HO OnG Notes

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OBSTETRICS AND GYNAECOLOGY BY: FAREHA HATTA MBBS (UiTM)

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Dear%colleagues,% % These%are%some%of%the%important%topics%in%OnG%which%I%think%will%help%most%of%us% to% grasp% the% practical% knowledge% of% the% subject.% I% have% emphasized% on% the% fundamental% aspect% and% stuff% that% we% need% to% know% to% achieve% a% better% understanding% in% OnG.% Different% people% have% different% opinions% about% management,% thus% there% is% no% exact% management% per% se.% It% is% all% about% experience.% Always% refer% to% your% hospital% protocol% for% the% latest% updates% on% management.% ! ! TOPICS!

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DEFINITION%IN%OBSTETRICS% IOL%&%AUGMENTATION%OF%LABOUR% INSTRUMENTAL%DELIVERIES% CAESAREAN%SECTION% HYPERTENSION%IN%PREGNANCY% GESTATIONAL%DIABETES%MELLITUS% PPROM%&%PROM% POSTPARTUM%HEMORRHAGE% MISCARRIAGES% ECTOPIC%PREGNANCY% GESTATIONAL%TROPHOBLASTIC%DISORDERS% MENORRHAGIA%

% % % % % Thank%you%Allah%for%giving%me%the%strength%and%patience%to%go%through%one%of%the% most% difficult% postings% in% housemanship.% Alhamdulillah,% I% survived% in% OnG.% I’ve% gained%so%much%from%this%posting%and%no%word%can%describe%my%%excitement%upon% successful%completion%of%the%posting.%Alhamdulillah.%!% % With%that,%I%present%to%you%my%latest%personal%HO%notes%in%OnG.% % % % Dr%Nurfareha%Mohd%Hatta% MBBS%(UiTM)% Hosp.%Tengku%Ampuan%Rahimah,%Klang.%

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! DEFINITION(IN(OBSTETRICS( $ $ Presentation$ − The$part$of$the$fetus$in$the$lower$pole$of$uterus$overlying$the$pelvic$brim$ − Example:$cephalic$(vertex,$face,$brow),$breech$(frank,$complete,$footling),$shoulder$ $ Attitude$ − Relation$of$the$different$part$of$fetus$to$one$another$ $ Lie$ − The$relation$of$the$long$axis$of$the$fetus$to$the$uterus$ − Example:$longitudinal,$transverse,$oblique$ $ Position$ − The$relationship$of$the$presenting$part$to$the$mother’s$pelvis$ $ $ OA! $ $ ROA! LOA! !

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LOT!

ROT! ROP!

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LOP! OP!

Presenting$part$ − The$leading$point$of$the$fetus$in$the$lower$pole$of$uterus$overlying$the$pelvic$brim$ (on$VE)$ − Example:$vertex,$buttocks,$feet$ $ Denominator$ − Arbitrary$part$of$the$presentation$of$the$fetus$(the$bony$point)$ − Example:$occiput$in$vertex$presentation,$sacrum$in$breech$presentation,$mentum$in$ face$presentation$ $ Engagement$ − Descent$of$the$biparietal$diameter$through$the$pelvic$brim$ $ Vertex$ − DiamondLshaped$area$of$the$fetal$skull$bounded$by$the$2$parietal$eminences$and$ anterior$and$posterior$fontanelles$ $ Effacement$ − Shortening$of$the$cervix$ − Normal$cervical$length:$~$2.5$cm$ $

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! Station$ − The$level$of$the$presenting$part$in$relation$to$ischial$spine$ $ Caput$ − Diffuse$swelling$of$the$scalp$caused$by$pressure$of$the$scalp$against$the$dilating$ cervix$during$labour$ $ Moulding$ − Overlapping$of$the$bones$of$the$fetal$head$ − Parietal$bones$overlap$occipital$and$frontal$bones$ − Significant$moulding$and$caput$!$sign$of$CPD$ − Degree$of$moulding$ • No$moulding$ • +1$–$parietal$bones$are$touching$ • +2$–$parietal$bones$are$overlapped$but$easily$reduced$ • +3$–$irreducible$(sign$of$relative/absolute$CPD)$ $ $ $

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! INDUCTION(AND(AUGMENTATION(OF(LABOUR( $ Induction$–$Stimulation$of$contractions$before$the$spontaneous$onset$of$labour$ Augmentation$–$Stimulation$of$spontaneous$contractions$that$are$considered$inadequate$ $ Indications$of$IOL:$ − Post$dates$ − Maternal$factors$ • Significant$APH$ • Gestational$HPT$disorders$ • GDM$ • Underlying$renal$or$lung$disease$ − Fetal$factors$ • Suspected$fetal$jeopardy$ • Reduced$fetal$movement$at$term$ • Fetal$demise$(IUD),$severe$IUGR$ − MaternalOfetal$factors$ • Prolonged$PROM$(if$more$than$24$hours)$ • Chorioamnionitis$$ $ Contraindications$of$IOL$ $ Maternal$ Fetal$ Small$pelvis$(in$case$of$CPD)$ Macrosomia,$CPD$ Abnormal$placentation$ Multifetal$gestation$ Active$genital$herpes$infection$ Severe$hydrocephalus$ Cervical$abnormalities$ Malpresentation$(obstructed$labour),$ transverse$fetal$lie$ Prior$classical$or$other$high$risk$caesarean$ NonOreassuring$fetal$status$ incision$ Placenta$praevia$or$vasa$praevia$ Umbilical$cord$prolapse$ $ Bishop$score$$ − To$assess$whether$cervix$is$favourable$and$to$determine$whether$the$patient$needs$ cervical$ripening$or$to$proceed$with$augmentation$ − If$Bishop$score$$5$contractions$in$10$mins)$ − Uterine$rupture$(especially$in$scarred$uterus)$ − Hyponatremia$due$to$excessive$water$retention$(oxytocin$has$ADH$properties,$when$ administered$in$high$doses)$ − Hypotension$(as$a$result$from$rapid$IV$injection$of$oxytocin)$ − Fetal$distress$ $ FAILED$INDUCTION$&$AUGMENTATION$!$CAESAREAN$SECTION$

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! References:$ 1. HTAR$OnG$protocol$ 2. Ten$Teachers$Obstetrics$

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OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$INSTRUMENTAL$DELIVERY$

! INSTRUMENTAL+DELIVERY+ $ a.k.a$Operative$Vaginal$Delivery$ $ A$delivery$in$which$the$operator$uses$forceps$or$a$vacuum$device$to$assist$the$mother$in$ transitioning$the$fetus$to$extrauterine$life.$ $ Indications$ − Prolonged$2nd$stage$of$labour$ • Nulliparous$–$3$hours$with$regional$anaesthesia,$2$hours$without$ • Multiparous$–$2$hours$with$regional$anaesthesia,$1$hour$without$ − Maternal$distress$(underlying$cardiac$disease,$HPT$crisis,$etc)$ − Presumed$fetal$compromise$ − Maternal$exhaustion$ $ Prerequisites$ FT$Fully$dilated$cervix$ OT$OP/OA$position$ RT$Ruptured$membrane$ CT$Cephalic$ ET$Empty$bladder$(to$catheterize$first)$ PT$Pain$relief$(adequate$analgesia)$ ST$Skills,$Station$low$ $ Complications$ The$relative$merits$of$vacuum$extraction$and$forceps$have$been$evaluated$in$a$Cochrane$ Systematic$Review$of$ten$randomized$controlled$trials$involving$2923$primiparous$and$ multiparous$women$ $ Compared$with$forceps,$vacuum$extraction$is:$ • more$likely$to$fail$delivery$with$the$selected$instrument$(OR:$1.7;$95%$CI:$1.3–2.2)$ • more$likely$to$be$associated$with$cephalohaematoma$(OR:$2.4;$95%$CI:$1.7–3.4)$ • more$likely$to$be$associated$with$retinal$haemorrhage$(OR:$2.0;$95%$CI:$1.3–3.0)$ • more$likely$to$be$associated$with$maternal$worries$about$baby$(OR:$2.2;$95%$CI:$1.2– 3.9)$ • less$likely$to$be$associated$with$significant$maternal$perineal$and$vaginal$trauma$(OR:$ 0.4;$95%$CI:$0.3–0.5)$ • no$more$likely$to$be$associated$with$delivery$by$caesarean$section$(OR:$0.6;$95%$CI:$ 0.3–1.0)$ • no$more$likely$to$be$associated$with$low$5Tminute$Apgar$scores$(OR:$1.7;$95%$CI:$1.0– 2.8)$ • no$more$likely$to$be$associated$with$the$need$for$phototherapy$(OR:$1.1;$95%$CI:$0.7– 1.8).$ $ $ $ $ $ $ $ $

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! FORCEPS$DELIVERY$ $ $ The$blade$has$two$curves:$ Cephalic$curve$–$relates$to$ fetal$head$ Pelvic$curve$–$relates$to$ maternal$pelvis$

! $ $ Conditions$when$forceps$are$preferable:$ − Poor$maternal$effort$ − Operator$or$maternal$preference,$when$either$instrument$would$be$suitable$ − Large$amount$of$caput$ − Gestation$of$less$than$34$weeks$ − Marked$active$bleeding$from$a$fetal$bloodTsampling$site$ − AfterTcoming$head$of$the$breech$ − Face$presentation$ $ Types$of$forceps:$ $ 1. Wrigley’s$–$for$liftTout$deliveries$and$Caesarean$section$

$ 2. Neville$Barnes$ $ $ $ $ $ $ $ $ $ $ 3. Rotational$forceps$(Kielland’s$forceps)$ $

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! Classification$of$forceps$delivery:$ $ OUTLET$ − $ − − − − LOW$ −

MID$

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Fetal$head$is$at$or$on$the$perineum$ Scalp$is$visible$at$the$introitus$without$separating$the$labia$ Fetal$skull$has$reached$the$pelvic$floor$ Sagittal$suture$is$in$the$AP$diameter$or$right$OA$or$OP$ Rotation$does$not$exceed$45$degrees$ Leading$point$of$the$fetal$skull$is$at$the$station$+2$cm$or$ more$ • Rotation$≤$45$degrees$from$OA$position$ • Rotation$>$45$degrees$including$OP$position$ $ Leading$point$of$the$fetal$skull$is$above$station$+2$cm$but$ not$above$the$ischial$spines$ • Rotation$≤$45$degrees$from$OA$position$ • Rotation$>$45$degrees$including$OP$position$ Head$is$engaged$

$ Technique:$ − Procedure$explained$to$patient$ − Lithotomy$position$ − Clean,$drape$and$catheterize$ − Assemble$the$blades$ − Left$blade$applied$first$(hold$like$a$pencil)$ − Right$blade$follows$ − Proper$application$and$positioning$of$forceps$will$bring$the$blades$together$and$locks$ easily$ − If$fail,$to$proceed$with$LSCS$ $ Clinical$checks$for$forceps$application:$ − Sagittal$suture$lies$in$the$midline$of$the$shanks$ − Operator$is$unable$to$place$more$than$a$fingertip$between$the$fenestration$of$the$ blade$and$the$fetal$head$on$either$side$ − Posterior$fontanelle$is$no$more$than$a$finger$breadth$above$the$plane$of$the$shanks$of$ the$forceps$ − Apply$traction$intermittently$and$synchronously$with$uterine$contraction$ − Direction$of$traction$should$be$in$the$axis$of$the$birth$canal$ − Head$descent$must$be$present$during$each$contraction$ $ $ VENTOUSE$DELIVERY$ $ • Risk$of$damage$to$the$maternal$tissue$is$considerable$ • Preterm$pregnancy$(+125mmHg+ $

MAP+$120$bpm$or$15mg$ Hydralazine$given$ $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ $ $ $ $ IV$Labetolol$20mg$(at$ least$1$min)$followed$at$$ 10$mins$intervals$by$40,$ 80,$80,$160$ H each$ml$contains$ 5mg$(1$ampoule$=$ 25mg$in$5ml$

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$$$$$$$$$$OR$ Labetolol$infusion$(if$HR$>$120$ bpm$or$side$effects$of$ hydralazine)$ H 200mg$in$50cc$normal$ saline$ H start$at$5ml/hour$ (20mg/hour)$and$double$ every$30$minutes$by$10,$ 20,$40$

$ $ $ $ Source:$HTAR$protocol$ farehatta$ $

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OnG$ $ H

H

AntiHPT:$ $ AntiHPT$ Methyldopa$

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HPT$IN$PREGNANCY$

MOA$ Starting$dosage$ Max.$dosage$ Centrally$acting$ 250mg$TDS$ 3000mg/day$

Side$effects$ PostHpartum$ depression$ Bronchoconstriction,$ IUGR,$heart$block$ Headache,$flushing$ Tachycardia,$ hypotension$

Labetolol$

α,$β$blockers$

100mg$TDS$

2000mg/day$

Nifedipine$ Hydralazine$ (only$IV)$

CCB$ Vasodilator$

15mg$TDS$ 25mg/day$

60mg/day$ 300mg/day$

$ Role$of$Aspirin$in$PIH$and$PE$ • Women$at$high$risk$of$PE$are$advised$to$take$low$dose$aspirin$75mg$daily$starting$from$12$ weeks$ • High$risk:$previous$PIH,$chronic$hypertension,$chronic$kidney$disease,$autoimmune$ disease,$DM$

$ $ Management$of$Eclampsia$ H Obstetrical$emergency!$ H Put$on$left$lateral$position$with$head$slightly$lowered$ H Maintain$airway$ H Give$O2$by$ventimask$ H Set$2$IV$lines$(large$bore$branula)$ H Abort$fit$by$MgSO4$ • 1$ampoule$contains$2.47gm$(~2.5$gm)$of$50%$MgSO4$in$5ml$ • IV$regime$ ! LOADING$dose:$4gm$MgSO4$ H 8ml$=$4gm$(need$2$ampoules),$then$mixed$with$12ml$normal$saline$in$20cc$ syringe$ H Give$20ml$slow$bolus$IV$over$10H15$minutes$ ! Followed$by$MAINTENANCE$dose$1gm/hour$for$at$least$24$HOURS$after$last$fit$ H 5gm$of$MgSO4$(2$ampoules$=$10ml)$mixed$with$40ml$normal$saline$in$50cc$ syringe$using$infusion$pump$titrating$at$10ml/hour$ ! Recurrent$seizure$–$repeat$IV$MgSO4$but$at$a$lower$strength$dose;$2gm$given$slow$ bolus$over$10H15$minutes$ • IM$regime$(usually$given$at$KK)$ ! LOADING$dose:$10gm$MgSO4$ ! 4$ampoules$H$2$ampoules$of$10ml$(5gm)$with$1ml$lignocaine$2%$for$each$buttock$into$ upper$outer$quadrant$of$the$buttock$in$zigzag$manner$ ! MAINTENANCE$therapy$with$further$IM$5gm$MgSO4$(2$ampoules)$every$4$hours$ (alternate$buttocks)$ ! Recurrent$seizure$–$IM$5gm$MgSO4$ H After$fit$aborted,$to$take$GXM$and$PE$profile$ H Assess$GCS$level$and$neurological$status$ H Close$monitoring$of$vital$signs$ H Monitoring$during$MgSO4$therapy$ • Clinical$signs$of$MgSO4$toxicity$ ! Loss$of$deep$tendon$reflexes$(knee$jerk)$ ! Respiratory$depression$30)! P Age!>35!y/o! P Family!history!of!DM! P Prev.!big!baby!(>4.0!kg)! P Prev.!unexplained!stillbirth! P Prev.!congenital!abnormalities! P Prev.!GDM! P PCOS! P Polyhydramnios! P Presence!of!glycosuria!in!>2!occasions! ! MGTT!!→!done!at!around!12P14!weeks! !!!!!!!!!!!!!→!if!normal!but!have!significant!risk!factors,!to!repeat!at!28P32! !!!!!!!!!!!!!!!!!!weeks!and!again!at!32P34!weeks! !!!!!!!!!!!!!→!if!high!risk,!to!repeat!as!early!as!24!weeks! ! !!!!!!!!!!!!!!!!!!!Normal!range!MGTT:! !!!!!!!!!!!!!!!!!!!FBS!P!!20U! P Hourly!DXT!monitoring! P Start!sliding!scale!(depend!on!DXT!reading)! P 4!hourly!BUSE,!RBS! P Take!GSH! P Pain!relief! P Hourly!CTG!monitoring! P Urine!ketone!2!hourly!if!labour!>!8!hours!(to!look!for!dehydration)! ! Sliding!scale!regime:! DXT! Insulin!infusion! (6.0( − Microscopic(examination(of(vaginal(fluid( • Characteristic(ferning(of(the(crystalline(pattern(of(dried(amniotic(fluid(owing(to(its( sodium(chloride(and(protein(content(( − Litmus(test((red(to(blue)( − Amniocater( − High(vaginal(swab( − Ultrasound(to(look(for(oligohydramnios( ( Management(of(PPROM( − Assess(for(signs(of(infection,(watch(out(for(signs(of(chorioamnionitis( − FBC,(CRP( − Sterile(speculum(examination( • Look(for(POOLING(of(fluid(in(the(posterior(fornix( farehatta( (

OnG!

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!!!!!!!!!PPROM,(PROM!

! • Cough(reflex(–(fluid(leaking(out(of(cervix( • Os(open(or(close?( • Litmus(test( • Amniocater(if(in(doubt( • Take(sample(of(HVS(for(culture( − CTG((for(>30(weeks)( − Steroids(administration(for(fetal(lung(maturity((IM(Dexamethasone(12mg(BD)(for(24] 36(weeks(of(gestation( − Start(prophylactic(antibiotic((T.(EES(250mg(QID(for(10(days)( − Strict(pad(chart(monitoring( − Avoid(digital(VE(unless(contraction(is(stronger( − Ultrasound(scan(for(fetal(assessment( − Inform(Paeds(for(neonatal(support(especially(ventilator(booking( − Monitor(vital(signs,(look(for(temperature(spike( − EXPECTANT(management:( ( Maternal( Fetal( Temperature( Fetal(movement(–FKC( FBC(and(CRP(biweekly( Growth(scan(biweekly( Pad(chart(–(change(of(liquor(colour( Daily(fetal(heart(monitoring( Uterine(assessment(](clinical( ( ( Expectant(management(is(the(preferred(management(provided(there(is(no(fetal(or(maternal( contraindication(till(34]36(weeks(of(gestation(depending(on(the(ventilator(support.( ( If(patient(is(in(labour,( − >34(weeks(:(consider(steroids(and(allow(labour(to(progress( − (18(hours((for(GBS( prophyaxis)( • Alternative:(IV(Ampicilin(2gm(stat(and(1gm(QID( ( ( ( ( ( References:( 1. HTAR(OnG(protocol( 2. Royal(College(of(Obstetricians(&(Gynaecologists(–(Preterm(Prelabour(Rupture(of( Membranes( 3. Ten(Teachers(Obstetrics(

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! POSTPARTUM)HEMORRHAGE) $ Primary$PPH$0$Blood$loss$of$≥$500$ml$from$genital$tract$within$24$hours$after$delivery$ Secondary$PPH$0$Abnormal$or$excessive$bleeding$from$the$birth$canal$between$24$hours$and$ 6$weeks$postnatally$ $ Priorities$ − Call$for$help$(to$assist$in$controlling$bleeding)$ − Assess$the$patient’s$condition$ − Find$the$cause$of$bleeding$ − Stabilize$or$resuscitate$the$patient$ − Prevent$further$bleeding$ $ Causes$of$PPH$ 4$T$–$tone,$trauma,$tissue,$thrombin$ Tone$ Trauma$ Tissue$ Thrombin$

Uterine$atony$(most$common$cause)$ Genital$ tract$ trauma,$ laceration,$ hematoma,$ uterine$ inversion,$ uterine$ rupture$ Retained$placenta$ Coagulation$disorder$

$ Risk$factors$ − Prolonged$3rd$stage$of$labour$ − Multiple$pregnancy$ − Caesarean$section$ − Episiotomy$ − Antepartum$hemorrhage$ − History$of$PPH$ − History$of$retained$placenta$ − Fetal$macrosomia$ − Polyhydramnios$ − Grandmultipara$ − Anemia$$ $ GENERAL$measures$in$managing$PPH$ − ABC$ − Set$2$IV$lines$(large$bore$branula)$and$take$blood$for$FBC,$GXM$(4$units),$PT,$aPTT$ − Stabilize$ patient$ with$ crystalloids$ (Hartmann’s$ or$ normal$ saline)$ or$ colloids$ (Gelafundin,$Hemacel)$and$run$fast$ − High$flow$oxygen$ − Monitor$parameters$closely$ • General$condition$ • Level$of$consciousness$ • BP,$PR$ • Pad$chart$ • Strict$I/O$charting$ − Abdominal$palpation$ • If$the$uterus$is$not$contracting$and$soft$(boggy)$!$atony$ " Perform$uterine$massage$to$stimulate$contraction$

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" Empty$bladder$ " Give$uterotonic$drugs$ • If$the$uterus$is$well$contracted,$the$cause$of$bleeding$is$likely$to$be$genital$tract$ trauma$ Careful$inspection$of$cervix,$vagina,$vulva,$perianal$area$for$lacerations,$hematoma$ Manual$exploration$of$uterine$cavity$–$remove$clots,$retained$tissue$ Consider$coagulopathy$if$no$other$cause$identified$

$ SPECIFIC$measures$in$managing$PPH$ $ 1. Uterine$atony$ − Initially$ treated$ with$ bimanual$ uterine$ compression$ and$ massage$ to$ produce$ contraction$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ − Medical$treatment:$ • IM$ Syntometrine$ 1ml$ (Syntocinon$ 5U$ +$ Ergometrine$ 0.5mg)$ –$ contraindicated$in$HPT,$heart$disease$ • IM/IV$Syntocinon$5U$if$Syntometrine$is$contraindicated$ • IV$Pitocin$40U$in$500mls$normal$saline$at$40dpm$–$may$increase$up$to$80U$ • IM$Carboprost$(Hemabate)$250mcg$–$dose$can$be$repeated$every$15$mins$ up$to$a$maximum$of$2mg$ *$Carboprost$is$150methyl$prostaglandin$F2a$ − Insert$Foley’s$catheter$to$empty$bladder! − Check$the$placenta$for$completeness$to$rule$out$retained$placenta$and$look$for$ cervical$lacerations$to$rule$out$genital$tract$trauma! − If$bleeding$persists$!$surgical$intervention! • Balloon$tamponade! • Hemostatic$brace$suturing$(B0Lynch$compression$sutures)! • Bilateral$ligation$of$uterine$arteries!

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Selective$arterial$embolization! Hysterectomy$(last$resort$if$everything$fails)!

2. Retained$placenta! − Assess$the$patient’s$condition$&$estimate$blood$loss! − Empty$the$bladder! − Attempt$controlled$cord$traction$! • If$successful,$examine$the$placenta$to$ensure$completeness.$Maintain$the$ uterine$ contractions$ by$ massaging$ the$ fundus$ of$ the$ uterus.$ Put$ up$ IV$ Pitocin$40U$in$500mls$normal$saline$and$run$over$406$hours! • If$fails$!$manual$removal$of$placenta$under$anaesthesia! • Cover$with$broad$spectrum$antibiotics$(IV$Cefuroxime$1.5gm$and$IV$Flagyl$ 500mg)!

! 3. Genital$tract$trauma$ − Stabilize$patient$first$ − Put$patient$in$lithotomy$position$ − Find$the$bleeding$point$if$visible$and$clamp$it$ − Suture$tear$immediately$ − Watch$out$for$further$bleeding$ − For$examination$under$anaesthesia$(EUA)$if$ • Failed$to$identify$the$source$of$bleeding$ • Patient$restless$or$uncooperative$or$vital$signs$are$unstable$ • Bleeding$continues$despite$repair$done$ − Cover$with$broad$spectrum$antibiotics$

$ Prevention$of$PPH$ − Active$management$of$the$third$stage$of$labour$lowers$maternal$blood$loss$and$reduces$ the$risk$of$PPH$ − Prophylactic$oxytocics$should$be$offered$routinely$in$the$management$of$the$third$stage$ of$labour$in$all$women$as$they$reduce$the$risk$of$PPH$by$about$60%$ − For$ women$ without$ risk$ factors$ for$ PPH$ delivering$ vaginally,$ oxytocin$ (10U$ by$ IM$ injection)$is$the$agent$of$choice$for$prophylaxis$in$the$third$stage$of$labour$ − For$women$delivering$by$caesarean$section,$oxytocin$(5U$by$slow$IV$injection)$should$be$ used$to$encourage$contraction$of$the$uterus$and$to$decrease$blood$loss$ $ $ References:$ 1. HTAR$OnG$protocol$ 2. American$Family$Physician$–$Prevention$&$Management$of$Postpartum$ Hemorrhage$ 3. Royal$College$of$Obstetricians$&$Gynaecologists$–$Postpartum$Hemorrhage$

farehatta!

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OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$MISCARRIAGES$

! MISCARRIAGES) ) Spontaneous$loss$of$pregnancy$before$the$fetus$reaches$viability,$before$22$weeks$of$ gestation$ $ Classification$of$miscarriage$ Types$ Description$ Threatened$miscarriage$ − PV$bleeding$or$spotting$that$may$persist$for$days$or$ weeks,$cramping$abdominal$pain$ − Cervical$os:$Closed$ − Uterus$≈$date$ − USG:$IUGS$seen,$viable$fetus,$FH$+,$fetal$echo$+$ − Plan:$Allow$discharge$with$reassurance;$TCA$2/52$to$ repeat$scan$to$confirm$fetal$viability;$TCA$stat$if$pass$out$ POC,$PV$bleed,$abdominal$pain$ − DDX:$ectopic$pregnancy,$twisted$ovarian$cyst$ Inevitable$miscarriage$ − Bleeding$is$heavy$or$increasing,$and$abdominal$cramping$ is$present$but$NO$passing$out$POC$ − Cervical$os:$Open$ − Uterus$≈$date$ − USG:$IUGS,$no$fetal$heart$beat$ − Plan:$ • Counseling$ • Keep$patient$in$ward$until$expulsion$has$occurred$ completely$ • Monitor$VS$and$pad$chart$ • Analgesics$ • Repeat$per$speculum$if$PV$bleeding$and$abdominal$ pain$increasing$ • If$expulsion$has$not$occurred$within$12$hours$for$ Cervagem$1mg$to$hasten$the$process$ Incomplete$miscarriage$ − Pass$out$parts$of$POC$but$some$remains$in$the$uterus,$PV$ bleeding$(may$be$heavy$bleeding),$abdominal$pain$ − Cervical$os:$Open$ − Uterus$$1000$U/L)$&$no$sign$intrauterine$ gestation$on$TVS$–$viable$intrauterine$gestation$is$extremely$unlikely$

farehatta$

OnG$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ECTOPIC$PREGNANCY$

! • $ $ $ $ $ $ $

Serum$quantitative$hCG$can$be$used$to$differentiate$between$an$ectopic$ pregnancy$&$a$failing$intrauterine$gestation$

A$steady$decrease$in$ hCG$in$48$hours$$

Suboptimal$increase$ (