weeks of pregnancy (long term therapy is controversial).
4. In pregnancies at 28 – 34 weeks of maturity, steroids are given for foetal lung maturity.
   Inj. Betamethasone 12 mg IM 2 doses 24 hours apart.
   Or
   Inj. Dexamethasone 6 mg IM four doses 12 hours apart or 12 mg IM two doses 12 hours apart.
   (CAUTION: Contraindicated if clinical or laboratory evidence of
   chorioamnionitis is present).
5. Cap. Ampicillin 500 mg or Erythromycin 500 mg 4 times a day for 5-7 days.

Patient may be discharged after 1 week of tocolysis followed by regular antenatal surveillance.

Delivery

In cases of ineffective tocolysis or with contraindications for tocolysis, labor is allowed to progress and mode of delivery is decided as per obstetric indications. Careful foetal monitoring required throughout labor

• if any sign of hypoxia, caeserean section is better but foetus should have a fairly good chance of survival depending on neonatal care facility.

Patient education

• Restricted physical activity after discharge.
• Sexual abstinence till at least 34 weeks of gestation.
• Explain the risk of recurrence in subsequent pregnancy. Therefore need for early booking and prophylactic measures in next pregnancy.

References

1. Clinical Problems of Preterm Labor. In: Clinical Obstetrics and Gynaecology, 2000, pp 43, 713-818.
2. Preterm Birth. In. Williams Obstetrics, 20th Edition, 1997, Appleton and Lange, pp 797-826.
3. Preterm Labor. In: Practical Guide to High Risk Pregnancy and Delivery, Fernando Arias (ed), 2nd Edition, 1998, Mosby, pp 71-100.
4. Recent Advances in Preterm Labor. In: Recent Advances in Obstetrics and Gynaecology No 20, H John Bonnar (ed), Churchill Livingstone, pp 97-110.

Diabetes In Pregnancy

Pregnancy can be complicated by preexisting insulin dependent or noninsulin-dependent diabetes or gestational diabetes. Gestational diabetes is defined as the carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.

Treatment

All pregnancies in diabetic females should be managed at a tertiary care center.

Nonpharmacological

Dietary advice: Total daily calorie intake should be 30 KCal/kg current pregnancy body weight if her current weight is 80-120% of ideal prepregnancy weight. In case current weight is <80% or >120% of ideal prepregnancy weight, then calorie intake is 36-40/kg current pregnancy weight or 24/kg current pregnancy weight respectively. Total daily calorie intake should be 30-35 KCal/kg current pregnancy weight. Complex carbohydrates should provide about 50% of the total calories, which should be well distributed throughout the day. High fiber diet is beneficial with 30-50 g fibers daily. Total diet should be distributed in 3 major meals and 3 mid meal snacks.

General measures: Ultrasound assessment of foetal gestational age is to be done as early as possible. Foetal congenital anomalies should be ruled out by Level II USG scan at 16 – 18 weeks and maternal serum alpha-feto protein at 16-18 weeks. Serial USG for foetal growth monitoring & biophysical scoring for assessment of foetal well being after 32 weeks of gestation.

Pharmacological

A. Antenatal Management

a. Preexisting diabetes
Oral hypoglycaemic agents are contraindicated during pregnancy. If patient is on oral hypoglycaemics, switch over to insulin therapy as soon as pregnancy is diagnosed.

1. Inj Insulin: 0.6-0.8 U/kg in 1st trimester, 0.7 – 0.9 U/kg in 2nd trimester and 0.8 – 1.2 U/kg in 3rd trimester.
   Usually a combination of intermediate acting and regular insulin in proportion of 2:1 is given. 2/3 of the total requirement is given in the morning before breakfast and 1/3 is given at night with regular insulin before dinner and intermediate at bedtime. Dose adjustment is done according to the twice weekly blood sugar monitoring.
2. Hospitalization is required in cases of excessive vomiting, infections, maternal complications like hypertension, retinopathy, nephropathy, foetal compromise like macrosomia or intra uterine growth retardation (IUGR) or poor diabetic control.

b. Gestational diabetes

1. General management is same as outlined above.
2. Diet control. Patient is reassessed after 1 week. If control not achieved insulin therapy is started. Usually single injection in the morning is sufficient. If pregnancy >28 weeks, 20 units intermediate + 10 units regular insulin single injection 15 – 45 min before breakfast is started.

If pregnancy <28 weeks, start with the half dose. Daily monitoring of blood glucose is done. If fasting plasma sugar is >105 mg% or postprandial >120 mg%, dose of insulin is increased. Regular insulin is adjusted to normalize post breakfast glucose and intermediate for post lunch glucose control. If evening or fasting glucose is elevated, 2nd daily injection is added. If both are elevated, mixture of intermediate and regular insulin before dinner is added. If only fasting is elevated, add intermediate acting insulin at bedtime.
Or
Inj. Regular Insulin 3 times a day before each main meal which can be combined with one dose of intermediate acting insulin at bed time in case there is fasting hyperglycaemia.

Apart from routine antenatal monitoring, blood sugar monitoring is required throughout pregnancy. Therapeutic goal is to achieve plasma blood sugar levels fasting <105 mg% and 2 hour postprandial <120 mg%. When levels are high daily monitoring with insulin dose adjustment is required.

Once control is achieved, patient can be managed at home with weekly blood sugar profile.

B. Management during labor

In uncomplicated case with good glycaemic control pregnancy can be continued till expected date of delivery. In presence of complications or foetal compromise pregnancy is terminated at 38 weeks or earlier if required. If estimated foetal weight is >4 kg, caesarean section is performed. Labor is managed with intensive monitoring. Blood sugars are monitored 3-4 hourly aim is to keep blood sugars between 100-120 mg%, using the sliding scale method.

In the postpartum period, the requirement of insulin is decreased.

Patient education

• In known diabetics, good blood sugar control should be achieved in preconception period to avoid high risk of congenital anomalies.
• Strict adherence to the dietary advice & insulin therapy is essential throughout pregnancy. As insulin requirements change throughout pregnancy therefore, frequent blood sugar monitoring is required throughout pregnancy.
• Patient on insulin therapy should be told about symptoms of hypoglycaemia like palpitations, sweating, dizziness, and its management.
• In cases of gestational diabetes, there is risk of recurrence in subsequent pregnancies and later on risk of frank diabetes is there.
• Contraceptive advice. Combined oral contraceptive pills and intrauterine devices are preferably avoided. Barrier methods, progestogen only pills/implants/injectables or sterilization can be offered.

References

1. Diabetes. In: Williams Obstetrics, F Gary Cunningham, Paul. MacDonald, Kenneth J Leveno, et al, (eds), 1997, pp 1203 -1223.
2. Insulin Management of Type I & Type II Diabetes in Pregnancy. In: Clinical Obstet Gynaecology, John W. Hare, 1991, pp 34(3), 494 – 504.
3. Management of Gestational Diabetes. In: Clinical Obstet Gynaecology, Donald R. Coustan.1991, pp 34(3), 558 – 564.
4. Diabetes. In: Medical Disorders in Obstetrics Practice, Michael Deswiet (eds), 1991.

Pregnancy With Heart Disease

Organic heart disease in pregnancy is commonly due to rheumatic heart disease or congenital heart disease. Pregnancy with its increased cardiovascular stress is a potential cause for worsening of the existing heart disease.

Treatment

All pregnant women with heart disease should be managed at a tertiary level center with multidisciplinary approach. Depending on the limitation of physical activity patient is classified into class I to IV of New York Heart Association (NYHA). Much of the clinical approach to the pregnant women with heart disease is according to NYHA class irrespective of the aetiology of the heart disease.

Nonpharmacological

• NYHA class III & IV patients are to be hospitalized throughout the pregnancy while class I & II can be managed as outdoor patients with more frequent antenatal visits and admitted at 38 weeks.
• Rest for 10 hours each night and 1 to 2 hour after each meal. Light housework & walking without climbing stairs is permitted. No heavy work is allowed.
• Avoid high salt intake.
• Screen and treat at the earliest for excessive weight gain, abnormal fluid retention, anaemia, pregnancy induced hypertension, infections.

Pharmacological (in consultation with the cardiologist and for details see section on CHF)

In case of rheumatic heart disease,

1. Inj. Benzathine penicillin 1.2 mega units IM 3 weekly.
2. Treat any infections with appropriate antibiotics.
3. In patients with mechanical prosthetic valves.

Inj. Heparin is given throughout pregnancy to maintain PTT at 1.5 to 2.5 times the normal control.
(CAUTION: Oral anticoagulants are not safe during pregnancy because of risk of congenital anomalies in the foetus. But if required, can be given after first trimester and continued till 4 weeks before delivery. However, oral anticoagulants are safe during lactation).

Labor management

1. Vaginal delivery is contraindicated in coarctation of aorta. In other cases caesarean is performed for only obstetrical indications.
2. Pain relief is important during labor. Best option is to give continuous epidural analgesia. It is contraindicated in women with intra cardiac shunts, aortic stenosis, pulmonary hypertension, and hypertrophic cardiomyopathy. Inj. Morphine can also be given for pain relief.
3. Fluids should be restricted to 75 ml/min. Bolus Oxytocin & Methyl ergometrine should be avoided.
4. Antimicrobial prophylaxis for infective endocarditis required in all patients with cardiac lesions undergoing any operative procedure or in labor.

Inj. Ampicillin 2 g + Inj. Gentamicin 1.5 mg/kg (maximum 120 mg) IV or IM 30 min before procedure followed by Cap. Ampicillin 1 g IM or IV; or Cap. Amoxycillin 1 g orally 6 hours after initial dose.

If patient is allergic to penicillin Inj. Vancomycin 1 g IV (over 1-2 hours) plus Inj. Gentamicin 1.5 g/kg (maximum 120 mg). Infusion to be completed within 30 min before procedure.

Patient education

• Depending on the type & severity of cardiac lesion maternal risk of pregnancy should be discussed with the patient ideally before pregnancy.
• Option of corrective surgery preferably before pregnancy.
• 2 – 5% risk of congenital heart disease in foetus if mother has congenital heart disease.
• Contraceptive advice: sterilization, progestogen only method or barrier method.
• In severe cases option of medical termination of pregnancy if pregnancy <12 weeks.

References

1. Cardiovascular Disease, In: William’s Obstetrics, F. Gary Cunningham, Paul. MacDonald, Kenneth J Leveno, et al, (eds), 1997, pp 1079 – 1102.
2. Heart Disease in Pregnancy. In: Medical Disorders in Obstetric Practice, Michael de Swiet (ed), 1991, pp 198 – 248.

Eclampsia

Treatment (to be managed at a tertiary care level)

Principles of management are control and prevent recurrence of convulsion and control of hypertension. Treat any complication that arise and delivery safely as soon as possible. Continue anticonvulsant therapy 24 h after delivery or last fit whichever is latest.

Nonpharmacological

Place the patient in left lateral position in a separate, quiet room. Secure and maintain airway. Use mouth gag or airway to prevents tongue biting/tongue falling back. Intubate if patient is deeply unconscious, poor arterial blood gases, extensive laryngeal oedema, and extreme restlessness.

• Suction to remove oropharyngeal secretions.
• Oxygen by face mask.
• Set up IV access.
• Monitor heart rate and respiration, BP, urine output.
• Lab. Investigations: haemogram with platelet count, liver & kidney function tests, urinary proteins, coagulation profile, fundus examination.

Pharmacological

1. Inj. Magnesium sulphate loading dose of 14 g of which, 4 g as 20% solution given slowly IV over 5 -10 minutes and 5 g as 50% solution given deep IM in each buttock (total 10 g IM) If fits are not controlled in 15 min, give 2 g Magnesium sulfate as 20% solution slow IV.
   Maintenance dose 5 g magnesium sulfate as 50% solution deep IM every 4 hours in alternate buttock Or Continuous IV regimen 4 g loading dose over 20 minutes followed by 1 g/h slow continuous IV infusion.
   (CAUTION: Side effects are respiratory depression and neuromuscular depression in mothers. Neonatal respiratory and neuromuscular depression).
   If respiratory depression occurs, give calcium gluconate 1 g IV as 10% sol. If respiratory arrest occurs, immediate endotracheal intubation and ventilation is to be done.
   Monitoring: Check for respiratory rate to be more than 16/min, patellar reflex to be present and urine output >25 ml/h before giving magnesium sulfate.
   Or
   Inj. Phenytoin loading dose of 15-25 mg/kg slow IV not exceeding 25 mg/min diluted in normal saline for first 750 mg and then 12.5 mg/min followed by 100 mg IV 8 hourly.
   ECG tracing to be taken every minute for 10 min during infusion of first 750 mg.
2. Fluid management should be closely monitored to prevent complications such as pulmonary oedema, left ventricular failure and adult respiratory distress syndrome.
   IV fluid should be at the rate of 1 mg/kg/hr or previous days urine output plus 30 ml.
3. Anti hypertensives: as described in preeclampsia. Aim is to gradually lower the BP to 140-150/90-100 mm Hg.

Definitive management is termination of pregnancy irrespective of the foetal maturity. Termination is by labor induction and vaginal delivery or caesarean section.

Indications of caesarean section are: all deeply unconscious patients unless delivery is imminent, uncooperative patient due to restlessness, if vaginal delivery is unlikely to occur within 6-8 hours from the onset of 1st eclamptic seizure, and other obstetric indications.

Care after delivery

• Patients of eclampsia and severe preeclampsia need intensive monitoring for at least initial 72 hours.
• Continue anticonvulsant till 24 hours after delivery or fit, whichever occurs later.
• Gradually decrease the dose of antihypertensives.
• Patient is discharged after 10-14 days of delivery or earlier if BP controlled without antihypertensives.
• Follow up after 6 weeks for reevaluation.

Patient education

• Delivery is the only definitive treatment. Underlying disease remains till delivery and complications can arise despite control of BP on treatment.
• Symptoms of severe pre eclampsia like headache, vomiting, epigastric pain, decreased urine output, blurring of vision should be immediately reported.
• Need for prolonged hospitalization.
• Early booking in next pregnancy as there is 25-30% risk of recurrence.
• Prophylactic measures like low-dose aspirin can be started in early pregnancy.
• Need for re evaluation at 6 weeks postpartum for reclassification and investigations of hypertension and need for long- term antihypertensives.
• High risk of development of chronic hypertension in later life.

References

1. Preeclampsia and Eclampsia. In: Practical Guide to High Risk Pregnancy and Delivery. Fernando Arias (ed), 2nd Edition Reprint 1998, Mosby, pp 183-212.
2. Hypertensive Disorders in Pregnancy. In: Williams Obstetrics. 20th Edition, 1997, Appleton and Lange, pp 693-744.
3. Advances in Management of Severe Preeclampsia and Antihypertensive Therapy. In: Recent Advances in Obstetrics and Gynecology. No. 20, John Bonnar (ed), 1998, Churchill Livingstone, pp 111-124.
4. Treatment of Severe Preeclampsia/Eclampsia Syndrome. In: Progress in Obstetric and Gynecology, Studd (ed)., 2000, Vol.14, Churchill Livingstone, pp 102-119.

Preeclampsia

Pre eclampsia is one of the commonest causes of maternal and perinatal morbidity & mortality. It affects around 5-8% of all pregnancies.

Preeclampsia is principally a syndrome of signs, occurring more frequently in primigravida. When superimposed with convulsions it is termed as eclampsia. Other high risk factors are – multiple pregnancy, hydramninos, and molar pregnancy.

Treatment

Hospitalize all cases. Definitive therapy is to terminate pregnancy. The choice between immediate delivery and expectant management depends on:

1. Severity of disease.
2. Condition of mother and foetus and
3. Period of gestation (POG).

A. Mild pre eclampsia

Expectant management: in cases of mild pre eclampsia without foetal and maternal compromise, with gestational age <37 weeks.

Nonpharmacological

Complete bed rest preferably in left lateral position and regular diet adequate in proteins & calories with omission of extra table salt.

Pharmacological

1. Antihypertensive treatment is started if there is persistent diastolic blood pressure over 100 mmHg. Aim of treatment is to achieve a systolic BP less than 130 mmHg and diastolic BP less than 90 mmHg.
   Tab. Methyldopa 250 mg 8 hourly or 6 hourly (maximum dose 2 g/day).
   Or
   Tab. Atenolol 50-100 mg once a day.
   If BP is not controlled in 72 hours with the above, add any of the following :
   Cap. Nifedipine 10 mg 8 hourly.
   Or
   Tab. Nifedipine retard 10 mg 12 hourly (maximum 30 mg 12 hourly).
   Or
   Tab. Labetalol 100-200 mg 8 hourly (maximum 600 mg 6 hourly).

Monitoring

• Daily monitoring of weight gain, BP, urine albumin, urine output.
• Weekly lab investigations – haemogram with platelet count, liver and kidney function tests specially serum uric acid.
• Foetal monitoring by clinical & USG growth assessment, daily foetal movement count, non stress test twice weekly and biophysical score weekly.
• In case of mild pregnancy induced hypertension without proteinuria, if after hospitalization BP is controlled with rest without any antihypertensive drug, patient can be discharged after initial evaluation if no maternal/foetal compromise is detected. It can be practiced only in reliable patients who will follow instructions for monitoring as above, and also will report ominous symptoms immediately. (Ominous symptoms are persistent severe headache, visual disturbances such as dimness of vision, double vision or blindness, epigastric pain, nausea, vomiting and oliguria).

Definitive management

Termination of pregnancy by labor induction/caesarean section in the following conditions:

• Gestational age 37 weeks, foetal compromise like severe growth retardation, oligohydramnios, abnormal non-stress test or biophysical score, maternal compromise like development of features of severe pre eclampsia, onset of labor, rupture of membrane or bleeding.

B. Severe preeclampsia (Treatment preferably in a tertiary care center)

Nonpharmacological

• Observation in intensive care for 24 hours
• Assessment of maternal and foetal conditions. BP monitoring 2-4 hourly, hourly urine output monitoring, watch for sign and symptoms of impending eclampsia and foetal distress.
• Lab Investigations: haemogram with platelet count, liver and kidney function tests, urinary proteins, coagulation profile, fundus examination, obstetric ultrasound with BPS.
• Intravenous fluids Ringer’s Lactate at rate of 60 ml/h (maximum 125 ml/h).

Pharmacological

The aim of the treatment is gradual lowering of blood pressure so that diastole BP is lowered by not more than 30 mmHg to maintain adequate perfusion and systolic BP is maintained above 90 mmHg to avoid uteroplacental insufficiency.

1. Immediate managementTab. Nifedipine 10 mg orally can be repeated after 30-60 min. (maximum dose 20 mg 4 hourly).
   (CAUTION: Side effects-Tachycardia, headache, flushing, and aggravation of angina. Rapid fall in BP can cause foetal distress).
   If BP is not controlled with oral treatment then IV drugs are started with intensive monitoring.Inj. Labetalol initial dose is 50 mg slow IV followed by infusion at 60 mg/h, doubling every 15 min until BP is controlled or maximum dose 480 mg is reached.
2. Maintenance therapyAfter initial control of acute hypertension, patient is started on maintenance therapy with antihypertensives as described in management of mild preeclampsia.
3. Prophylactic anticonvulsants in women with severe preeclampsia especially in cases with signs and symptoms of impending eclampsia. Magnesium sulfate sol (50%) 10 ml (5 g) in each buttock (total of 10 g) followed by second dose in alternate buttocks every 4 hours. Before each dose monitor for presence of patellar reflex, respiratory rate >16/min and urine output > 25 ml/h.After initial evaluation and stabilization of the patient further management is decided depending on foetal maturity and maternal response:

Expectant management: Considered if pregnancy in between 24-34 weeks and hypertension controlled with maximum of two drugs, urine output is normal, lab investigations are normal and no foetal compromise. Patient should be hospitalized till delivery.

Managed as mentioned in the mild pre eclampsia with antihypertensives, bed rest and more frequent maternal and foetal monitoring.

Definitive management is termination of pregnancy:

• Pregnancy beyond 34 weeks – stabilize maternal condition and terminate pregnancy.
• Pregnancy less than 24 weeks – stabilize maternal condition and terminate pregnancy.
• Patient on expectant management develops following features: uncontrolled hypertension despite maximum dose of 2 antihypertensive drugs, eclampsia raised liver enzyme >2 time with right upper quadrant pain and tenderness, pulmonary oedema, platelet < 1 lac/cu mm, creatinine > 1 mg/dl over baseline, persistent headache, vomiting and visual disturbance suggestive of impending eclampsia and foetal compromise.After delivery, intensive monitoring should be continued for 72 hours with prophylactic anticonvulsant continued till 24 hours postpartum. Dose of anti hypertensives should be gradually reduced.

Anaemia In Pregnancy

Prevalence of anaemia in pregnancy in India is 80% and severe anaemia is 10-15%. Causes of anaemia in pregnancy are the same as those encountered in the non pregnant state. However, Iron deficiency anaemia is commonest in pregnancy. In about 40-50% of cases there is associated folic acid deficiency.

Anaemia in pregnancy is defined as haemoglobin concentration of less than 11 g/dl and haematocrit of less than 33%. It is further classified depending on Hb levels as mild 10-10.9 g%, moderate 7-10 g% and severe <7 g%.

Treatment (Iron deficiency anemia)

Nonpharmacological

1. Diet rich in iron – jaggery, green leafy vegetable, sprouted pulses, cooking food in iron utensils.
2. Diet rich in protein – pulses, lentils, milk and milk products.
3. All cases of severe anaemia to be admitted especially those with features of anoxia or cardiac failure

Pharmacological

1. Oral Iron Therapy: Ferrous sulfate and Ferrous fumarate. Recommended dose is 200 mg elemental iron daily in divided doses. Not to be taken with meals, milk, coffee or tea. Continue therapy till blood picture returns to normal and then continue with 100 mg elemental iron for 3 months to build up the stores. (Common side effects are epigastric pain, nausea, vomiting, constipation, and diarrhoea).
2. Tab. Mebendazole 100 mg 2 times a day for 3 days.
   Or
   Tab. Albendazole 400 mg single dose.

Monitoring of response to therapy

Subjective improvement of feeling better, weight gain and improved appetite after 1-2 weeks. Reticulocyte response observed in 5-10 days (increases to 5-6%) and rise in Hb/haematocrit in 2-3 weeks. The concentration is expected to rise at the rate of 0.1-0.25 g/dl/day or 0.8 -1 g/dl/week.

If no improvement in 3 weeks reevaluate for: incorrect diagnosis, non compliance, defective absorption, continuing loss, associated deficiencies

Role of parenteral therapy is limited as rate of rise of haemoglobin with parenteral iron is similar to oral iron preparation.

Specific indications are: severe intolerance to oral iron, malabsorption, non compliance and moderate to severe anaemia in advanced pregnancy.

Total dose of iron to be given is calculated using following formulae:
% deficiency of Hb x weight in lbs x 0.03 + 300 mg.
Or
Simple method 250 mg of elemental iron needed for each gram of Hb deficit.
(CAUTION – Oral iron is suspended at least 24 hours prior to therapy to avoid reaction).

Inj. Iron dextran or Iron sorbitol complex (available as 50 mg/ml) IM after an initial test dose of 0.5 ml, the injections are given daily or on alternate days in doses of 2 ml IM using Z technique. To prevent staining of skin one can pass small amount of saline/air down the needle before withdrawing it.
(CAUTION – Emergency drugs to be kept ready for resuscitation in case of anaphylactic reaction).
Or
Intravenous Route: Total Dose Infusion (TDI) (to be given as inpatient).

Inj. Iron Dextran is diluted in 5% dextrose. Initial infusion is given slowly at 8 drops per min. for half an hour to watch for reaction, then increase gradually to 40 drops/min. Total iron dose is administered in a single sitting. If >2000 mg then only half dose is given in one day.

Monitor for adverse reactions like rigor, chest pain, and hypotension. If present stop the infusion.
(Note: see also anaemia in common conditions and paediatrics section)

Indication for blood transfusion are

Severe blood loss, severe anaemia beyond 36 weeks of pregnancy or anaemia refractory to oral and parental therapy or anaemic patient with anoxia or cardiac failure.

Management of anaemic patients during labor

1. Propped up position, oxygen therapy.
2. Sedation and pain relief.
3. Digitalization may be required in cardiac failure due to severe anaemia.
4. Cut short 2nd stage by forceps.
5. Active management of 3rd stage of labor with Inj. Methylergometrine maleate 0.2 mg IV at the delivery of anterior shoulder. Inj. Methylergomertrine to be avoided in patients of anaemia with cardiac failure.

Megaloblastic anaemia in Pregnancy

Folic acid Deficiency

Treatment

Tab. Folic acid 5 mg daily to be continued for at least 4 weeks in puerperium.

Vitamin B12 deficiency

Treatment

Inj. Cyanocobalamin 250 mcg IM every month.

Dimorphic anaemia

Treatment is prescription of both iron and folic acid in therapeutic dose.

Patient education

• Dietary advice as mentioned earlier.
• Common side effects of therapy should be explained to the patient.
• Tell patient that stools turn black after oral iron therapy, so no need for concern.
• Iron supplementation should continue for at least 3 months in post partum period.
• Adequate spacing of at least 3 years between 2 pregnancies.

References

1. Haematological Disorders. In: William’s Obstetrics, 21st Edition, 2001, McGraw Hill Company Inc., pp1307-1323.
2. Haematological Problems During Pregnancy. In: Practical Guide to High Risk Pregnancy and Delivery. Fernando Arias (ed), 2nd Edition, 1992, Harcourt Asia Pvt Ltd., pp 245-262.
3. Anaemia and Pulmonary Tuberculosis. In: Practical Obstetric Problems. Ian Donald (ed) 5th Edition, 1998, BI Publications, pp 198-226.
4. Medical and Surgical Illness complicating Pregnancy. In: Textbook of Obstetrics, DC Dutta (ed), 4th Edition, 1998, New Central Book Agency (P) Ltd., pp 277-292.
5. Haematinics and Erythropoietin. In: Essential of Medical Pharmacology, KD Tripathi (ed), 4th Edition ,1999, Jaypee Brothers Medical Publisher Pvt Ltd., pp 580-595.

Medical Termination Of Pregnancy

The Govt. of India has legalized medical termination of pregnancy up to 20 weeks of gestation by MTP Act 1971. Under this act, pregnancy can be terminated under following clauses:

Clauses and requirements

1. Damage to the life of the pregnant woman.
2. Grave injury to the physical or mental health of the pregnant woman.
3. Pregnancy caused by rape.
4. Substantial risk, that if the child was born, it would suffer from such physical or mental abnormalities as to be seriously handicapped.
5. Failure of any contraceptive method or device.

Necessary consent form as laid down in the Act should be duly filled and signed. Opinion of two registered medical practitioners is mandatory for second trimester MTP (>12 weeks).

First Trimester MTP Methods

Surgical method: Suction & evacuation done in all centres approved under MTP Act. MVA (Manual Vacuum Aspiration) can be done in all PHCs.

Patient education

• Details of the method and small risk of complications should be explained.
• Medical method fails in around 5% cases and these will require surgical curettage.
• Should be motivated for concurrent contraception and option of all available methods both temporary and permanent should be discussed.

Second trimester MTP Methods

Conducted in secondary and tertiary care level. None of the second trimester methods are 100% safe & effective. That is why many methods both surgical and medical, are available and being used. For second trimester MTP medical methods are preferred.

• Methods are usually combined so as to increase the success rate and to shorten induction abortion interval. Most commonly extra amniotic ethacridine is combined with oxytocin or prostaglandins by various routes.
• Better results if some method for cervical ripening is used 6 – 12 hours before.
• If some method fails switch over to other method or surgical method.

Methods of cervical ripening: 6-12 hours before the procedure any of the following can be inserted intra cervically laminaria tent/Isaptent/Lamicel/PGE2(alpha) gel 0.5 mg.

Surgical methods: Hysterotomy (To be carried out by an experienced obstetrician and gynaecologist because of high risk of injury, haemorrhage and incomplete evacuation and scar endometriosis).

Patient education

1. Explain the details of the method and the need for hospital admission.
2. Risk of complications around 5 times higher than that of first trimester. Small risk of uterine rupture is there.
3. Patient should be motivated for concurrent contraception and option of all available methods both temporary and permanent should be discussed.

References

1. Manual on MTP an Update. Manju V Matalya, MJ Jassawalla (eds), 1999, FOGSI Publication.
2. Abortion. In: Williams Obstetrics, F Gary Cunningham, Paul MacDonald, Kenneth J Leveno, et al, (eds), 1997, pp 579-605.
3. The Abortion Problem. In: Postgraduate Obstetrics & Gynaecology, MK Krishna Menon, PK Devi, K Bhaskar Rao (eds), 1989, pp 89-105.

Septic Abortion

Any abortion associated with fever and signs of pelvic or generalized sepsis is considered septic abortion. Most septic abortions result from illegal abortions but sepsis may follow spontaneous & elective abortions.

Treatment (To be managed at a tertiary care level)

Before starting antibiotic therapy, high vaginal or cervical swab & blood culture should be obtained.

Pharmacological

1. IV fluids for correction of electrolyte imbalance (see section on shock).
2. Oxygenation: O2 by facemask in severe cases. In cases of adult respiratory distress syndrome intubation and ventilatory support is
   required, and hydrotherapy if required.
3. If blood pressure is not controlled with fluid replacement, Inj. Dopamine infusion in 5% Dextrose 2 – 5 mcg/kg/min and dose titrated according to clinical and haemodynamic response (for details see section on shock).
4. In cases of shock, acidosis is corrected by IV Sodium bicarbonate 50-100 mEq in normal saline.
5. Inj. Penicillin 3,000,000 units IV every 4 hours (after test dose).
   Or
   Inj. Ampicillin 500 mg IV 6 hourly (after test dose).
   Or
   Inj. Cefuroxime or Ceftazidime 1-2 g IV 2 times a day (after test dose).
   Or
   Inj. Chloramphenicol 500 mg IV 6 hourly.
6. Inj. Gentamicin 1.5 mg/kg then 1 mg/kg IV 8 hourly.
   Or
   Inj. Amikacin 250 – 500 mg IV 8 hourly.
7. Inj. Metronidazole 500 mg IV 8 hourly.
   Or
   Inj. Clindamycin 600 mg IV 6 hourly.
   Continue antibiotic therapy for 48-72 hours until culture sensitivity results provide an indication for changing the initial antibiotic regimens. Monitor pulse, temperature, blood pressure, respiratory rate, urine output, and serum electrolytes. In severe cases CVP & ABG monitoring is required. Therapeutic goals are to maintain systolic BP >90 mmHg, urine output >30 ml/min, arterial PO2 >60 mmHg, and CVP 6 – 12 cm of H2O.
8. A) Uterine curettage: if patient’s condition is stable, within 1 hour of antibiotic therapy, evacuation of the uterus by gentle curettage to remove infected products. If general condition is low at admission, curettage after 6 – 8 hours of antibiotic therapy & treatment of hypovolemia is done.
   B) Laparotomy in case of injury to the uterus, suspected injury to the gut, presence of foreign body in the abdomen as evidenced by X ray or felt through the fornix, peritonitis, and (septic shock or oliguria not responding to the conservative treatment).
   Or Colpotomy in cases of pelvic abscess.

References

1. Abortion. In: William’s Obstetrics, F Gary Cunningham, Paul MacDonald, Kenneth J Leveno, et al (eds), 1997, pp 579-605.
2. Septic Shock in Obstetrics. In: Critical Care Obstetrics. Steven L Clark, David B Cotton, Gary DV Hankins, et al (eds), 1991, pp 289 – 305.
3. The Abortion Problem. In: Postgraduate Obstetrics & Gynaecology. MK Krishna Menon, PK Devi, K Bhaskar Rao (eds), 1989, pp 89-105.

Ectopic Pregnancy

Treatment of ectopic pregnancy should be undertaken at a secondary/tertiary care level set up. Laparoscopic surgery or laparotomy is done in all cases of ectopic pregnancy except in a few selected cases who are highly compliant and reliable and fulfill the following criteria:
- Unruptured ectopic pregnancy in haemodynamically stable patient.
- Gestational sac size < 3.5 cm in greatest diameter.
- Serum hCG titer < 10,000 mIU/ml.
- Gestation< 6 weeks.
- Absence of foetal cardiac activity.

Treatment

Pharmacological (For unruptured ectopic pregnancy)

1. Obtain pretreatment hCG titers, haemogram, liver and renal function tests.
2. Inj. Methotrexate 50 mg/sq meter body surface area IM given on day 1.
3. Repeat hCG titers on day 4 & 7.
4. If day 7, hCG titers reflect a drop of at least 15% from maximum levels then weekly hCG titers till negative.
5. If fall <15% or there is rise then Inj. Methotrexate is repeated

Patient education

• Resolution of ectopic pregnancy may take up to 6 weeks.
• 5 – 10% cases require surgery despite medical therapy.
• Signs and symptoms of tubal rupture such as vaginal bleeding, abdominal pain, weakness, dizziness or syncope must be reported promptly.
• Patient should refrain from alcohol and folic acid containing vitamins during this period.
• Sexual relation should be avoided during therapy.

References

Williams Obstetrics F. Gary Cunningham, Paul. MacDonald, Kenneth J. Leveno et al (eds), 1997.

Threatened Abortion

Nonpharmacological

Bed rest.

Pharmacological

1. Inj. Morphine 15 mg IM stat for those who have pain and are anxious.
   Or
   Inj. Pethidine 50 mg + Promethazine 25 mg IM stat for those who have pain and are anxious.
2. Tab. Folic acid 5 mg daily.
3. Monitor for the continuation of pregnancy.
   Discharge the patient 48 hours after bleeding stops.

Patient education

• To report immediately if bleeding recurs or it is more than normal periods.
• Continue bed rest for at least 2 weeks.
• Abstinence till at least two follow-up visits in the next 4 weeks when normal continuation of pregnancy is documented.
• High fibre diet to avoid constipation.
• Need of follow up after 2 weeks for foetal growth by clinical and/or USG parameters.
• After suction evacuation for abortion.
  • Reassurance if no living child.
  • Need for contraceptive.
  • When to resume coitus.
  • When to attempt conception.

References

1. Abortion. In: William’s Obstetrics, 20th Edition, 1997, Prentice-Hall International, Inc., pp 597-606.
2. Haemorrhage in Early Pregnancy. In: Textbook of Obstetrics, 4th Edition, 1998, New Central Book Agency (P) Ltd., pp 170-215.

Bleeding In First Trimester Of Pregnancy (Abortion)

Table 1: Evaluation of patients presenting with bleeding in the first trimester of pregnancy

Treatment

• Abortion can be treated at a primary care level.
• Molar and ectopic pregnancy should be treated at a secondary/tertiary care level.
• Hospitalize all patients of bleeding in the first trimester.
• Assess for blood loss and take immediate measures to combat hypovolemia as indicated.

Surgical therapy: suction evacuation in all cases of abortion and molar pregnancy except threatened abortion.

• Laparotomy/laparoscopic removal of ectopic pregnancy except a few selected cases of unruptured ectopic pregnancy (see details).

Patient education

• Exact etiology of abortions is not always apparent.
• Very early abortions are often nature’s selection to abort a nonviable, chromosomally abnormal conceptus.
• Increased abortions are seen with increasing parity and maternal age.
• Recurrent abortions 2 or more consecutive abortions should be investigated before planning the next pregnancy.
• Effective contraception should be initiated soon after abortion as ovulation can occur as early as 2-3 weeks after an abortion.

Nausea And Vomiting In Pregnancy

Nausea & vomiting of mild to moderate intensity are especially common complaints from early pregnancy until about 16 weeks. In few cases it may progress to hyperemesis.

Treatment

Nonpharmacological

Reassurance and advise to take frequent small, dry carbohydrate rich meals and avoid fatty or spicy foods, especially avoid large volume of drinks in the morning.

Pharmacological

A. Mild to moderate cases

1. Tab. Doxylamine succinate 10 mg + Pyridoxine HCl 10 mg 1-2 tablets at bed time. If required one more tablet can be added in the morning and afternoon.
   Or
   Tab. Metoclopramide 10 mg 2-4 times a day in moderately severe cases.

B. Hyperemesis Gravidarum

Nonpharmacological

1. Admit all cases in the hospital away from a stressful home environment.
2. Stop oral intake of fluids & nutrition.
3. Serum electrolytes & urinary ketones to be checked at admission and 6 hourly.
4. Emotional support, psychiatric referral if required.

Pharmacological

Adequate & appropriate fluid & electrolyte replacement. Normal saline or Ringer’s lactate solutions are appropriate solutions & KCl is added as required. If urinary ketones are present, then 1 liter of 10% dextrose is transfused over 3-4 hours.

In prolonged vomiting

Tab. Thiamine 25-50 mg 3 times a day (if orally tolerated). If vomiting are not controlled with fluid and electrolytes replacement in 6 – 8 hours.

1. Inj. Metoclopramide 10 mg IV or IM 8 hourly.
2. Inj. Ranitidine 50-100 mg 6 hourly.
3. If not controlled, Inj. Promethazine chloride 25-50 mg IM or IV 8 hourly or Inj. Chlorpromazine 25-50 mg IM 4-6 hourly.

Once vomiting are controlled for 24 hours, oral intake is gradually started.

If well tolerated then only IV fluids are omitted. At first dry carbohydrate foods are given in the form of small meals at frequent intervals. Gradually full diet is introduced. In prolonged and severe disease, parenteral nutrition may be necessary. Give Tab. Metoclopramide 10 mg 3 times a day and Tab. Ranitidine 150 mg 2 times a day.

If well tolerated for 48 hours, patient can be discharged from the hospital with dietary advice, reassurance & continue Tab. Metoclopramide for 5-7 days or longer depending on the response.

Patient education

• Adjust timing of medication in relation to the time of sickness.
• This is a benign disorder & gets relieved by 14 – 16 weeks of pregnancy.

References

1. Gastrointestinal Disorders. In: Williams Obstetrics F Gary Cunningham, Paul. MacDonald, Kenneth J Leveno et al (eds), 1997, pp 1145-1172.
2. Disorders of Gastrointestinal Tract, In: Medical Disorders in Obstetric Practice, Michael de Swiet (ed), 1991, pp 521-583