1

ALGORITHMS
 President’s Message

From the desk of Dr.

Rishma Dhillon Pai –
President, FOGSI
2017

Dear Colleagues,
It is a matter of pride and honor for me to present to you this ‘Times of Gynaecology – Decision
Tree’. It started as a thought in my mind, to put together a concise, clear and systematic algorithm
on important subjects in obstetrics and gynecology. This has germinated and bloomed into a
wonderful publication on eleven different topics being presented to you in a simple systematic
format.
75 expert gynecologists from across the length and breadth of India got together for two days and
brain stormed in groups and together - to bring out this decision tree. Two days of intense debate,
discussions, disagreements and consensus, at the end of which these algorithms were put
together. They were further modified and then are being brought to you. These of course are only
opinions of our experts and not recommendations or guidelines and are only meant to give you all
a systematic flow chart to follow, using your own expertise to make final judgements.
I would like to thank Abbott and Science Integra for felicitating these discussions and helping
integrate the entire decision tree.
I hope you enjoy reading this decision tree, as much as we enjoyed putting it together.
“The key to pursuing excellence is to embrace an organic, long-term learning
process, and not to live in a shell of static, safe mediocrity. Usually, growth comes
at the expense
of previous comfort or safety.” — Josh Waitzkin

Best wishes!

Dr. Rishma Dhillon Pai

President 2017 - Federation of Obstetrics & Gynaecological Societies of India (FOGSI)
President (Elect- 2018) – Indian Society for Assisted Reproduction (ISAR)
Hon. Gen. Secretary - Indian Association of Gynaecological Endoscopists (IAGE)
Hon. Gen. Secretary- Mumbai Obstetrics and Gynaecological Society
Board Member - World Endometriosis Society (WES)
 CONTENTS
LUTEAL PHASE SUPPORT IN INTRAUTERINE
INSEMINATION .......................................................................................... 1

INFERTILITY ................................................................................................. 4

SCREENING IN PREGNANCY. ................................................. 12

Menopause .................................................................................................. 17

Vaccination .................................................................................................. 35

Hypertensive Disorders
in Pregnancy ............................................................................................... 38

Postpartum hemorrhage ................................................................... 44

Polycystic ovary syndrome ............................................................. 47

Reversible contraception practice ............................................. 54

Ectopic pregnancy ................................................................................. 58

Acute uterine bleeding ........................................................................ 63

This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and image s of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for a ny errors, omissions or
© 2017
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, National Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
1 Luteal phase Support In Intrauterine Insemination

LUTEAL PHASE SUPPORT IN

INTRAUTERINE INSEMINATION
Moderators : Dr. Nandita Palshetkar, Dr. Pratap Kumar
Panel Members : Dr. Jayam Kannan, Dr. Charumati Pekhale,
Dr. Sunita Arora, Dr. Pritimala Gangurde,
Dr. Anu Chawla

Preface
Intrauterine insemination (IUI) enhances the probability of pregnancy in
sub fertile couples. The success of IUI depends on various factors
including quality of the luteal phase; and deficiency in this phase is
associated with insufficient production of progesterone that is essential for
embryo implantation and maintenance of early pregnancy. The clinical
conditions that manifest as luteal phase deficiency (LPD) status are stress,
polycystic ovary syndrome (PCOS), aging, ovulation stimulation, ovulation
induction with or without gonadotropin releasing hormone (GnRH)
agonists, and assistant reproductive technologies (ART).
The medication to support luteal phase include progesterones, estrogens,
and human chorionic gonadotrophin (hCG). There is an on going debate on
optimal luteal phase support with many physicians favoring the use of hCG,
despite the risk of ovarian hyper-stimulation syndrome (OHSS).
The aim is of the FOGSI team is to uncover a protocol which is simple,
effective, and acceptable to the patients.
2 Luteal phase Support In Intrauterine Insemination

LUTEAL PHASE SUPPORT IN INTRAUTERINE INSEMINATION

Start – on the day of

LUTEAL PHASE SUPPORT oocyte retrieval

Duration
• IUI – positive
pregnancy test
to 10–12 weeks
of gestation
• IVF – 10–12
weeks of gestation

A B
IUI IVF (LPS needed
in all ART cycles)

See next
CC/ letrozole CC/ letrozole
Gonadotropin page
(not needed) + gonadotropin

LPS needed LPS needed

MODES

Progesterone
(All routes similarly effective,
most preferred is oral)
Oral – dydrogesterone 10 mg TDS
Vaginal – MVP 200 mg TDS,
Vaginal gel 90 mg OD
3 Luteal phase Support In Intrauterine Insemination

LUTEAL PHASE SUPPORT IN INTRAUTERINE INSEMINATION

B
IVF (LPS needed
in all ART cycles)

MODES

Progesterone GnRH agonist–

(All routes Estrogen (17-b estradiol progesterone HCG
similarly effective) or estradiol valerate)t +
• Oral – progesterone Triptorelin
dydrogesterone No beneficial effect 0.1 mg SC 6th day
10 mg TDS except in FET after OPU (Definite
beneficial effect)
• Vaginal – GnRH agonist trigger
MVP 200 mg TDS,
* 17-b estradiol has
vaginal gel 90 mg
OD minimal liver load as
compared to
• IM 50 mg OD
estradiol valerate
• SC 25 mg OD

• HCG +
• HCG along progesterone
• Not • No beneficial
recommended effect
• Beneficial in
cycles with GnRH
agonist triggers

ART: assisted reproductive technology; CC: clomiphene citrate; GnRH: gonadotropin-releasing hormone; HCG: human chronic
gonadotropin; FET: frozen embryo transfer; IM: intramuscular; IUI: intrauterine insemination; IVF: in-vitro fertilization; LPS: luteal
phase support; MVP: micronized vaginal progesterone; OD: once daily; OPU: ovum pick-up; SC: subcutaneous; TDS: trice daily
dosing; IUI: intrauterine insemination; IVF: in-vitro fertilization.
Dusterberg B et al. All pharmacokinetics and biotransformation of Estradiol Valerate in Ovariectomized women.
*

Horm Res. 1985; 21:145-54.

4

INFERTILITY
Moderators : Dr. Rishma Pai, Dr. Sudha Tandon
Panel Members : Dr. Hrishikesh Pai , Dr. Nikita Lad, Dr.
Meenu Handa, Dr. Sarita Sukhija, Dr.
Kedar Padte

Preface
Infertility is the inability to achieve pregnancy after 12 months of regular,
unprotected intercourse. Infertility is estimated to affect one in seven to one
in eight couples of reproductive age, with male infertility being responsible
for 20% of the cases.

Since, around 85% of couples conceive spontaneously within 12 months

of regular intercourse, identifying those who would benefit from infertility
evaluation is important. Older women (>35 years) or couples with known
risk factors for infertility may require evaluation at 6 months. Moreover,
anxiety over infertility may increase stress and decrease libido, further
complicating the problem; hence, formal counseling is encouraged for
couples experiencing infertility. However, physicians need to be familiar
with the workup and prognosis for the infertile couples.

The flowchart guides through the process of approach to an infertile couple,

the necessary diagnosis and management strategies are provided as a
practical guide for infertility treatment.
5 INFERTILITY

Female factor infertility

Infertility is defined as the inability to conceive despite regular sexual

intercourse without using contraception for one year*.

Preliminary Assessment
• Age of both partners
• Duration of infertility: duration of infertility and contraceptive use
• Lifestyle: timing of sexual intercourse, alcohol, smoking, drugs,
occupation, and stress
• Menstrual/medical/surgical/sexual history and physical examination of
both partners
• Obesity/ low body weight

Preliminary Health
• Folate
• Rubella: if negative , vaccinate the female and wait for 1 month (RCOG)
• Thyroid
• Prolactin
• Thalassemia test of either one of the partner.
• AMH and AFC are recommended and HIV, HBsAg, and Anti-HCV
are compulsory for all

A5
*NICE
6 INFERTILITY

Initial Investigation &

Subsequent Treatment

Tests for ovulation

• Check for regular menstruation
• Check serum
progesterone 7 days prior
If normal
to expected menstruation
• Serum FSH/LH Day 2–5 of cycle
• Ultrasound monitoring • Test for ovarian reserve
• Serum AMH/AFC on day 2
USG
If abnormal

WHO Group I WHO Group II (PCOS), normal WHO Group III (Ovarian
Low FSH & E2 FSH, Normal/high LH & E2 Failure) High FSH, Low E2

• Lifestyle changes
Gonadotropins Offer genetic testing (KT)
• Weight reduction (BMI <29)/ and
MI & DCI (optional)
• CC or Letrozole (3–6 cycles)
• If no ovulation after 3 cycles
»» Offer metformin + Consider donor oocyte
CC/Letrozole with/without IUI
IUI / IVF/ICSI »» Gonadotropins /ovarian drilling
• USG monitoring
• Offer Bariatric surgery, if BMI >35
ICSI

AMH: anti-Mullerian hormone; AFC: antral follicular count; BMI: body mass index; CC: clomiphene citrate; E2: estradiol; FSH: follicle-stimulating
hormone; LH: luteinizing hormone; MI & DCI: Myo-inositol & D-chiro-inositol; PCOS: polycystic ovary syndrome; HBsAg: hepatitis B surface
antigen; HCV: hepatitis C virus; HIV: human immunodeficiency virus; ICSI: intracytoplasmic sperm injection; RCOG: Royal College of Obstetricians
and Gynaecologists; USG:ultrasonography; WHO: World Health Organization.
7 INFERTILITY

Tests for Tubal Patency after Semen

Analysis & Ovulation Assessment

• HSG/HyCoSy
• Hystero/laparoscopy – suspected
tubal pathology/ if no conception
after 3-4 cycles COS with/without IUI

Normal Abnormal

Timed intercourse
If corrected Corrective tubal surgery
IUI – 3-4 cycles

Not corrected

IVF/ICSI

Uterine Factors

Abnormal/damaged/ Rule out genital

absent uterus tuberculosis

Surgical correction of
pathology

Corrected uterine cavity

Not corrected
& one tube patent

TIC IVF
IUI Surrogacy
8 INFERTILITY

Unexplained Infertility

If age <35 years and/or If age >35 years and/or

good ovarian reserve poor ovarian reserve

TIC – 3–6 months

IVF/ICSI COS + IUI – 3–6 months
COS + IUI – 3–6 months

COS: controlled ovarian stimulation; HyCoSy: hystero salpingo contrast sonography; HSG: hysterosalpingogram;
ICSI: intracytoplasmic sperm injection; IUI: intrauterine insemination; IVF: in-vitro fertilization; TIC: timed intercourse.

Male factor infertility

Infertility is defined as the inability to conceive despite regular sexual

intercourse without using contraception for one year*.
Preliminary Assessment
• Age of both partners
• Duration of infertility: duration of infertility and contraceptive use
• Lifestyle: timing of sexual intercourse, alcohol, smoking, drugs,
occupation, and stress.
• Menstrual/medical/surgical/sexual history and physical examination of
both partners
• Obesity/low body weight

Preliminary Health
• Folate
• Rubella: If negative , vaccinate the female and wait for 1 month (RCOG)
• Thyroid
• Prolactin
• Thalassemia test of either one of the partner
• AMH and AFC are recommended and HIV, HBsAg and Anti HCV
are compulsory for all

*NICE
9 INFERTILITY

Initial Investigation & Subsequent

Treatment (male)

Semen analysis
• The results of semen analysis conducted as part of
an initial assessment should be compared to WHO
2010 reference value in the recommendations
• If the results of the first semen analysis is
abnormal, a repeat confirmatory test should
be offered ideally after 3 months or earlier, if
there is a gross abnormality in semen report

Normal Abnormal

Mild oligoteratozoospermia Azoospermia / severe

(>5 million/mL) oligoteratozoospermia (<5 million/mL)

Antioxidants + CC
+DNA fragmentation FSH – Low FSH – High
Testosterone – Low Testosterone – Low
Testicular volume – Low Testicular volume – Low

Follow female algorithm

Hypogonadotropic Hypergonadotropic
Hypogonadism (HH) Hypogonadism (HH)

See
next page
10 INFERTILITY

Prolactin, TSH Cabergoline thyroid Offer genetic testing

CT/MRI brain replacement (Klinefelter’s - Y micro
deletion SPERM
H/O trauma,
orchitis, donation
radio/chemoTx

Congenital HH Adult HH

TESA /TESE IUI

HCG and FSH/ or Testosterone microTESE
pulsatile GnRH replacement therapy

IUI /Semen Freezing ICSI

1 Sperm concentration >15x106/mL, motility >42%, morphology >4%

Optional
EUA update 2015
11 INFERTILITY

IUI /Semen Freezing

ICSI

FSH – Normal Low ejaculatory

Testosterone – Normal volume <1ml
Testicular vol - Normal

Post-ejaculatory Positive
Obstructive urinalysis

ICSI
Negative
Infective CBAVD

If azoospermia TESE
TRUS versus Vasography
PESA, TESA Offer CFTR mutation if planning
TESE testing to female reconstructive surgery

IF female+CFTR
ICSI
test male

Palpable
Varicocele**

Abnormal semen Young men with

analysis with N S/A
Normal/corrective
female factors

Follow with S/A

OFFER surgical repair every 1 o 2 years

AMH: anti-Mullerian hormone; AFC: antral follicular count; CAVD: congenital absence of the vas deferens; CC: clomiphene citrate;
CT: computed tomography; CFTR: cystic fibrosis transmembrane conductance regulator; DNA: deoxyribonucleic acid; FSH: follicle-stimulating
hormone; HBsAg: hepatitis B surface antigen; HCV: hepatitis C virus; HCG: human chronic gonadotropin; HIV: human immunodeficiency virus;
ICSI: intracytoplasmic sperm injection; IUI: intrauterine insemination; MRI: magnetic resonance imaging; PESA: Percutaneous epididymal
sperm aspiration; RCOG: Royal College of Obstetricians and Gynaecologists; TRUS: transrectal ultrasound; TESE: testicular sperm extraction;
TESA: testicular / epididymal sperm aspiration; TSH: Thyroid-stimulating hormone; WHO: World Health Organization.
12

SCREENING IN PREGNANCY
Moderators : Dr. Narendra Malhotra, Dr. Mala Arora
Panel Members : Dr. Ranjana Khanna, Dr. Pragya Mishra,
Dr. Abha Rani Sinha, Dr. Navneet Magon,
Dr. Ganpat Sawant

Preface
Pregnancy is a normal physiological process and any intervention that is
offered to the pregnant or expectant mother should have known benefits and
should be acceptable to the woman. Screening in pregnancy is the process of
surveying a population of women with markers and defined screening cut-off
levels, to identify those at higher risk for a particular disorder. All pregnant
women, regardless of age, should be offered, through an informed counselling
process, the option of a prenatal screening test for the most common clinically
significant fetal aneuploidies in addition to a second trimester ultrasound for
dating, assessment of fetal anatomy, and detection of multiples.
During the entire antenatal period, clinician should remain alert to risk factors,
signs or symptoms of conditions that may affect the health of a pregnant
woman such as pre-eclampsia and diabetes. Screening tests assess the
degree of risk, or chance, of a fetus that may potentially have certain common
birth defects, but there is no certainty that the baby born will actually have the
problem. If a pregnant women has a positive screening result, she should
have genetic counseling and undergo one of two invasive diagnostic tests,
that have greater accuracy and reliability than genetic screening alone.
The FOGSI protocol has been arrived at after careful consideration of
evidences to achieve best practice for screening of women of all
pregnancies and provides information for decision making about
appropriate treatment in specific circumstances.
13 SCREENING IN PREGNANCY

SCREENING IN PREGNANCY
(Recommended three antenatal visits, [preferable 5])
At booking general physical exam heart/lungs/breast/abdomen
In all trimesters
• Maternal weight/BMI
• Blood pressure/mean arterial pressure
• Urine dipstick (albumin, sugar)

Antenatal Screening

Confirm pregnancy
(Clinically/β HCG/
UPT/Ultrasound

Viability Test
(Fetal heart rate)
(Clinical/Fetal Monitor/USG)

Pregnancy

Urine dipstick + All routine Maternal blood pressure

Maternal weight
blood tests (both arms) (Sitting)

Body mass index (BMI) MAP

Pregnancy

First -trimester

BMI, MAP, CBC, (Peripheral) MSU + Culture

Recommended Preferable
smear, electrophoresis, HPLC HCV, Rubella IgG

Blood group
Wt, BP, Hb and Rh (Both Urine — R/M, VDRL, HpB, HIV, TSH; DIPSI

partners Dating Scan +NT + Dual marker + Cervical length

14 SCREENING IN PREGNANCY

Double marker + NT + others

Intermediate risk
High risk <1:100 Low risk > 1:1000
1:101 – 1: 999

NIPT Quadruple/triple test +

Reassure
CVS anomaly scan

BP: blood pressure; CBC: complete blood count; Hb: hemoglobin; HCV: hepatitis C virus; Second trimester
HPLC: high performance liquid chromatography; MSU: midstream urine; NT: nuchal anomaly scan
translucency; R/M: routine microscopy; OGTT: oral glucose tolerance test; TSH: thyroid
stimulating hormone; UPT: uterine pregnancy test; USG: ultrasonography; Wt: weight.

ANTENATAL CHECKLIST

First Trimester Recommended Preferable

Weight BMI
Blood pressure Mean arterial pressure
Hemoglobin Complete blood count/
Peripheral smear/Hb
Electrophoresis/ HPLC
Blood group ABO & Rh
(both partners)
Urine routine MSU + culture
VDRL/ Hep B / HIV HCV / Rubella IgG
TSH Thyroid function test / thyroid
antibodies
Vitamin D
DIPSI test 75 gms 2 hours blood HbA1C / OGTT/ 6 point blood
sugar sugar test
Dating scan + NT Cervical length
Double marker (free  HCG + Uterine artery Doppler
PAPP A1 ) NIPT
(Contingent Screen2) Placental Growth Factor1 (PLGF)
Per speculum exam Pap smear, bacterial vaginosis
and chlamydia screen
1Low levels predict pre ecclampsia
2 Low risk no further test (1 : 1000)
Intermediate risk (101 : 999) to proceed to second trimester screening vs NIPT
High risk (1 : 100) to go for NIPT / CVS
15 SCREENING IN PREGNANCY

SECOND TRIMESTER

Pregnancy

Second-trimester
(18-24 weeks)

Recommended Preferable
Repeat blood tests NIPT
Hemoglobin Uterine artery Doppler
TSH 2D-4D scan
Urine dipstick Fetal echocardiography
DPISI
Quadruple/triple marker
Anomaly scan
Cervical length

Second Trimester Recommended Preferable

18-24 weeks Repeat bloods (Hb / blood sugar

/ TSH) & urine test as indicated
Quadruple OR Triple marker NIPT
Anomaly scan 3D/4D scan/ Fetal Echo
Uterine artery Doppler
Cervical length
DIPSI screen 75 gms 2 hour 6 points blood sugar HbA1C
blood sugar

Quadruple/triple marker test

+ Anomaly scan (18-24 weeks)

High risk >1:250 Low risk (<1 : 250)

NIPT Reassure
Amniocentesis Routine antenatal care

DIPSI: Diabetes in Pregnancy Study Group India; HbA1c: hemoglobin A1c; NIPT: non-invasive prenatal tests; TSH: Thyroid-stimulating hormone.
16 SCREENING IN PREGNANCY

THIRD TRIMESTER

Pregnancy

Third-trimester
24 weeks onwards

Recommended Preferable
Repeat blood tests DIPSI
Hb Color Doppler
TSH CTG (NST)
Urine dipstick Modified biophysical
DPISI profile
Quadruple/triple marker Doppler velocimetry
Anomaly scan
Cervical length

Third Trimester Recommended Preferable

24 weeks onwards Repeat DIPSI screen TSH/Hb/ HbA1C

urine
Growth scan with liquor volume Fetal Doppler velocimetry
and placental localisation
Fetal movement count CTG (NST)
(6 in 2 hours post-prandial) Modified biophysical score
Doppler velocimetry

BP: blood pressure; BMI: body mass index; CBC: complete blood count;, CTG (NST): ; CVS: ; DIPSI: ; GCT: Glucose Challenge Test;
Hb: hemoglobin, HbA1C: hemoglobin A1C, Hep B: hepatitis B virus, HCV: hepatitis C virus; HIV: human Immune deficiency virus;
HPLC: high performance liquid chromatography; HbA1C: hemoglobin A1C, R/M: Routine microscopy, MAP: , MSU: midstream urine;
NT Scan: nuchal translucency scan; NIPT: Non invasive prenatal testing; OGTT: Oral glucose tolerance test; PAPP A: pregnancy-
associated plasma protein A; PlGF: placental growth factor; TSH: thyroid stimulating hormone; VDRL: Venereal Diseases Research
Laboratory Test; Wt: weight.
17

Menopause
Moderators : Dr. Maninder Ahuja / Madhuri Patel
Panel Members : Dr. Niranjan Chavan, Dr. Mandakini Megh,
Dr. Vineet Mishra, Dr. Rajnikant Contractor

Preface
Menopause is a biological stage in a woman’s life marked by cessation of
menstruation and associated with infertility. A woman not menstruating for
one year after her last period is termed as being postmenopausal. Reduced
estrogen levels associated with menopause affects the body by causing
vasomotor, musculoskeletal, urogenital, and psychological symptoms. It
also has a profound effect on the bone and the cardiovascular system,
which can significantly affect a woman’s quality of life. Therefore, women
need to know about the available therapeutic options, their risks and
benefits in order to make an informed decision for effective treatment. The
following flowchart helps in the diagnosis and guides the process of the
management and treatment of menopause symptoms.
18 Menopause

MENOPAUSE

• Define menopause
• Types of menopause
• Diagnosis of menopause
• Initial assessment at menopause
• Classifying women to plan management
• MHT

Menopause

Retrospective diagnosis - Hormonal changes: FSH and

History of amenorrhea >1 LH Estradiol, Inhibin, AMH-
year Not done routinely only in
Age at menopause : In India cases of POF* and To find out
46.7 yrs + 4.6 yrs* ovarian reserve

Presentation of patient.

Healthy with no symptoms- Symptomatic and

assessment and Symptomatic –assessment
management co-morbidities –assessment

Personal history, family List symptoms, risk Symptoms assess

history , past history assessment co- morbidities of diabetes,
H/T, CHD, MS, gall bladder

Symptoms in woman

AMH: anti-Mullerian hormone; CHD: coronary heart disease; FSH: follicle-stimulating hormone; H/T: hypertension; LH: luteinizing hormone;
MHT: menopausal hormone therapy; MS: metabolic syndrome; POF: premature ovarian failure.
19 Menopause

Menopause definition

• Twelve months of amenorrhea

• Retrospective diagnosis
• Diminution of ovarian hormones estradiol and raised follicle-stimulating
hormone (FSH) and luteinizing hormone (LH)
• No independent biological marker
• Objective sensitive marker: Irregular cycles
• Average age in India is 46.5 years and rest of world is 52 years
• Can be premature before 40 years, natural or surgical

No need to conduct tests routinely to diagnose menopause

Hormonal changes

• FSH ↑
• LH ↑
• Antimullerian hormone (AMH) ↑
• Inhibin↑
• Estradiol↓
• Estrogen becomes main hormone
• Ovaries go on producing androgens – androstenedione till 65 years↓

Routine diagnosis is by clinical history

20 Menopause

Presentation

with symptoms and risk With symptoms and

Healthy with no symptoms
factors comorbidites

Management of symptoms

MHT indicated in Dysfunctional uterine bleeding (DUB)

• Hot flushes and night sweats • Transvaginal sonography (TVS) < 4mm in PMW
• Urogenital atrophy • Pipelle aspiration
• Oral contraceptive pills (OCP)
• Prevention of Osteoporosis
• Progesterone
• Intrauterine devices (IUDs)
• Tranexamic acid
• SSG
• Hysteroscopy
• Ablation techniques
• Hysterectomy

Management of healthy menopausal woman with no

symptoms
• Education
• Counseling
• Documentation in mid-life OPD card and assessment of risk factors
• Lifestyle modifications, weight control, and nutrition
• Vitamin D 800–1200 IU
• Calcium 1200 mg
• Vitamin B12 supplementation
• Moderate alcohol, no smoking
• Exercise, aerobics, range of movement, resistance, and weight
training, stretching, yoga, and meditation
21 Menopause

Symptoms in perimenopause and menopause

Early symptoms
Vasomotor: Hot flashes, night sweats mood disturbances, and irritability
Menstrual: Irregular cycles, first short and then long AUB

Intermediate symptoms
Musculoskeletal
Aches and pains, arthralgia
Urogenital atrophy, itching of vagina, dryness, frequency of urine,
dyspareunia, and low libido

Late symptoms
Osteoporosis, metabolic syndrome, CHD, cancers, and Alzheimer’s disease

Basic universal assessment of all women in

perimenopause and menopause
Documentation in mid-life OPD card

Personal history:
• Last menstrual period, age of menarche
• PCOD, OH, hypertension, PIH, diabetes , CHD,
fracture, thromoboembolic, cancer
• Diet and physical activity,
• Sleep, sexual diseases, CKD or liver disease,
• Gall bladder or pancreas problem
• OCP use or MHT use or OCT,
• Alcohol or drug use,
• Eye or hearing problem

Family history of CHD, hypertension, diabetes, breast cancer, colon cancer,

ovarian cancer, dementia , Alzheimer’s disease, and fragility fractures
22 Menopause

Universal assessment

Physical examination Investigations

• Height • Hb, BS
• Weight • HbA1c
• BMI • TSH
• Blood pressure • Lipid Profile
• Waist measurement • If indicated, KFTs, LFTs
• Gait • PAP/LBC/VIA
• Eye • Mammography after 42 years or
• Hearing US breast

• Hand shake • DEXA scan if more than 5 years

after menopause and earlier if
• Breast, chest, P/A P/V / P/S risk factors
• TVS
Call for re-evaluation every year and loss of height is very important.

Management of vasomotor symptoms

General
Loose clothing, dress in layers, cool air, and avoid hot spicy food
Menopausal hormone therapy
Within 10 years of menopause or before 60 years of age
After counseling and assessment for risk of MHT, stroke, DVT or any
other co-morbidity where MHT is contraindicated.

Co-morbidities

Assess for risk factors or presence of: • Thyroid

• Diabetes • Osteoporosis
• Hypertension • Kidney and liver disease
• CHD • Dementia
• Cancers and treated cancers of • Gall bladder and pancreas,
ovary, cervical, and endometrium if symptomatic

Call for re-evaluation every year and loss of height is very important
23 Menopause

MHT

If indicated
• For hot flushes , night sweats, irritability, insomnia because of hot
flushes
• For urogenital syndrome vaginal route
• For prevention of osteoporosis

Types of MHT

• Estrogen alone when no uterus

• Combination of estrogen-progesterone
• Selective estrogen receptor modulators (SERMs)
• Tibolone/selective tissue estrogenic activity regulator (STEAR)
• TSEC–bezadoxiphene + CEE for osteoporosis and if risk of breast cancer
• Ospemifene for urogenital atrophy

Routes of administrations

• Oral • Vaginal tablets

• Transdermal spray • Creams
• Patches • Intramuscular
• Gel • Intrauterine device

How MHT

• Estrogen alone continuous,if no uterus

• Estrogen+ progesterone sequential, when uterus is there – within 1 year
of menopause
• Continuous combined in later menopause
• SERMS when risk of breast cancer and osteoporosis risk is there.
Can cause increased hot flashes so not given before menopause.
• OCP is in POF and in AUB and contraception in perimenopause
24 Menopause

Estrogens salts

Natural estrogens
• 17 β-estradiol tab (17 b-estradiol has minimal liver load as compared to
estradiol valerate and CEE)
• Estradiol valerate tab
• Estrone cream
• Estriol
• CEE tablets and vaginal cream
Synthetic estrogens
• Ethinyl estradiol is 750–1,000 times more potent than natural estrogens
• Enhances hepatic effects that increases synthesis of clotting factors,
angiotensin, and SHBG

Progesterone

• Given when uterus is present, to prevent endometrial hyperplasia of

because of estrogens
• Not needed when vaginal route of estrogens are given
Types of progesterone
• Dydrogesterone
• Micronized progesterone (preferred as less thrombogenic and < risk of
breast cancer)
• Levonorgestrel/IUD
• Tibolone
• Medroxyprogesterone acetate (not lipid friendly, increased risk of breast
cancer)
• Cyproterone acetate, dienogest, and drospirenone (in OCP)
25 Menopause

MHT: How long and when?

• Within 10 years of menopause and before 60 years of age

• For shortest periods for the relief of symptoms
• For hot flashes, it can be continued beyond 60 years with proper
counselling
• Vaginal route daily for 2 weeks and then twice weekly for 1 year.
• If patient needs more, than it can be used for longer periods with
counselling

Progesterone

• Given when uterus is present, to prevent endometrial hyperplasia of

because of estrogens
• Not needed when vaginal route of estrogens is given
Types of progesterone
• Dydrogesterone + estrogen (safe)
• Micronized progesterone ( preferred as less thrombogenic and < risk of
breast cancer)
• Levonorgestrel/IUD
• Tibolone
• Medroxyprogesterone acetate (not lipid friendly, increased risk of breast
cancer)
• Cyproterone acetate, dienogest, and drospirenone (in OCP)
26 Menopause

Duration of therapy

Premature menopause
• Up to natural age of menopause
• Further continuation of therapy according to the indication and need
Natural menopause
• Safety data of EPT therapy with CEE+MPA is 3–5 years, with ET
safety data for use is 7 years of treatment with 4 years follow up
• 17-b estradiol and dydrogesterone can be given 3–5 years

According to the Indian Menopause Society (2013), International

Menopause Society (2016), and the North American Menopause
Society (2012):
• MHT should begin within 10 years of menopause or <60 years of age
• Premature menopause: MHT upto natural age of menopause 3-5 years
• Continuation of therapy should be decided at the discretion of the well-
informed woman and her health professional

Contraindications to MHT

• Known or suspected estrogen-sensitive malignant conditions


• Undiagnosed genital bleeding

• Untreated endometrial hyperplasia

• Previous idiopathic or current venous thromboembolism
• Active or recent arterial thromboembolic disease
• Untreated hypertension

• Active liver disease

• Known hypersensitivity to the active substances of MHT or to the
excipients

• Porphyria cutanea tarda (absolute contraindication)
27 Menopause

Non-hormonal treatments

Non-hormonal treatments for relief of menopausal symptoms

• Gabapentin: 300 mg TID × 6 weeks–3 months
• Venlafaxine: 25–75 mg/day
• Paroxetine: 7.5–20 mg/day
• Fluoxetine: 10–20 mg/day
• Isoflavones: 70 mg–100 mg daily × 6 weeks–3 months (equal producer
patients have to be identified)
• Lycopene: 18–24 mg daily
• Isoflavones, bioidentical hormones

Dosage of MHT
Choice of
• Ultra low dosage
• Low dosage
• Normal dosage

Exceptions to low dosage

• Premature ovarian failure
• Severe osteoporosis
• Predominance of psychological problems, e.g. climacteric depression

Dosage

• 17 β-estradiol oral, mg/day: Ultra low dosage: 0.5, low dose: 1,

normal: 2, high: 4 mg
• CEE oral, mg/day: Ultra low dosage: 0.15, low dosage: 3-4.5,
normal: 0.625, high: 1.2 mg
• Estradiol valerate oral, mg/day: Low: 1, high: 2 mg
• Transdermal 17 β-estradiol μgm: Ultra low dosage: 14, low dose: 25,
normal: 50, high:100 μgm
28 Menopause

Non-oral transdermal route indications

• Transdermal estrogen has a neutral effect on triglycerides, C-reactive

protein, and sex hormone binding globulin
• Triglyceridemia
• Hyperlipidemia
• Increased C-reactive protein
• Migraine
• Diabetes
• DVT
• Gall bladder disease,
• Smoking
• Controlled hypertension
• Personal preference

Progesterone

• Dydrogesterone
• MPA
• Micronised progesterone
• Norethisterone
• Cyproterone acetate
• Dienogest
• Select dydrogesterone or micronized progesterone, early reports of
neutral effect on breast cancer
• Metabolically friendly
Androgenic progesterone
• Blunt positive effect of estrogens on lipids, implicated in breast cancer,
and CVD
• Used for hemostatic control in DUB
29 Menopause

Progesterone use in surgical menopause

• After endometriosis surgery with hysterectomy to take care of residual

tissue
• After supracervical hysterectomy
• After ablation technique on endometrium

Use of levonorgestrel in IUD

• During perimenopause
• Contraception
• Control of bleeding: AUB
• Women with side effects for oral progestogens

Dose of progesterone

• Dydrogesterone 10–20 mg/day

• For conversion of endometrium micronized progesterone 100–200 mg
• MPA 5–10 mg /day
• Levonorgestrel 0.20 mcg
• Norethisterone 1.25–2.5 mg

SERM: Selective Estrogen Receptor Modulators

• A drug that acts like estrogen on some tissues but blocks the effect of
estrogen on other tissues
• Used in osteoporosis, positive effect on bone
30 Menopause

MHT and breast

• Risk not increased in first-time hormone users [GRADE A]

• The MHT attributable risk is small and decreases when treatment stops [B]
• 17 b-estradiol has negligible risk of breast cancer
• The increased risk is primarily associated with the addition of a synthetic
progestogen to estrogen therapy and to duration of use [B]
• The risk may be lower with micronized progesterone or
dydrogesterone [C]
• Any possible increased risk associated with MHT may be decreased by
selecting women with lower baseline risk including low breast density and
by providing education on preventive lifestyle measures (reducing weight,
reducing alcohol intake, and increasing physical activity) [D]

Estrogen-androgen combination

• Continued VMS despite estrogen replacement

• Decreased well-being despite estrogen replacement
• Surgical menopause
• Acquired sexual desire dysfunction
• In India, androgen formulations for use at menopause are unavailable
Tibolone is a good alternative

Endometrial surveillance

• Endometrial thickness of ≤ 4 mm in TVS do not require endometrial

sampling
• Endometrial thickness is > 4 mm on TVS: endometrial sampling
• Endometrium thickness =6 mm on TVS with homogeneous and normal
morphology, women on hormonal therapy and hypertensive medication
is acceptable
• Homogenous endometrium and local thickening even with thin
endometrium needs investigation by Pipelle aspirations and HPE or
hysteroscopy directed biopsy
31 Menopause

Indications for Dexa scan

• All women 5 years beyond the age of natural menopause

• Women less than 5 years since menopause with a particular risk factor
• Women with fragility fractures
• Women in menopause transition with secondary causes
• Radiological evidence of osteopenia and presence of vertebral
compression fractures
• Before initiating pharmacotherapy for osteoporosis
• The interval testing should be based on calculated individual risk,
mostly be scheduled between 1 and 5 years later

Venous thromboembolism and MHT

• Oral estrogen is contraindicated in women with a personal history of

VTE [A]
• Transdermal estrogen should be first choice in obese women with VMS
[B]
• VTE risk increases with age and with thrombophilic disorders
• The risk of VTE increases with oral MHT but is rare below 60 years of age
• Two times more VT risk is associated with CEE*

WE DON’T NEED THROMBOPHILIA PROFILE BEFORE STARTING MHT

Check list

• Mid life OPD card

• Breast self exam card
• Cuscos speculum and light
• Cx cancer screening kits
• 5% Acetic acid
• Colposcope (if possible) *Smith N et al. JAMA Intern Med. 2014;174(1):25-31.
32 Menopause

Risk factors for osteoporosis

Non modifiable Modifiable

• Female • Physical activity: muscle
• Menopause building exercises

• H/O fragility # • BMI

• H/O fragility# in family • Smoking

• Alcohol >3 drinks/day
• Calcium
• Sun exposure
• Fall prevention

Risk of DVT

• Previous history of DVT during pregnancy, prolonged bed rest or surgery

• High risk profession like air hostess
• Personal history or family history
• Known thrombophilia (F5 Leiden, Protein C, antithrombin III)

Risk of diabetes mellitus

Non modifiable Modifiable

• Hypertension • Advancing age
• Dyslipidemia • Endogenous estrogens
• Polycystic ovary syndrome • Late menopause
• Physical inactivity • Nulliparity and Infertility
• Obesity • Genetic factor
33 Menopause

Risk of Alzheimer

Modifiable Non modifiable

• Physical inactivity • Age
• Diabetes • Family history
• Hypertension • Genetic factor apolipoprotein
• Dyslipidaemia (APOE)

• Smoking • Auto-immune diseases

• Obesity • Head trauma

• Depression • Traumatic brain injury

• Stress & social engagement

• Diet
• Poly pharmacy and thyroid
medications

Risk of breast cancer

Modifiable Non modifiable

• Age at first child • Age and gender
• Breastfeeding • Benign breast disease
• BMI • Family history of inherited cancers
• Alcohol • BRCA1 & BRCA2
• Hormone Therapy? • Menstrual history: Ages at
menarche and menopause
• Breast density on mammogram
• Medical history of Hodgkin’s
lymphoma
34 Menopause

Risk factors of Endometerial cancer

Modifiable Non Modifiable

• Obesity • Advancing Age
• Diabetes • Endogenous estrogens
• Hypertension • Late menopause
• Polycystic ovarian • Nulliparity and infertility
syndrome • Genetic factor
• Unopposed estrogen
therapy

Bibliography

1. ACOG, Clinical management guidelines for obstetrician

gynecologists number 141, January 2014.
2. 2016 IMS Recommendations on women’s midlife health and
menopause hormone therapy. Endocrine Society, 2015.
3. North American Menopause Society, 2012.
4. Indian Menopause Society.
5. Consensus Guidelines.

AUB: abnormal uterine bleeding, CEE: conjugated equine estrogen CHD: coronary heart disease, CKD: chronic kidney disease,
CVD: cardiovascular disease, DUB: dysfunctional uterine bleeding, DVT: deep vein thrombosis EPT: estrogen and progesterone
therapy Hb: hemoglobin, HbA1c : Hemoglobin A1c; HPE: histopathological evaluation IUD: Intrauterine devic KFTs: Kidney
functions tests, LFTs: liver function tests, MHT: menopausal hormone therapy, OCP: Oral contraceptive pill, OPD: outpatient
department; PAP/LBC: Pap smear and liquid-based cytology; PCOD: Polycystic ovary syndrome, PIH: pregnancy-induced
hypertension, POF: premature ovarian failure; SHBG: Sex hormone–binding globulin TSEC: Tissue-selective estrogen complex
TSH: Thyroid-stimulating hormone TVS: Transvaginal sonography; VIA: visual inspection with acetic acid; VMS: vasomotor
symptoms.
35

Vaccination
Moderators : Dr. Sarita Bhalerao, Dr. Neerja Bhatla
Panel Members : Dr. Kawita Bapat, Dr. Arun Nayak, Dr.
M C Patel, Dr. Krishnendu Gupta

Preface
Immunization of a pregnant woman enables a number of important health
benefits for both mother and the baby. Vaccine-preventable diseases have
been shown to cause significant morbidity and mortality among maternal,
neonatal, and young infant. Furthermore, some of these infections can be
serious enough to waste pregnancy, or affect the infant post delivery.
Vaccination of the pregnant women has been shown to strengthen her
immune systems to fight off serious infectious diseases. It helps in
protecting the mother from infections and this immunity passes to her infant
during pregnancy, keeping the child safe during the first few months of life.
The fear that fetus can be at risk after vaccination of the mother during
pregnancy has no scientific bases. There have been no study to show if there
is risk for fetus after maternal vaccination with inactivated vaccines or
bacterial vaccines or toxoids. Since live vaccine poses a theoretical risk to a
developing fetus, all live vaccines should be avoided during pregnancy.

Lack of awareness of risk and benefits of vaccination during pregnancy

is a common barrier for its use.
36 Vaccination

Vaccination in Adult
Women

Pregnancy Post-natal/Lactation Older women

Adolescents Pre-pregnancy Refer next
Refer table below page Refer next page

HPV

Rubella Human papilloma virus (HPV) Varicella

• Vaccination history; • Licensed 9–45 years (bivalent and • Vaccination history;

H/o Rubella
• Check Rubella IgG
whenever possible
• Single dose Rubella
vaccine or MMR vaccine
• Counsel to AVOID
pregnancy for 4
weeks after vaccine
administration
• Thereafter, no need
to check antibody titre
quadrivalent) H/o varicella
• Ideally administered before sexual • 2 doses: 0 and 1 month
exposure: • Counsel to AVOID
»» If <15 years: 2 doses (0 and 6 months) pregnancy for 4
»» If >15 years or immunocompromised: weeks after vaccine
3 doses (0, 1 / 2 and 6 months) administration.
»» Cervarix: 0, 1 and 6 months
»» Gardasil: 0, 2 and 6 months
• Counsel to AVOID pregnancy for 4 weeks
after vaccine administration, in case the
woman becomes pregnant
• HPV testing not necessary before
vaccination.

• All vaccines are optional

• FOGSI recommends HPV vaccination inn all adolescents for protection against cancer of cervix

Pregnancy

Strongly recommended Recommended Not recommended

TT:2 doses or Influenza vaccine HPV

Tdap (during flu season) MMR
Intramuscular after first trimester Varicella
TT
• 1st dose: Between 16–20 weeks, 2nd dose: After 4–6 weeks after the 1st dose.

Tdap
• Can replace TT (wherever available)
• Single dose replaces both doses of TT: Administered 28–36 weeks, if previously immunized
• If not immunized: 2 doses of TT and 1 dose of Tdap.
37 Vaccination

Recommended vaccines under “Special Situations”

• Rabies: Where the benefits outweigh the risks involved
• Hepatitis A
• Hepatitis B
• Cholera
• Typhoid

• In general, routinely recommended

vaccines can be administered safely.
Postnatal / • No adverse effects on immune
lactation response (maternal or fetal).
• Limited data available: No
adverse events reported.

Older women
Influenza vaccine

CounselLing

• The lady must be counseled properly clearly explaining the benefits and
side-effects of the concerned vaccine; consent must be obtained.
• AEFI (Adverse Events Following Immunization) reporting: Risk
of anaphylaxis must be explained.

Adverse Events Following Immunization

• Mild reactions (common): Injection site pain, redness, swelling,

induration.
• Moderate reactions (occasional): Fever, headache, myalgia, joint
pains, lymph node swelling, and gastrointestinal disorders.
• Severe reactions (rare): Circulatory reactions, chills, paresthesia,
allergic reactions, and anaphylaxis.

HPV: human papillomavirus; IgG: immunoglobulin G; MMR: Measles, mumps, and rubell.
Documentation must be made regarding that the “patient and accompanying relatives, if present, were properly counseled
about the potential benefits and risks of the vaccine prior to administration”.
38

Hypertensive Disorders in
Pregnancy
Moderators : Dr. Suchitra Pandit / Dr. Pratima Mittal
Panel Members : Dr. Ashis Mukhopadhyay, Dr. Atul Munshi,
Dr. Sudhir Shah, Dr. Nita Thakre,
Dr. Alpesh Gandhi

Preface
Hypertensive disorders during pregnancy (HDP) are a major cause of
maternal morbidity and mortality and are known to complicate about 3-10% of
all pregnancies. About 10-15% of all maternal deaths are contributed by
hypertensive disorders of pregnancy especially in the developing world.
Preeclampsia and eclampsia has been seen to occur, most often after 20
weeks of gestation.
A noteworthy feature is that the prevalence of hypertension during
pregnancy has been seen to be significantly higher in women with
previous history of cesarean section (17.6 vs 6.5%) as compared to
women with no history of cesarean section. A significantly higher rate of
prior cesarean section were recorded in women with chronic
hypertension as compared to normotensive women.
The complications of HDP which are responsible for maternal morbidity and
mortality include cerebro-vascular accidents, acute renal failure and pulmonary
edema, all of which are potentially preventable. So, the need of the hour is
to enable an effective screening strategy to diagnose hypertension
during pregnancy and also to device a comprehensive protocol for
management of such cases.
39 Hypertensive Disorders in Pregnancy (HDP)

Hypertensive disorders in Pregnancy

Classification Prevention and Prediction Diagnostic Evaluation

• Gestational Risk Identification: age >40; < 20 • Signs: Hypertension

Hypertension • BMI >30 Rapid weight gain
• Preeclampsia/eclampsia • Family history of preeclampsia Progressive edema
• Chronic hypertension • Inter-pregnancy interval >10 yrs • Warning S/S:
• Preclampsia • Nulliparity »» Headache
superimposed on • H/O Prev HDP,CKD, diabetes, »» Epigastric pain
hypertension APLS, Autoimmune disease »» Visual disturbances
• Multiple pregnancy »» Oliguria
• Gestational trophoblastic • Proteinuria/protein:
disease creatinine ratio in urine
Prevention by: Low Dose Aspirin • Full blood count with
from 12 weeks platelets
Calcium supplementation 1 gm BD • Urea, creatinine
Prediction uterine artery Doppler electrolytes
in high risk cases • LFT including LDH
Categorize: Non severe
severe
40 Hypertensive Disorders in Pregnancy (HDP)

Non-Severe Severe

Systolic 140–159 mmHg Systolic  160 mmHg

Diastolic 90–109 mmHg Diastolic  110 mmHg

• Expectant management upto • Serum creatinine >1.1 mg/dl

37 weeks in absence of • Oliguria
»» Organ involvement • Pulmonary oedema
»» Thrombocytopenia • Epigastric/RUQ Pain
»» HELLP syndrome • Impaired LFT (SGPT levels twice normal)
»» Symptoms of cerebral irritation • Thrombocytopenia, platelets <100,000/μL
»» Abruption • Headache, visual disturbance, convulsions
»» Fetal compromise
• Anti hypertensive drugs, if required

Management

Monitoring

Multidisciplinary team approach

Maternal Fetal Hospitalization and Monitoring
Prophylactic magnesium sulphate
Antihypertensives
Strict I/O chart
Maternal and fetal assessment

Daily fetal kick count

• B P frequently till stable NST
• Full blood count USG for fetal growth and
Urea, creatinine electrolytes wellbeing
• LFT including LDH
• Evaluate progress and severity
of organ involvement
41 Hypertensive Disorders in Pregnancy (HDP)

Hypertensive Disorders: Obstetric management

Non-Severe Severe

< 26 weeks stabilize 26-34 weeks >34 weeks

≥ 37 weeks gestation deliver and deliver expectant Stabilize and deliver
< 37 weeks gestation management:
individualize and deliver Steroids
Abnormal fetal Test results, neuroprotection by
Fetal growth restriction magsulfate sulfate
and deliver

Worsening of fetal /maternal

condition Delivery Indications

Steroids
Deliver

Maternal Fetal
• Severe disease • Severe FGR
• Imminent • Poor NST
eclampsia • Fetal
• HELLP syndrome compromise
• Abruptio

Severe HDP: complications

Requires multi disciplinary management

Severe HDP: Complications

REQUIRES MULTI DISCIPLINARY management
• Eclampsia
• HELLP syndrome
• Neurological complications
• Pulmonary edema
• Acute kidney injury
• Peripartum cardiomyopathy
• Disseminated intravascular coagulation
• Multi-organ failure
42 Hypertensive Disorders in Pregnancy (HDP)

HDP: Management: Antihypertensive drug

Non-Severe Severe

Avoid drastic and sudden lowering of BP.

Start drugs when DBP >100 mm Hg
Maintain DBP : 90-100 mm Hg
• Tab Labetalol 200 mg 6 to 8 hourly
• Tab Nifedipine10 to 20 mg thrice a day Systolic
• Tab Methyldopa 250 to 500 mg 6-8 hrly if DBP > 110 mm Hg
available and patient is already having it • Inj Labetalol
Starting at lower
can be stopped if BP controlled with above • Tab Nifedipine
drugs
• Inj Hydralazinedoses. incremental
• Inj Labetalol : 20 mg IV, if no response then
40-80mg every 20-30 min, max of 220 mg :
for infusion: 1-2 mg/min
• Hydralazine (5 mg IV bolus then if needed, 5–
10 mg IV every 10-20 min to a maximum of 45
mg) (FIGO 2016)
• Nifedipine tablet (10 mg orally every 20-30 min
to a maximum of 30 mg) (FIGO 2016)

NOTE :

• No sublingual Nifedipine
• No Frusemide
• Avoid drastic and sudden lowering of BP.
• Can use Nifedipine + Magnesium sulphate, but with caution
• Prior to transfer to tertiary care start IV line and give Inj magnesium
sulphate

APLS: antiphospholipid antibodies; BP: blood pressure; CBC: complete blood count; CRP: C-reactive protein; CKD: chronic kidney
disease; DBP: diastolic blood pressure; FGR: fetal growth restriction; HDP: hypertensive disorders of pregnancy; HELLP: Hemolysis,
elevated liver enzymes, low platelet count syndrome; LDH: lactate dehydrogenase; LFT: liver function tests; LSCS: lower (uterine)
segment Caesarean section; NST: Non-Stress test; RFT: renal function tests; RUQ: right upper quadrant; SGPT: serum glutamic
pyruvic transaminase; USG: ultrasonography.
43 Hypertensive Disorders in Pregnancy (HDP)

Management of a pregnant woman presenting

with Eclampsia
Shout for help! IV access
(no.16 to 18 cannula)

Place woman on her left side

to reduce risk of aspiration of
secretions, vomitus and blood

Assess breathing Check airway and intubate, if

required

Rapidly evaluate vital sign If breathing, given oxygen

Simultaneouly, take patient’s history
(pulse, BP, and temperature).
from relatives
If pulse not palpable, CPR
initiated, and resuscitate
at 4-6 L/min by mask or
nasal cannulae Examine
neck for rigidity

Post convulsion: clean mouth and

throat, continue IV infusion at Investigation: Blood group, CBC with
platelets, sugar, LFT, RFT
maximum of 80 ml/hr. Catheterize
patient and I/O chart

Magnesium sulfate loading dose: 4 g IV as 8 ml of 50% solution diluted

in 12 mL saline over 5 minutes. 10 gm of 50% solution, 5 g in each
Start Magnesium sulphate buttock as deep IM injection (can add 1 mL of lignocaine in same
syringe. Maintenance dose of 5 gms IM 4 hourly on alternate buttock

Start anti hypertensive drugs if

diastolic BP>100 mmHg
Labetolol -10-20 mg IV, then 20-80 mg every
20-30 min, max of 220 mg: for infusion: 1-2 mg/min Nifedipine 10-30
mg PO, repeat in 45 min if needed Hydralazine Inj. 5 mg IV or IM, later
5-10 mg every 30 min once BP is controlled repeat every
3 hours to a max 5 doses
Provide ongoing care

• Monitor vital sign (pulse, BP & respiration > 16/min), patellar reflexes and
urinary output > 30ml/hr
• Maintain strict fluid balance chart to prevent fluid overload.
• Provide maintenance dose of anti-convulsive and anti- hypertensive drugs
• Auscultate lung base hourly for rales ( indication of pulmonary edema)
• Plan delivery, Monitor progress of labour, LSCS for obstetric indication
44

Postpartum hemorrhage
Moderators : Dr. Vanita Raut, Dr. S. Shanthakumari
Panel Members : Dr. M G Hiremath, Dr. Saraogi,
Dr. Mahesh Gupta, Dr. Dipak Bhagde,
Dr. M. Krishna Kumari

Preface
Postpartum hemorrhage is generally considered as ≥500 ml of blood loss
within 24 hours after birth, while severe PPH is blood loss ≥1000 ml within
24 hours. It is the most common cause of maternal death worldwide. Most
cases of PPH associated morbidity and mortality occur in the first 24 hours
following delivery, whereas other few cases of PPH also occur due to
abnormal or excessive bleeding from the birth canal between 24 hours and
12 weeks postnatally. Blood loss post-delivery is rarely measured in clinical
practice, hence there is lack of clarity. Measuring blood loss may improve
the care and outcome for women. Grand multiparity and multiple gestations
are known risk factors for PPH. Moreover, it may occur in women without
identifiable clinical or historical risk factors. Therefore, it is recommended
that active management of the third stage of labor should be offered to all
women during childbirth. Preventing delays in the diagnosis and treatment
improves the chances of survival. The following demonstrates the “care
pathway” for management of PPH, as a practical guide for clinicians.
45 Postpartum hemorrhage (PPH)

Postpartum haemorrhage (PPH)

Definition
Any bleeding after the delivery of a baby that may affect the hemodynamic
status/vital parameters of the mother.
Blood loss: Vaginal delivery >500 ml; caesarean section >1000 ml

Types
• Early
• Late (primary/secondary)

Prevention of PPH

Active management of third

Correct antenatal anemia Look for risk factors*
stage labour

Oxytocin 10 units in 1 min/5 units IV

Delayed cord clamping

Controlled cord traction with uterine

palpation

Inspection of lower genital tract and

placenta

*PPH can occur without any risk factor

46 Postpartum hemorrhage (PPH)

Management of post-partum hemorrhage

All components should be carried out simultaneously. Try to establish

cause of PPH.

Prevention of PPH

Communication Assessment Resuscitation Replace Arrest

• Inform patient 1. Clinical • ABC approach

and relatives • Pulse, BP,
• Call for Help- • Respiratory rate
obstetrician • Input/output
and 2. Assess Blood Loss
anaesthetist
3. Investigations
• Alert OT, ICU,
• CBC
Blood bank • Grouping and cross
matching
• Bedside clot testing
• Coagulation studies
• Platelet count
• PT - INR
• aPTT
• Fibrinogen
• Renal and liver functions
• 100% oxygen at
10-15 L/min
• 16 G cannula x 2
• Urinary catheter
• 3.5 L of warmed fluid initially
• 2L crystalloid followed by crystalloid/
colloid
• Blood transfusion group specific/ O -ve
• Coagulation factors
»» FFP
»» Cryoprecipitate
»» Platelets
• Massive transfusion protocol (MTP)

aPPT: activated partial
thromboplastin time; BP: blood
pressure; CBC: complete blood
count; FFP: fresh frozen plasma;
ICU: intensive care unit; OT:
operation theater; PT-INR:
prothrombin time-and
international normalized ratio.
• Uterine massage
• Bimanual uterine compression-AORTIC Compressium
• Drugs
• Uterotonics
»» Oxytocin
»» 10U IM / 5U IV followed by 20–40U IV in 500–1000ml at
125mL/hr »» Ergometrine every 5 mins, 5 doses, 0.25–0.5mg
IV/mcg IM »» Misoprostol 400–800 mcg rectal
»» Carboprost 0.25 mg IM every 15 mins, max 8 doses
• Tranexamic acid 1g IV
• Surgical intervention
»» Removal of retained placenta
»» Repair of tears
»» Uterine packing
»» Balloon tamponade
»» Brace sutures
»» Step in devascularisation
»» Arterial embolization
• Hysterectomy
47

Polycystic ovary
syndrome
Moderators : Dr. Jaideep Malhotra, Dr. Kuldeep Jain
Panel Members : Dr. Vinita Singh, Dr. H. P. Pattnaik,
Dr. A. Charmila, Dr. Seema Pandey,
Dr. Sushma Pandey

Preface
Polycystic ovary syndrome (PCOS) is one of the most common endocrine
disorders in women of reproductive age with prevalence estimates ranging from
2.2% to as high as 26%. This syndrome is a common disorder complicated by
hyperandrogenism and chronic anovulatory infertility associated with clinical
manifestations of oligomenorrhoea, hirsutism, and acne.
Women having PCOS are generally obese, exhibit an adverse cardiovascular
risk profile, and have a higher prevalence of impaired glucose tolerance, type
II diabetes, and sleep apnoea. These patients are also prone to high incidence of
cardiometabolic syndrome involving hypertension, dyslipidaemia, visceral obesity,
insulin resistance, and hyperinsulinaemia. Gynaecologists are observed to
frequently diagnose PCOS; therefore in order to offer a holistic approach
to the disorder, it is essential to have a good understanding of the long-term
implications of the PCOS diagnosis. The healthcare professionals need to educate
the women with PCOS regarding the possible long-term health risks and positive
effects of lifestyle modifications. Those with PCOS before pregnancy should be
diagnosed for gestational diabetes. The algorithm provided in
this chapter guides through the process of diagnosis, investigations and
management of adolescents, women and postmenopausal women with PCOS.
48 Polycystic ovary syndrome

PCOS

• Commonest endocrinopathy of
reproductive age group
• Worldwide prevalence of 5–15%.
• Four phenotypes
• Major symptoms related to-
hyperandrogenism, ovulatory
dysfunction, and polycystic
ovarian morphology

• Perimenopausal
Adolescent PCOS Adult PCOS • Menopausal
• PCOS

Seeking fertility Not seeking fertility

• Diagnosis
• Investigations
• Management
• Long-term
consequences
• Follow up
49 Polycystic ovary syndrome

Adolescent PCOS

Diagnosis Investigation Management

• Presence of oligo/ • Minimal 5 biochemical

Amenorrhoea (OD)
>2 years of menarche
• but hypocaloric diet x 6
All the three criteria- OD,
Hyperandrogenism,
PCOM must be present
• PCO with strict
interpretation of
ultrasonography findings
tests required-Grade A,
Evidence level-4
• Serum TSH, FSH, LH,
Prolactin (to rule out other
causes)
• Serum total testosterone
< 60 ng/dl
• Serum 17(OH)
progesterone at 8 am
• OGTT (at zero and 2 hours
after 75 g glucose load)
Lifestyle modification in
combination with balanced
months- 1st line treatment.
Grade-B, Evidence level-4 daily
strict physical activity sessions
for at least 30 min/day or 150
min/ week are recommended
(Grade A, EL 4).
Add metformin as second-line
therapy for weight loss.
Grade-B, Evidence level-4
Other insulin sensitizers like
inositol group can be tried
(Myoinositol plus D-chiro-
Inositol).

Low dose COCs-next line of management.

Pharmacological
Grade A, evidence level-4 treatment
• Use low-dose COCs (with or without anti-androgenicprogestins-
drospirenone and desogestrel) for the management of MI
Progesterone withdrawal
(Grade A, EL 4)
bleed- First line therapy
• Between 12-16 years of age, low-dose COCs only to be used,
Grade A, Evidence level-4
for short period (up to 7 days
Aim is to give minimum 4
• After 16 years of age long-term therapy accepted bleed per year.
• The duration of COCs to treat hyperandrogenism is not
established yet
• A break of 3 months every one year is recommended to
prevent thromboembolic events
50 Polycystic ovary syndrome

Selection of COCs may be

decided on the nature of
predominant symptoms

Menstrual irregularity Hirsutism Acne/alopecia

EE+Cyproterone acetate • COCs with anti-androgenic

(combination preferred) progesterone activity
+ temporary hair removal (drosperinone, desogestril,
Obese Non-obese
methods x 6 months. cyproterone acetate) along
1st line therapy with treatment based on
grade A, evidence level 1 clinical presentation and a
dematologist’s opinion .
EE + First-line therapy
drosperinone
EE + any third Grade A, Evidence level 1
better
generation • Add spironolactone/ • Cyproterone was found to
suited than
other third progesterone fenastride- if no desired be better suited for Indian
generation response or poor population.
pills tolerance
Grade A, Evidence level 2
• Treatment has to be
stopped 6 months before
trying for pregnancy
In case of non-tolerance and • Other permanent
contraindication to COCs- methods of hair removal
metformin can be used along therapies
with or without cyclic • There is no role of
progesterone bleed. metformin in treating
Grade A, Evidence level 4 hirsutism until the
Myoinositol + D-chiro- adolescent has a
Inositol improve insulin deranged GTT
sensitivity, body mass index • Myoinositol + D-chiro-
(BMI), and menstrual Inositol improve
irregularities@ hyperandrogenism @
• Adjuvants like omega 3
fatty acids or alternative
therapies (acupressure
etc) – evidence is
inconclusive
51 Polycystic ovary syndrome

Adult PCOS

Diagnosis
• Rotterdam’s criteria-2/3
• FSH, LH, TSH, E2 and prolactin to rule
out other causes
• Biochemical determination of Not seeking fertility
testosterone. Grade , Evidence level 4
• AMH Grade B, Evidence level 4
• 17 hydroxy progesterone in obese
and hirsute
Lifestyle modification by
• Progesterone withdrawal bleeding
diet and exercise (like in
Grade B, evidence level 4
adolescents)
Identification of metabolic
syndrome markers and
treat them properly.
Menstrual irregularities
also to be treated similarly
as adolescents.

Regular follow-up for

Seeking fertility metabolic syndrome,
carcinoma risk

Ovulation induction

Pre-conception counseling Life style modifications- with targeted weight

• Positive counseling
• Counseled on the need for
identification and correction of long-
term risk factors affecting fertility
before initiating treatment
(Grade A, EL 4).
• Regarding diet, lifestyle, cessation
of smoking, and folic acid intake.
• PCOS women with subfertility
should be counseled on length of
procedure, types, side effects,
success rate, and cost of
treatment (Grade B, EL 4).
reduction of at least 5–10% and preventing further
gain. Grade A, EL1
• By calorie restricting diet (500 calories) and physical
activities 60 minutes/day along with control of other
factors (alcohol consumption, excessive coffee
intake, cessation of smoking) for 3 months.
• The age-related decline in fertility should be given
appropriate consideration for considering the
duration of lifestyle management interventions
(Grade B, EL 4).
• In morbidly obese women (BMI >35) no OI before
improvement in BMI. Orlistat can be given up to 3
months.
• In obese women, myoinositol + D-chiro-Inositol
(40:1) for 6 months$
• Bariatric surgery- first line in BMI >50, second line
in BMI >35
• Positive role of yoga
52
Medical management
• Clomiphene citrate (CC)-
first line option for OI.
dosage 50-150 mg x 3-6
cycles, with per cycle
increment of 50 mg.
• Ultrasound monitoring
with CC recommended
to see the response and
reduce the chances of
multiple gestation and
hyper-stimulation.
• In unavailability of
USG, LH kit monitoring
recommended.
Pretreatment with combined
oral contraceptive pills
Low dose combined COCs
pretreatment (with/ without
lifestyle modifications)
for at least 2 months is
recommended in subfertile
PCOS patients with high LH
level (3 times the basal
levels) to normalize it
(Grade B, EL 4).
CC/ letrozole +
gonadotropin
ART: a third-line
treatment option in
women with PCOS who
fail to conceive or who
have other indications
for IVF (Grade A, EL 2).
Myoinositol plus D-chiro-
Inositol increases oocyte,
embryo quality, and
pregnancy rates.**
Ovulation Induction
• Letrozole/ AI- 2.5- 5 mg/
day for 3-6 cycles
• Best response in non-
obese PCOS
• And hyper LH PCOS.
• CC failure
• Gonadotropin failure
• Very soon may replace
CC as first-line
management of OI?
CC failure / CC resistance /
no conception
Melatonin, N-acetyl cysteine
(NAC), and myo-inositol
have emerged as novel
pharmacotherapeutics to
improve IVF outcomes for the
treatment of infertility.
Myoinositol + folic acid for 3
month*
IUI
• Not a routine treatment for
PCOS only.
• Recommended in PCOS with
mild male factor subfertility.
• PCOS women ovulating with
drugs but not conceiving
normally.
Polycystic ovary syndrome
LOD (surgical
management)
• Not a first line management
• Recommended mode in
women with CC resistance
and hyper LH PCOS, before
gonadotropin stimulation.
• Number of punctures
according to the size of
ovaries but not to exceed
4-6 holes/ovary. Grade B,
Evidence level 4
• No other factor
contributing to infertility
should be present.
Gonadotropins are second
line of treatment for
CC failure, CC resistance
Chronic low dose or low dose
step-up protocol preferred.
Minimum starting dose
37.5 IU to 75 IU. With weekly
increment of 50% dose till the
lead follicle reaches 12 mm,
then same dose to be continued
till trigger x 3 cycles.
Counseling regarding
increased cost, strict
monitoring, cancellation of
cycle, hyperstimulation and
multifetal gestation. Grade A,
evidence level 2
Luteal phase support-
Progesterone is recommended
in sub-fertile PCOS women
undergoing OI or assisted
reproduction (Grade A, EL 2)
Myoinositol 2 g +folic acid 200
mg twice daily.#
53 Polycystic ovary syndrome

Peri-menopausal/
menopausal PCOS

Diagnosis Investigations- Management

• Difficult to diagnose, • OGTT • Life style modifications
at least two criteria • Lipid profile • Insulin sensitizers and
must present adjuvants
• Total testosterone
(hyperandrogenism with
• Carotid intima thickness • Myoinositol + D-chiro-inositol
menstrual dysfunction) improves glucose
• PCOM if present- has • Thyroid profile
metabolism, which in turn
added advantage • Investigations related to improves lipid profile and
metabolic disease risk. reduces cardiovascular risk.$
• TVS/HPE endometrium • Peri- menopausal women
with menstrual irregularities
have to be treated like any
other adult.
• Multidisciplinary approach
has to be adopted for
various cardio-metabolic
complications.

Sleep apnea and depression Follow-up recommendations

• Proper history of sleep • Blood pressure monitoring
apnea to be taken, like yearly in non-hypertensive
day time sleepiness, PCOS
laziness etc • OGTT every year in non-
• Due to higher tendency of diabetic normal PCOS
depression and anxiety, • Abnormal GTT- as per
history to be taken and
requirement
proper behavioral and
• Cardiovascular risk- not to
expert therapy to be
be done routinely in
recommended
absence of any other high
risk factor or family history

@
Kalra B, Kalra S, Sharma JB. The inositols and polycystic ovary syndrome. Indian J Endocr Metab. 2016;20:720-4.
*Regidor PA, Schindler AE. Myoinositol as a safe and alternative approach in the treatment of infertile PCOS women: A German Observational Study. Int J
Endocrinol. 2016;2016:9537632.
** Colazingari S, Treglia M, Najjar R, et al. The combined therapy myo-inositol plus D-chiro-inositol, rather than D-chiro-inositol, is able to improve IVF
outcomes: Results from a randomized controlled trial. Arch Gynecol Obstet. 2013;288(6):1405–411.
# Papaleo E, Unfer V, Baillargeon JP, et al. Myo-inositol in patients with polycystic ovary syndrome: A novel method for ovulation induction. Gynecol Endocrinol.

2007;23(12):700–03.
$ Minozzi M, Nordio M, Pajalich R. The Combined therapy myo-inositol plus D-Chiro-inositol, in a physiological ratio, reduces the cardiovascular risk by

improving the lipid profile in PCOS patients. Eur Rev Med Pharmacol Sci. 2013;17(4):537–40.

AI: Aromatase Inhibitor; AMH: anti-Mullerian hormone; BMI: body mass index; COCs: combined oral contraceptive; E2: estradiol;
EE: ethinylestradiol; FSH: follicle-stimulating hormone; GTT: glucose tolerance test; HPE: histopathological evaluation; IVF: in-vitro
fertilization; LH: luteinizing hormone; LOD: laparoscopic ovarian drilling; OGTT: oral glucose tolerance test; OI: Ovulation Induction;
PCOM: polycystic ovarian morphology; TSH: Thyroid-stimulating hormone; TVS: Transvaginal sonography; USG: ultrasonography.
54

Reversible
contraception practice
Moderators : Dr. Ritu Joshi, Dr. Reena Wani
Panel Members : Dr. Shyamal Sett, Dr. Archana Baser,
Dr. Tarini Taneja, Dr. Komal Chavan,
Dr. Monika Doshi

Preface
Unintended pregnancies have significant social and economic consequences.
The effectiveness of different currently available methods in preventing
pregnancy varies widely. It is generally accepted that long-acting reversible
contraceptives (LARCs), including intrauterine devices (IUDs), and progestogen
implants, are most effective apart from permanent sterilization methods such as
vasectomy and tubal ligation. LARCs are safe and highly effective for women in
reducing unintended pregnancy and abortion rates due to their long duration of
action and requirements of minimal adherence.
Ovulation occurs at a mean of 39 days post-partum in non-lactating women,
which increases the risk of unintended and short-interval pregnancy. Around
70% of pregnancies are unintended during the first year post-delivery.
Therefore, use of reversible contraceptive methods can provide several
potential benefits and help in lowering the rate of unintended pregnancy and
avoiding short-interval pregnancy.
Before selecting a post-partum reversible contraceptive method, women
should be counseled prenatally, including counseling regarding the
advantages, risks of IUD expulsion, as well as contraindications. Therefore,
LARCs are recommended as effective means of contraception without its
impact on future fertility. The algorithms provide a process for availability,
methods, and selection of modern contraceptive options.
55 Reversible contraception practice

Selection of Modern
Contraceptives

Need for spacing?

Preferred route and duration?

Oral Non-Oral
Short-term reversible Long-acting reversible
• Hormonal
• Combined
• Progesterone
Administered by whom?
• As back-up, EC
• Extended use-algorithm
for OCS

Medical/Paramedical/
Self
Midlevel practitioner

Vaginal ring
Limited duration Extended duration

Combined
hormonal
Injectable IUD

Progestogen only
Non hormonal
Progestogen only Copper
Transdermal DMPA • Short duration

patch* • Extended duration

Injectable SC Hormonal
• LNG-IUS

Implants

*Desire for regular cycles

56 Reversible contraception practice

Long-acting reversible contraception (LARC)

Time of use / administration
IUD
Injectables Copper LNG Implant
Interval    
Post abortal    
Post partum ----  * <48 hrs >4 weeks *>6 weeks
>6 weeks
Emergency ----  ---- ----
* 6 weeks postpartum if lactating

Options for Contraception

Non LARC Hormonal Barriers

LARC methods
Efficacy compliance Less reliable
Consider alternative if patient Condoms protect from STI
is on enzyme inducers Risk is minimal (MEC)

Combined hormonal
POP
Check MEC

Can be used when E is C/I

Unpredictable bleeds
COC Patch Ring
Scanty menses
Good for lactating mothers
• Regular bleed
• Non contraceptive benefits

Condoms Diaphragm
Intrauterine Implants Injectables

with
spermicide
Copper IUD Hormonal IUD Male Female
HCP needed
Not
available

5-10 yrs life 5 yrs life 3 yrs In 2 or 3 monthly inj

Heavier, longer lighter HCP Unpredictable bleeds
painful periods bleed required Frequently
Useful in Light amenorrhea delayed
postpartum and bleed return to fertility
postabortal cases
57 Reversible contraception practice

Selection for reversible

contraceptive

• Access age, history

• Basic examination
(general, breast, pelvic)
• Review medical history
• Current medications
• Duration of contraception
devices

• Categorize according to
patient need and MEC

1. Adolescents
2. Medical disorders
3. Postpartum/post aborted
4. Perimenopausal
5. Special categories

C/I: contraindicated; COCs: combined oral contraceptive; DMPA: depo-medroxyprogesterone acetate; EC:
emergency contraception; HCP: health care provider; IUD: Intrauterine device; LNG- IUS: levonorgestrel
intrauterine system; MEC: medical eligibility criteria; POP: progestin-only pills; SC: subcutaneous; STI:
sexually transmitted infections.
58

Ectopic pregnancy
Moderators : Dr. Alka Kriplani, Dr. Chaitanya Ganapule
Panel Members : Dr. Bijoy Nayak, Dr. Atul Ganatra,
Dr. Navina Singh

Preface
Ectopic pregnancy is a high-risk condition wherein a fertilized ovum gets
implanted outside the uterine cavity. This condition poses a significant
threat to women of reproductive age and is a leading cause of maternal
death during the first trimester. It is reported to affect around 1% to 2% of
all pregnancies. Risk factors for ectopic pregnancy include surgery or
infection that causes tubal damage, as well as maternal smoking and in
vitro fertilisation. However, the majority of women with an ectopic
pregnancy have no identifiable risk factor. Advances in diagnosis and
treatment of ectopic pregnancy have reduced the mortality rates by 50%.
First-trimester bleeding and abdominal pain may be indicative of common
symptoms of an unruptured ectopic pregnancy. It is essential to consider
ectopic pregnancy when a pregnant woman presents with these symptoms.
The details involving clinical history on pregnancy dating, the onset and
intensity of symptoms, and a review of risk factors can help in determining
the best diagnostic course, as well as the speed of processing the workup.
Noting the severity of symptoms is important; especially for those with more
severe bleeding, and hemodynamic instability. Surgical treatment may be
warranted in such cases. The following flowcharts may help in guiding the
diagnostic and treatment approaches for patients with ectopic pregnancy.
59 Ectopic pregnancy

PUL

Repeat β hCG Measurement

Every 48 hrs

β hCG levels plateaus or

β hCG levels decrease β hCG shows normal rise
shows suboptimal rise

Failed pregnancy TVS when discriminatory

TVS
(intrauterine or ectopic) level is reached

Weekly β hCG measurement

Go to A
until negative

Intrauterine
Adnexal mass Negative
pregnancy

Medical or Failed pregnancy

surgical treatment (intrauterine or
ectopic)

Medical or
surgical treatment

Incidence 11/1,000
• Ampullary
• Isthmic
Classical triad • Cornual
• Amenorrhea • Interstitial
• Pain Ectopic pregnancy • Scar
• Bleeding • Ovarian
Risk factors • Abdominal
• Cervical
• History of PID
• Tubal surgery /ligation
• Previous ectopic pregnancy
• Infertility
• ART
• Smoking
• Maternal age >40
• Pregnancy with IUCD
60 Ectopic pregnancy

Ectopic pregnancy

Initial Assessment
• Vital signs
• UPT/β hCG (whenever possible)

Haemodynamically
Haemodynamically stable
unstable

• β hCG Presumptive ruptured

• TVS (tool of choice) ectopic pregnancy/
• TAS (if TVS not available) hemorrhage

• Empty uterine cavity Immediate surgical

• In homogenous/ non-cystic adnexal mass treatment
• No specific endometrial sign
• Free fluid in POD is not diagnostic

Management

Expectant Medical Surgical

Indications
• Ready to come for follow up
• No significant pain
• β hCG <1500 mIU

Repeat β hCG after 48 hrs

Falling level Increasing levels

Follow up weekly with β hCG Manage as per medical

till levels <5 mIU management/surgical
61 Ectopic pregnancy

Indications
• No significant pain
• Adnexal mass <35 mm
Medical
• β hCG :1500 to 5000 mIU
• No visible heart beat
• No intrauterine pregnancy

Methotrexate (drug of choice)

Multiple doses
• 1, 3, 5 and 7th day
Single dose preferred D1: (50 mg/m2)
50 mg/m2 • Haemogram (CBC) • Inj Leucoverine
Repeat β hCG on Day • LFT, RFT, Rh type; blood group 0.1 mg /kg on 2, 4,
4 & Day 7 6, & 8th day

If decrease >15% If decrease is <15% Decrease if >15%

F/U with weekly β 2nd dose of Inj Weekly β hCG till If decrease is <15%
hCG till <5 mIU methotrexate negative
Weekly β hCG till
negative

Table 1. Multiple-dose MTX treatment protocol

Treatment day Laboratory evaluation Intervention

hCG, CBC with differential, liver function tests,
Pre-treatment Rule out spontaneous abortion RhoGAM if Rh negative
Creatinine, blood type, and antibody screen

1 hCG MTX 1.0 mg/kg IM

2 LEU 0.1 mg/kg IM

MTX 1.0 mg/kg IM if <15% decline day 1 – day 3 if >15%, stop
3 hCG
treatment and start surveillance

4 LEU 0.1 mg/kg IM

MTX 1.0 mg/kg IM if <15% decline day 3 – day 5 if >15%, stop
5 hCG
treatment and start surveillance

6 LEU 0.1 mg/kg IM

MTX 1.0 mg/kg IM if <15% decline day 5 – day 7 if >15%, stop
7 hCG
treatment and start surveillance

8 LEU 0.1 mg/kg IM

Note: suverilance every 7 days (until hCG < 5 mIU/mL), screening laboratory studies should be repeated every week after the last dose of MTX, CBC= complete blood count, MTX= methotrexate,
IM=intramuscularly, LEU= leucoverin.
62 Ectopic pregnancy

Laparoscopy
Surgical Laparotomy
(if laparoscopy not possible)

Salpingectomy Salpingotomy
Indications Indications
• Healthy contralateral tube Salpingotomy
• Contralateral tube damage
• No other fertility reducing With tubal repair
• Other fertility reducing
factor (in expert hands)
factors
• Family complete • Desires fertility
(Contralateral tubal
sterilization may be
offered)
F/U with β hCG after 7 days and
weekly thereafter till <5 mIU

If levels plateau/increasing
(persistent trophoblast) then
manage medically

Cervical pregnancy

• Medical management is the choice with systemic

methotrexate
• Surgical management only if life threatening bleeding

Scar pregnancy

• Medical management is the choice with systemic

methotrexate
• Surgical management only if life threatening bleeding

CBC: complete blood count; HCG: human chronic gonadotropin; PUL: pregnancy of unknown location; RFTs: Renal functions tests,
LFTs: liver function tests, POD: pouch of Douglas; PID: pelvic inflammatory disease; TAS: transabdominal scan; TVS: transvaginal
scan; IUCD: intrauterine contraceptive device; UPT: uterine pregnancy test.
63

Acute uterine bleeding

Moderators: Dr. Prakash Trivedi, Dr. Bhaskar Pal
Participants: Dr. Rajesh Modi, Dr. Rekha Kurian,
Dr. Geetendra Sharma, Dr. Archana Verma,
Dr. Rajendra Nagarkatti

Preface
Acute uterine bleeding (AUB) which is unrelated to pregnancy has been
described as “bleeding that is sufficient in volume as to, in the opinion of
the treating clinician, require urgent or emergent intervention”. Many
women of reproductive age experience acute bleeding when not pregnant,
but this aspect has not received much attention. Also, uterine hemorrhage
occurs secondary to pregnancy.

AUB is a relatively common clinical condition in women and can be source

of distress and a challenge for clinicians; and many of these women are
managed with inpatient surgical procedures. Medical treatment with single
or combined gonadal steroidal drugs given parenterally or orally show
promise, but further researcher is need to better define the appropriate
drugs, dose, and administrative scheduling.

In case of women with AUB medical management should be the first-

choice. Surgical approaches should be considered unless bleeding is
suspected to related to retained products of conception or from
intrauterine lesions such as aborting submucous leiomyomas.
64 Acute uterine bleeding

AUB

• History1
• Rule out pregnancy
• Examination
• Cervical cytology if appropriate
• CBC, TSH, USG (TVS±SIS)2,3

Increased risk Suspicion of Suggestive No structural

of hyperplasia/ intracavity pathology of structural problem; possibly
Malignancy4 (AUB-M, (polyp/SM fibroid/ problem (Myoma/ hormonal (AUB-
AUB-COEIN) malignancy5,6) Adenomyosis) COEIN)
(AUB-P, AUB-M)

Endometrial
sampling Hysteroscopy Fibroid Adenomyosis
& proceed (AUB-L) (AUB-A)

Specimen Specimen
adequate inadequate Family not Family
complete complete

Medical
management Prefers to
UAE retain uterus

Myomectomy7 UAE/HIFU

Medical
management, Offer hysterectomy
COCP, Ulipristal, if family complete
GnRHa, Low dose & over 40 years
Mifepristone

Wants fertility: Family complete; young Does not want to

• Trenaxamic acid or wants to preserve preserve uterus &
• Progesterones esp uterus > 40 years
Dienogest Dienogest/LNG
• GnRHa short term IUS/GnRHa
• Adenomyomectomy Adenomyomectomy
65 Acute uterine bleeding

No structural
problem; possibly
hormonal (AUB-
COEIN)

Medical management8,9
• Tranexamic acid
• Mefenamic acid
• COC pillsv
• LNG IUS
• Ormeloxfene
• Cyclical progesterone
(21/28 days)
• Inj DMPA

Succeeds Fails

Continue medical
management Offer endometria Offer hysterectomy if
ablative procedures if family complete and
family complete over 40 years

1History
Age, H/o amennorhoea, history suggestive of bleeding disorder, hormone intake (Progesterone/COCP/Danazol/Tamoxifen), h/o drug intake (antithrombotics etc),
risk factors eg DM, Hypertension, Obesity, Thyroid disorders.
2When to investigate?

AUB persisting for 3 months

Any AUB causing anaemia
Any postmenopausal bleeding
3Other specific tests
SIS only if doubtful intracavity pathology
Tests for coagulation (suggestive history, puberty menorrhagia)
MRI for pre-op evaluation of fibroids if indicated
Pre-operative investigations
Increased risk of hyperplasia/malignancy
4

Women 40 years, Intermenstrual bleeding, DM, Obesity, Hypertension, Prolonged unopposed exposure to estrogen
5Postmenopausal bleeding
Any postmenopausal bleeding needs an ultrasound assessment on Endometrial thickness (ET) preferably by TVS. Hysteroscopy with curettage is indicated if ET
4mm.
6Endometrial carcinoma

Treatment is total hysterectomy with bilateral salpingo-oophorectomy with bilateral pelvic

lymphadenectomy 7Pre-treatment of Myoma prior to surgery
Only indicated for hysteroscopic myomectomy for submucus fibroids 4cm or severe anaemia while waiting for surgery
GnRHa or Ulipristal acetate used
Reduces fibroid volume
May obscure tissue planes
Management of acute bleeding
8

Tranexamic acid (may need parental) & high dose hormones (Progesterones/COCP,Estrogen)
Coagulopathy
9

May need replacement of coagulation factors

Treatment with hormones & trenaxamic acid (no NSAID)

CBC: complete blood count; COCP: Combined oral contraceptive pills; DMPA: depot medroxyprogesterone acetate;
GnRHa: Gonadotropin releasing hormone agonist; HIFU: High-Intensity Focused Ultrasound; LNG_IUS: Levonorgestrel intra-
uterine system; TSH: Thyroid-stimulating hormone; UAE: Uterine artery embolization; USG: ultrasonography.
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Bacterial vaginosis
checklist
BACTERIAL VAGINOSIS
CHECKLIST
Moderators : Dr. Nandita Palshetkar, Dr. Ameet Patki
Panel Members : Dr. Rajesh Modi, Dr. Sunita Arora, Dr.
Meenu Handa, Dr. Sarita Sukhija, Dr.
Pushpa Nagar , Dr. Dhanashri Natu

From left to right: Dr. Dhanashri Natu, Dr. Sarita Sukhija, Dr. Rajesh Modi, Dr. Nandita Palshetkar,
Dr. Ameet Patki, Dr. Sunita Arora, Dr. Meenu Handa, Dr. Pushpa Nagar
 Preface
Bacterial vaginosis is the most common urogenital disease affecting about 19-24% of
the women during the reproductive age, and occurs as a result of imbalance in the
vaginal microbiota. Disruption of the normal Lactobacillus and subsequently increase in
predominantly anaerobic bacteria including Gardnerella vaginalis, Mycoplasma
hominis, Prevotella, and Peptostreptococcus have led to its occurrence.
Lactobacillus is associated with supporting full-term birth and healthy
pregnancy, and is the dominant microbe in the vagina of women. Hence, its
disruption increases the risk of potentially severe gynaecological and obstetric
complications. Bacterial vaginosis is associated with an elevation of cervico-
vaginal pro-inflammatory cytokines including interleukin-1 beta (IL-1β) and IL-8,
which initiates the cascade of inflammatory events involved in labour. Bacterial
vaginosis is associated with increased risk of pelvic inflammatory disease, tubal
factor infertility, late miscarriage, chorioamnionitis, premature rupture of
membranes, preterm birth, and postpartum endometritis.
Antibiotic therapy is the current treatment for bacterial vaginosis, but its
uncertainty in preventing preterm birth in women has been reported. Also,
antibiotics are unable to fully eradicate bacterial vaginosis vaginal biofilms-
associated bacteria, which can explain its high recurrence rates. Therefore,
probiotics have been suggested as an add-on to antibiotic therapy in restoring
vaginal lactobacilli and reversing bacterial vaginosis.
The flowchart created by FOGSI guides through the process of bacterial vaginosis in
terms of flora included, diagnosis, and management options in the affected women.

Best wishes!

Dr. Rishma Dhillon Pai

President 2017 - Federation of Obstetrics & Gynaecological Societies of India (FOGSI)
President (Elect- 2018) – Indian Society for Assisted Reproduction (ISAR)
Hon. Gen. Secretary - Indian Association of Gynaecological Endoscopists (IAGE)
Hon. Gen. Secretary- Mumbai Obstetrics and Gynaecological Society
Board Member - World Endometriosis Society (WES)

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The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
2 chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
Normal vaginal flora
Over 50 microbial species have been recovered from the vaginal tract and Lactobacillus is
the predominant species.

Bacterial vaginosis -DYSBIOSIS

• It is abnormal vaginal discharge characterized by an overgrowth of predominantly anaerobic
organisms (Prevotella spp., Peptostreptocci, Mobiluncus spp., and Gardnerella vaginalis) in
the vagina leading to a replacement of lactobacilli and an increase in vaginal pH.

• It often remits spontaneously, but may present as chronic or recurrent disease.

• Often seen in women of childbearing age and sometimes even menopausal women.

• Depletion of lactobacilli population and the presence of Gram-negative anaerobes, or in

some cases Gram-positive cocci, and aerobic pathogens.

Bacterial vaginosis
• Depletion of lactobacilli population

• Presence of Gram-negative anaerobes, Gram-positive cocci, and aerobic pathogens

Symptoms
• Offensive fishy smelling vaginal discharge

• Not associated with soreness, itching, or irritation

• Approximately 50% women are asymptomatic

Signs
• Thin white, homogenous discharge coating the walls of the vagina

• No evidence of inflammation

• Unpleasant fishy odour of discharge

3
 Bacterial vaginosis Diagnosis
Clinical diagnosis
AMSEL’S Criteria: At least three of the four criteria are present for the diagnosis to
be confirmed.
• Homogeneous gray-white discharge

• Fishy smell ( using few drops of 10% KOH, positive whiff test)

• Clue cells on wet mount microscopy

ii Full blown ≥ 20%

ii Partial >0 and <20%

• Vaginal pH >4.5

Laboratory diagnosis
Gram stained vaginal smear (Hay/Ison criteria, Nugent criteria)

Hay/Ison criteria:
• Grade 1 (Normal): Lactobacillus morphotypes are predominate

• Grade 2 (Intermediate): Mixed flora with some Lactobacilli is present, Gardnerella or

Mobiluncus morphotypes are also present

• Grade 3: Predominantly Gardnerella and/or Mobiluncus morpho types and few or absent
Lactobacilli.
• Grade 4: Predominantly Gram-positive cocci

The Nugent score:

• Normal: < 4

• Intermediate: 4-6

• Bacterial vaginosis: > 6

4
 Diagnostic and differential diagnosis algorithm

Vaginal discharge

White cottage-cheese
Gray thin, watery or
appearing, homogenously
yellowish-green
thick

Check pH

>pH 4.5 <pH 4.5

Saline microscopy

Clue cells with

Trichomonads
positive Whiff test
No Trichomonads
No Clue Cells
Trichomonads
Bacterial vaginosis
Vaginalis
Cervicitis
Obtain GC/
Chlamydia DNA
probe, NAAT on
Probe or urine

Positive Negative
PID No diagnosis

Hyphae seen No hyphae seen

Candida Obtain a yeast

Vulvovaginitis culture

Negative

Normal
GC:Neisseria gonorrhoeae; NAAT: nucleic acid amplification test; physiological
PID: pelvic inflammatory disease discharge

5
 Whom to screen?
AMSEL’S Criteria: At least three of the four criteria are present for the diagnosis to
be confirmed.
• All symptomatic patients

• Asymptomatic with high risk (previous adverse pregnancy outcome like recurrent
miscarriage, preterm delivery, preterm pre-labour rupture of membranes)

Screening Test
• Amsel’s Criteria

Complications
• Bacterial vaginosis is not a sexually transmitted but it may be associated with
sexually transmitted infections (STIs) and other genital infections.
• Increased risk of acquiring human immunodeficiency virus (HIV) in pregnant women.

• Decrease incidence of Chlamydia have been reported in women treated

for asymptomatic bacterial vaginosis
• Its prevalence is high in women with pelvic inflammatory disease (PID)

• It is common in women undergoing elective termination of pregnancy (TOP), and

is associated with post-TOP endometritis and PID
• In pregnancy bacterial vaginosis is associated with late miscarriage, preterm
birth, preterm premature rupture of membranes, and postpartum endometritis
• It is associated with an increased incidence of vaginal cuff cellulitis and
abscess formation following transvaginal hysterectomy
• It is associated with non-gonococcal urethritis in male partners

6
Management
General advice: (Grade C)

• To avoid vaginal douching

• Avoid use of shower gel

• Avoid use of antiseptic agent or shampoo

Treatment for SCREEN POSITIVE

Asymptomatic with high

Symptomatic (1A) Women undergoing some
risk pregnancy (1A)
Pregnant/non pregnant surgical procedure (1A)
(preferable to be treated
before 20 weeks)

Co-treatment with antibiotic and probiotic

• Metronidazole* 400 mg twice daily for 5-7 days (A)
OR
• Metronidazole 2 g single dose (A)
OR
• Intravaginal metronidazole gel (0.75%) once daily for 5 days (A)
OR
• Intravaginal clindamycin cream (2%) once daily for 7 days

• Probiotics: Lactobacilli species like acidophilus, rhamnosus,

reuterii, fermentum etc. for 15 days

*Alcohol to be avoided when patient is on metronidazole

• Treatment of recurrence: Co-treatment with antibiotics and probiotics but

probiotics is preferred
(BASHH: British Association for sexual health and HIV 2012)

7
Antenatal CARE
checklist

1
ANTENATAL CARE CHECKLIST
Moderators : Dr. Suchitra Pandit, Dr. HP Pattanaik
Panel Members : Dr. Sujata Dalvi, Dr. Geetha Balsarkar,
Dr. Vanita Raut, Dr. Anahita Chauhan,
Dr. Ritu Joshi

From left to right: Dr. Ritu Joshi, Dr. Sujata Dalvi, Dr. Suchitra Pandit, Dr. HP Pattanaik,
Dr. Vanita Raut, Dr. Geetha Balsarkar, Dr. Anahita Chauhan

1
 Preface
Routine antenatal care should be provided to all pregnant women to
ensure the best health conditions for both pregnant mothers and their
fetuses during pregnancy. Antenatal care includes risk identification,
prevention and management of pregnancy-specific or other concomitant
condition, education, and health promotion.
Most guidelines recommends screening interventions that include screening for
syphilis, human immunovirus, anemia (hemoglobin levels) and pre-eclampsia and
routine ABO and RhD testing. Also, most commonly used interventional
screening include screening for fetal anomalies, Down syndrome, early
ultrasound (first and second trimester), and late ultrasound and/or Doppler.
By mapping the current guidelines and practices related to routine antenatal
care, a checklist for antenatal care has been created to suite Indian women.
This antenatal checklist offers recommendations on clinical care for all
pregnant women, but it does not offer information on the additional care that
will be required by some women such as those with cardiac diseases or
renal diseases etc.

Best wishes!

Dr. Rishma Dhillon Pai

President 2017 - Federation of Obstetrics & Gynaecological Societies of India (FOGSI)
President (Elect- 2018) – Indian Society for Assisted Reproduction (ISAR)
Hon. Gen. Secretary - Indian Association of Gynaecological Endoscopists (IAGE)
Hon. Gen. Secretary- Mumbai Obstetrics and Gynaecological Society
Board Member - World Endometriosis Society (WES)

This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
© 2018 Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for a ny errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, N ational Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.
These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
2 chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
 Confirm pregnancy and encourage
early registration

FIRST VISIT

HISTORY EXAMINATION INVESTIGATIONS

• Name, age, occupation, • General • Hb/CBC

marital status
• Spontaneous/assisted
conception
• Menstrual and obstetric
history
• Medical, surgical, and family
history
• Personal history (diet,
allergies, medications,
vaccinations, addictions)
»» Height, weight, BMI
»» Temperature, pulse
»» BP, pallor, edema
• Systemic
»» Respiratory system
»» Cardiovascular system
»» Liver
»» Spleen
• Thyroid and breast
• Obstetric examination
»» Per Abdomen–as per
period of gestation
»» PS and PV, if required
• Blood group and Rh type (If
Rh negative, check partners
blood group)
• Urine routine
• VDRL
• Blood sugar ((OGTT post
75 gms Glucose) (D)
• HIV (Pre and post-test
counselling)
• HBsAg (Hepatitis B)
• HCV (D)
• TSH (D)
• Rubella IgG (D)
• Thalassemia screening (D)
(if positive, check partners
status)
• Dating ultrasound scan (D)

RISK STRATIFICATION

LOW RISK
Refer to the low risk HIGH RISK
algorithm

• Additional antenatal visits

• Additional investigations and scans
• Appropriate referral and
multidisciplinary approach
• Vigilant Monitoring
BP: blood pressure, BMI: body mass index, CBC: complete blood • Antenatal steroids for lung maturity
count, D: desirable, Hb: hemoglobin, HCV: hepatitis C virus, • Timely delivery with
HIV: human immunodeficiency virus, OGTT: oral glucose
tolerance test, TSH: thyroid stimulating hormone, VDRL: neonatologist consultation
Venereal Disease Research Laboratory test.

3
 LOW RISK PATIENTS

I II III
ADVICE SUPPLEMENTAION AND VACCINATIONS
MEDICATIONS

• Diet (balanced and • Folic acid • Injection TT– 2 doses,

addition of proteins) • Iron, calcium, vitamin 4–6 weeks apart
• Oral and personal hygiene D3 (after 2nd trimester) • Replace 1st TT with Td
• Physical activity and rest • Deworming (D) and 2nd TT with Tdap (D)
• Avoidance of • Antimalarial prophylaxis • Influenza vaccine
substance abuse in endemic areas

1. Pregnant women are

recognized as high-risk
group, and vaccination
prevents morbidity and
mortality due to seasonal
and pandemic influenza
2. Recommended from
26 weeks onwards
of pregnancy
3. Inactivated flu vaccines
4. Live flu vaccines are
contraindicated*

Subunit have favourable reactogenicity compared to split vaccines.

D: Desirable; TDaP: Tetanus, diphtheria, and pertussis ; Td: Booster vaccine for tetanus and
diphtheria *Reference: Beyer WE et al. Clin Drug Investig. 1998;15(1):1-12.
# Centers for Disease Control and Prevention Key Facts About Influenza (Flu) Available from:
https://www.cdc.gov/flu/keyfacts.htm ; accessed on 3rd January 2018)

4
 LOW RISK PATIENTS LOW RISK PATIENTS

IV V
SCHEDULE OF VISITS MANAGEMENT PLAN

• 11–14 weeks: First trimester combined

• Once in 4 weeks–28 weeks
screening (Ultrasound scan+Dual marker) (D)
• Once in 2 weeks–28 to 36 weeks
• 15–18 weeks: If FTS not done,
• Once a week–36 to 40 weeks offer Quadruple marker (D)
• At each visit, check for weight, • GCT if not done earlier
BP, pallor, and fetal assessment
• 18–19 weeks: Anomaly scan
• Risk stratification may change
• 24–26 weeks: Hb/CBC, Urine routine, GCT
• Ask about and look for signs of
domestic violence, if suspected • 28–32 weeks: Growth scan (D)

• Confirm place of delivery and – Counsel about breastfeeding

encourage hospital delivery and contraception
• 34–36 weeks: Hb/CBC, Urine routine, GCT (D)

• 36 weeks: Educate about alert

signs of labour (pain, leaking,
bleeding, fetal movements)
• 36–38 weeks:–Ultrasound scan
(AFI, Weight, Lie) (D)
• >38 weeks: VE
• 39–40 weeks: Vigilant monitoring
and discuss need for IOL
• Post dated 40 weeks: Red flag

BP: blood pressure; D: Desirable; FTS: First trimester screening;

CBC: Complete blood count; GCT: Glucose challenge tests;
AFI: Amniotic fluid index; IOL: Induction of labour

5
Cesarean-section
checklist

1
CESAREAN-SECTION
CHECKLIST
Moderators : Dr. Hrishikesh Pai, Dr. Sunita Tandulwadkar
Panel Members : Dr. Maninder Ahuja, Dr. Ameya Purandare,
Dr. Surveen Ghumman, Dr. Sheela Mane,
Dr. Adarsh Bhargava, Dr. Selvyapirya Sarvanan

From left to right: Dr. Ameya Purandare, Dr. Maninder Ahuja, Dr. Selvapirya Sarvanan, Dr. Sunita
Tandulwadkar, Dr. Surveen Ghumman, Dr. Adarsh Bhargava, Dr. Hrishikesh Pai

3
 Preface
Caesarean section is a life-saving procedure that is widely used in the obstetric
practice. Due to the advances in anaesthetic services and improved surgical
techniques, the morbidity and mortality of caesarean procedure have reduced
drastically. However, it can cause a significant and sometimes permanent
complication, disability or death in settings that lack the facilities to conduct the
intervention safely. Caesarean sections should preferably be conducted when
medically necessary, as its impact on maternal and perinatal morbidity, pediatric
outcomes, and psychological or social well-being are unclear.
In a country that is under-resourced, we need interventions that will make a
difference, hence evidence-based strategies and interventions that reduce
morbidity and cost of operation can be beneficial to the patient. Also, the women
should be offered evidence based support to enable them to make informed
decision about childbirth with option of vaginal birth after caesarean section.
Due to the vastness of India and the variety in the types of hospital settings, the
checklist provided here may have to be individualized as demanded by
situations. However, minimum standards should be maintained, which include −
Information to woman, planned lower (uterine) segment Caesarean section,
procedural aspect, care of the woman. The checklist for caesarean provided is to
provide quick guidance in managing women scheduled for caesarean section.

Best wishes!

Dr. Rishma Dhillon Pai

President 2017 - Federation of Obstetrics & Gynaecological Societies of India (FOGSI)
President (Elect- 2018) – Indian Society for Assisted Reproduction (ISAR)
Hon. Gen. Secretary - Indian Association of Gynaecological Endoscopists (IAGE)
Hon. Gen. Secretary- Mumbai Obstetrics and Gynaecological Society
Board Member - World Endometriosis Society (WES)

This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
© 2018 Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for any errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.

4 These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
Definition
• Abdominal route of delivery
• When vaginal delivery is not possible not indicated
• For maternal or fetal indication
• To optimize outcome
• Elective/emergency Robson’s criteria
• After the period of viability 1 Nullipara, single cephalic, ≥ 37 weeks, spontaneous labour
Nullipara, single cephalic, ≥ 37 week
2 A. Induced
B. Caesarean section before labour
PATIENT DETAILS 3 Multipara, single cephalic, ≥ 37 weeks, spontaneous labour
Multipara, single cephalic, ≥ 37 weeks
• Age 4 A. Induced
B. Caesarean section before labour
• Parity Previous caesarean section, singleton cephalic, ≥ 37 weeks
A. Spontaneous labour
• Gestational age 5
B. Induced labour
C. Caesarean section before labour
• Single/multiple All nulliparous breeches
A. Spontaneous labour  
• Unscarred/scarred 6 B. Induced labour  
C. Caesarean section before labour 
• Vertex/non-vertex All multiparous breeches (including previous caesarean section)
(a) Spontaneous labour  
• Risk factors: Yes/no 7 (b) Induced labour  
(c) Caesarean section before labour  
All multiple pregnancies
A. Spontaneous labour  
8
B. Induced labour  
C. Caesarean section before labour  
All abnormal lies (including previous Caesarean section but excluding breech)
A. Spontaneous labour  
9 B. Induced labour  
C. Caesarean section before labour  
All singleton cephalic, ≤ 36 weeks (including previous Caesarean section)
A. Spontaneous labour  
10
B. Induced labour  
C. Caesarean section before labour  

INDICATIONS
Maternal Fetal Others
To be ticked as appropriate
Indications for CS as per government of India guidelines to be mentioned clearly.
Refer to the links below:
http://nhm.gov.in/nrhm-components/rmnch-a/maternal-health/guidelines.html
http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/C-section_document_Low_Res_5th_Jan.pdf

Maternal: Bad obstetric history, pregnancy after infertility treatment

Fetal: Fetal distress, FHR decelerations, meconium
Others: Lower segment Cesarian section (LSCS) on demand

Emergency Elective
To be ticked as appropriate
5
 Counseling
• Counseling for indicated LSCS
• Counseling for on demand

CONSENT
• Mention if emergency or elective
• Clearly denote high risk, if any
• Indication for the same
• Type of anesthesia
• Draft of consent should include “all risks, complications and consequences”
Kindly refer to the Consent Form as per Government of India guidelines by visiting the following links:
http://nhm.gov.in/nrhm-components/rmnch-a/maternal-health/guidelines.html
http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/C-section_document_Low_Res_5th_Jan.pdf

Procedural aspects of LSCS

Procedural aspects of LSCS

Preoperative assessment Anaesthetic care

• Check haemoglobin • Discuss post-LSCS

• Prescribe appropriate analgesia options
antibiotics • Offer antacids and H2
• Assess risk for receptor analogues
thromboembolic disease • Offer antiemetics
(offer graduated • Offer regional anaesthesia
stockings, hydration, early
• Reduce risk of
mobilization, and low
hypotension using:
molecular weight heparin)
– volume preloading with
• Introduce an indwelling
crystalloid or colloid
bladder catheter (Foley)
– lateral tilt of 15°
• General anaesthesia for
emergency LSCS should
include preoxygenation and
rapid sequence induction to
reduce the risk of aspiration

6
Surgical techniques
1. Use a transverse lower abdominal incision.

2. Wear double gloves for LSCS, especially for women who are HIV-positive.

3. Use controlled cord traction for removal of the placenta.

4. Close the uterine incision with two suture layers.

5. Facilitate early skin-to-skin contact for mother and baby.

6. Consider women’s preferences for birth.

7. Give oxytocin by slow intravenous injection.

8. Hemostasis and active management of 3rd stage.

9. Offer intraoperative contraception.
For technical minutiae, refer Government of India guidelines -
http://nhm.gov.in/nrhm-components/rmnch-a/maternal-health/guidelines.html
http://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/C-section_document_Low_Res_5th_Jan.pdf)

Postoperative monitoring
Postoperative monitoring

Recovery area Wards

One-to-one observations Regular observations

until the woman has (respiratory rate, heart
airway control and rate, blood pressure, pain
cardiorespiratory stability and sedation, bleeding,
and can communicate P/V and urine output.

Care of the woman and her baby after LSCS

1. Women to start breastfeeding as soon as possible.
2. Women who are feeling well and have no complications can eat or drink
after appearance of peristalsis.
3. After regional anaesthesia remove catheter when woman is mobile (>12
hours after top-up).
4. Keep wound clean and dry.
5. Offer discharge to women who are recovering and have no complications.

7
 PostOPERATIVE care and recovery

Recovery following LSCS

• Postnatal care Prescribe regular Informing the mother to

Monitor wound healing
• Specific post-CS care analgesia resume activities when
• Management pain is not distracting or
of pregnancy restricting
complications

CS complications to be looked for:

• Endometritis if excessive vaginal bleeding, foul smelling discharge,
uterine tenderness, abdominal pain, and/or fever.
• Thromboembolism if calf swelling or respiratory distress.

• Urinary tract infection if urinary symptoms and fever with chills.

• Wound discharge or disruption.

• Urinary tract trauma (VVF)- if leaking urine P/V.

Caeserean section on demand

• Separate consent.

• Patients and witness signature.

• Clearly mention that its patient’s preference and not obstetrician’s decision.

• Clearly mention risk, complications and future consequences.

8
Vaginal birth after cesarean (VBAC)
1. Indications*

• Singleton: One previous low transverse cesarean should be counseled and offered
TOLAC

• Individualize
• Even if patient not a good candidate but admitted to labor floor in active labor,
clinical judgement may be used
• Good candidates are those where balance of risk (low) and chance of success
(high) are acceptable to patient and provider
• Decisions surrounding TOLAC should include discussion of future pregnancies

2. Contraindication*

• Previous classical or “T” incision

• Prior uterine rupture

• Extensive transfundal uterine surgery

• Contraindication for vaginal delivery (e.g. placenta previa)

3. Counseling and consent

4. Delivery to be supervised by obstetrician in a setting where facilities for emergency CS

available
5. Close monitoring of labour and to look for signs of scar rupture

6. Early detection of scar rupture and appropriate management

7. Induction and augmentation of labour-
• Misoprostol not to be used
• PG gel and oxytocin to be judiciously used
*ACOG VBAC guidelines. Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery. Obstetrics & Gynaecology:
November 2017-Volume 130-Issue 5-p e217–233.
CS: Cesarean section; TOLAC: trial of labor after cesarean

9
Hyperglycaemia
in Pregnancy

1
HYPERGLYCAEMIA
IN PREGNANCY
Moderators : Dr. Parag Biniwale, Dr. Suvarna Khadilkar
Panel Members : Dr. Shanthakumari, Dr. Manavita Mahajan,
Dr. Meenakshi Ahuja, Dr. Lata Rajoria

From left to right: Dr. Manavita Mahajan, Dr. Suvarna Khadilkar, Dr. Parag Biniwale,
Dr. Meenakshi Ahuja, Dr. Shanthakumari, Dr. Lata Rajoria

1
 Preface
Hyperglycemia in pregnancy is the most common metabolic disorder of
pregnancy. This condition is highly associated with the risk of adverse
perinatal outcomes including cesarean section, induction of labor, large for
gestational age, macrosomia, and infant adiposity.
In addition, abnormal high blood glucose during pregnancy is associated with
an increased risk of long-term ill-health outcomes in the mother (type 2
diabetes and cardiovascular disease) and infants (obesity, neural tube
defects, and associated cardiometabolic risk).
Oral glucose tolerance test is the diagnostic test of choice that is usually
administered during 24 and 28 weeks of gestation. Risk factors that are
associated with this condition include physical inactivity, body mass index
(BMI) ≥30 kg/m2, hypertension, triglyceride level >250 mg/dL, family history of
diabetes, polycystic ovary syndrome, and maternal age ≥40 years.
As the prevalence of hyperglycemia in pregnancy and its adverse influence on
perinatal outcomes is increasing, clinicians must aim to reduce the hyperglycemia
and also the risk of adverse outcomes. Diet and lifestyle modification is highly
recommended as the first-line treatment, but additional pharmacological intervention
with oral hypoglycemic agents and insulin is required for severe cases.
Self-monitoring of glucose levels is necessary, particularly in women undergoing
pharmacological treatment. Understanding the increased risk of adverse outcomes
associated with high glucose level in pregnancy, the following protocol from FOGSI
provides an approach to achieve normal glycemia supporting pregnant women to
live healthy.

Best wishes!

Dr. Rishma Dhillon Pai

President 2017 - Federation of Obstetrics & Gynaecological Societies of India (FOGSI)
President (Elect- 2018) – Indian Society for Assisted Reproduction (ISAR)
Hon. Gen. Secretary - Indian Association of Gynaecological Endoscopists (IAGE)
Hon. Gen. Secretary- Mumbai Obstetrics and Gynaecological Society
Board Member - World Endometriosis Society (WES)

This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
© 2018 Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for a ny errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.

2 These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
Prevention
• Identify high risk group - e.g. obese, adolescents with polycystic ovary
syndrome (PCOS)
• Preconceptional care: Especially for high risk group (obese/PCOS/family history
of diabetes/gestational diabetes in previous pregnancy/comorbidities
• Women planning to conceive: Give folic acid and vitamin B12 supplements

Hyperclycaemia in pregnancy

Hyperclycaemia in pregnancy

Gestational diabetes
Diabetes in pregnancy
mellitus

Diagnosed before the start of Diagnosed for the first time

pregnancy during pregnancy

Type 1 Type 2 Type 1 Type 2

Maternal issues
Maternal Risk

Polyhydramnios Caesarean section

Pre-eclampsia Uterine atony

Prolonged labour Postpartum hemorrhage

Obstructed labour Infection

3
 Diabetes in Pregnancy Study Group India (DIPSI)
In the antenatal clinic, a pregnant woman after undergoing preliminary clinical examination, has to
be given a 75 g oral glucose load, without regard to the time of the last meal. A venous blood
sample is collected at 2 hours for estimating plasma glucose.
Advantage: The pregnant women need not be fasting. Causes least disturbance in a pregnant
woman’s routine activities. Serves as both screening and diagnostic procedure.

With 75 gm oral glucose tolerance test (WHO criteria)

Plasma glucose In pregnancy Outside pregnancy
2 hr > 200 mg/d Diabetes Diabetes
2 hr > 140 mg/dl & < 199 mg/dl Gestational diabetes Impaired glucose tolerance
2 hr > 120 mg/dl & < 139 mg/dl Gestational glucose intolerance -
2 hr <120 mg/dl Normal Normal

Pregnant woman in community

• PG BSL (DIPSI) > 200 mg %
at first visit —> overt DM
Testing for GDM at 1st antenatal visit (75 g
oral glucose - 2 hr plasma glucose value) • Look for hypertension
• Retinopathy:
Fundus examination
Positive (2 hr PG> 140 mg/dl) Negative (2 hr PG <140 mg/dl) • Nephropathy: Serum creatinine

Manage as GDM as per guidelines Repeat testing at 24-28 weeks DM: diabetes mellitus; GDM: gestational
diabetes mellitus, PG: plasma glucose.

Positve (2 hr PG 140 mg/dl) Negative (2 hr PG <140 mg/dl)

Manage as GDM as per guidelines Manage as Normal ANC

Antenatal caRe Monitor as high risk pregnancy

First Trimester Check blood pressure, HbA1C, monitor blood sugar level (fasting/postprandial)
Second Trimester Monitor blood pressure, blood sugar level (fasting/postprandial)
Third trimester Monitor blood pressure, look for polyhydramnios

4
Medical management
Maternal Risk
Plasma Glucose 140-199 mg/dl Medical nutrition therapy
Plasma Glucose >199 mg/dl Medical nutrition therapy + Insulin
After 1 week
Fasting Plasma Glucose target ~ 90 mg/dL
2-hr Post-Prandial Glucose target ~ 120 mg/dL

Fetal risks
Fetal risk
Spontaneous abortion Congenital malformation

Intra-uterine death Shoulder dystocia

Stillbirth Birth injuries

Neonatal hypoglycaemia Infant respiratory distress syndrome

Foetal monitoring
First trimester Clinical exam, dating scan, nuchal translucency
(NT) scan + biochemical screening, uterine arteries -
prediction of preeclampsia umbilical arteries, middle
cerebral artery (MCA) - for the detection and monitoring
of intrauterine growth restriction
Second trimester Clinical exam, anomaly scan 19 weeks, triple/quadruple
marker if not screened earlier, amniotic fluid index (AFI),
foetal echo 22 weeks
Third trimester Clinical exam (fundal height, abdominal girth), growth
scans 28, 32, 36 weeks, colour doppler as indicated,
AFI, non-stress test (NST) 32 weeks onward, if on
insulin
Assess EBW at 38 weeks Role of steroids: betamethasone to enhance lung
maturity

5
 Glycaemic control
Medical nutrition therapy: Lifestyle management, diet,
exercise Oral antidiabetics: Metformin, glyburide Insulin

Table 1. Pragmatic use of metformin in mild GDM$ , based on biopsychosocial health model
Domain Clinical situations
Contraindications
General All contraindications to metformin use in non-pregnant individuals
Pregnancy Ketonuria
specific Any evidence of maternal distress
Any evidence of fetal distress
Indications As monotherapy
Biological GDM not responding to medical nutrition therapy
GDM detected during late third trimester
Poor compliance with the treatment plan when the treatment plan
includes insulin
Lack of skills for self-management with insulin therapy and monitoring
As combination therapy, with insulin
Uncontrolled hyperglycemia, not responding to optimized insulin regimes
Unwanted weight gain with insulin therapy
Psychological If the suggestion of insulin causes extreme psychological stress
When suggestion of insulin causes patient to reduce nutritional intake in
order to maintain glycemia
Social If the suggestion of insulin causes extreme family/social stress
Financial burden
In health-care settings where insulin is not available or accessible
In health-care settings where regular glycemic monitoring is not feasible
Precautions Regular fetal surveillance
Regular maternal surveillance
Glucose loweringObstetricinmonitoringpregnancy
Medical monitoring
$An abnormal result on an oral glucose-tolerance test but a fasting glucose level below 95 mg/dl (Ref.: Landon et al.).
GDM: Gestational diabetes mellitus.

Acarbose Metformin Glyburide

Degree of hyperglycemia + + ++
Predominantly fasting +
hyperglycemia
Predominantly post- + +
prandial hyperglycemia

Risk of hypoglycemia Safe Safe High risk

Gastrointestinal tolerability Possible Possible –

Effect on insulin resistance – + –

Effect on weight Weight neutral Weight neutral Weight gain

Frequency of With each Once (sustained release) to Once or twice
administration meal thrice daily (immediate release) daily
6
Insulin Therapy
Pregnant woman with GDM

2 hr PPPG 120 mg/dl 2 hr PPPG 120 mg/dl

Start human insulin premis 30:70 Continue MNT, repeat 2 hr PPPG

• Subcutaneous injection, 30 mins after 2 week still 30 weeks and
before breakfast, once a day thereafter
• Dose of insulin calculated by blood
glucose level
120 mg/dl 120 mg/dl

Blood glucouse Dose of Insulin

Between 120–160 4 units
Between 160–200 6 units
More than 200 8 units

FBG & 2 hours PPPG every 3rd day

FBG <95 mg/dl & 2 hrs FBG <95 mg/dl & 2 hrs FBG 95 mg/dl & 2 hrs
PPPG <120 mg/dl PPPG 120 mg/dl PPPG 120 mg/dl

Continue same dose of Increase dose of insulin Give Inj. Insulin 2 dose pre
insuli + MNT by 2 U+MNT breakfast - by 4 U

Repeat FBG & 2 hr PPPG every 3rd day

till dose of insulin adjusted

FBG <95 mg/dl & 2 hrs FBG <95 mg/dl & 2 hrs FBG 95 mg/dl & 2 hrs
PPPG <120 mg/dl PPPG 120 mg/dl PPPG 120 mg/dl

Continue same dose of Increase dose of insulin Increase pre breakfast

insulin + by 2 U+MNT insulin - by 4 U

• Repeat FBG & 2 hr PPPG every 3rd day

• Adjust dose of insulin accordingly till FBG <95 mg/dl, 2hr PPPG <120 mg/dl

• Continue same dose of insulin + MNT

• Repeat FBG & 2 hr PPPG 2 weekly before 30 weeks & weekly after 20 weeks
FBG: fasting blood glucose; GDM: gestational diabetes; MNT: medical nutrition therapy; PPPG: post prandial plasma glucose.

7
 38-39 weeks

<3,800 g or appropriate for 3,800-4,000 g or large for

>4,000 g
gestational age gestational age

Poor control
Poor complicance Yes
Previous stillbirth
Vascular disease

No

Offer elective cesarean

Continue to 40-41 weeks Induce labour
delivery

Labour management – First stage

Hyperglycemia in pregnacy Admission CTG partograph blood sugar by glucometer 2 hourly
controlled on diet,
Target level: 80–120 mg%, continuous fetal monitoring
spontaneous labour
Spontaneous labour in Admission CTG partograph blood sugar by glucometer 2 hourly
patients of hyperglycemia Target level: 80–120 mg%, continuous fetal monitoring, IV fluid
in pregnacy on Insulin/ oral as per blood sugar levels
antidiabetics
CTG: cardiotocogram.

Labour management – second and third stage

Second stage Third stage
• Controlled ARM • Active management of third stage
• Anticipate - shoulder dystocia, assisted vaginal
• W/F- traumatic / atonic postpartum
delivery
hemorrhage
• Neonatologist/ Trained person to resuscitate

BLOOd Sugar management

Blood sugar monitoring 2 hourly: Target 80-120 mg%

Blood glucose level Amount of insulin added in Rate of normal saline

500 ml normal saline infusion

90–120 mg/dl 0 100 ml/hr (16 drops/min)

120–140 mg/dl 4U 100 ml/hr (16 drops/min)
140–180 mg/dl 6U 100 m/hr (16 drops/min)
>180 mg/dl 8U 100 ml/hr (16 drops/min)

8
New born and postpartum care
New born care Postpartum care
• Be careful - traumatic delivery • Breast feeding at earliest
• Hypoglycaemia • W/F infection
• RDS • Close monitoring of BSL, if on insulin
• Hyperbilirubinaemia • BSL F / PP on D3 if on MNT / OAD
• At 6 weeks - OGCT (DIPSI)
• Counsel for lifestyle , diet, exercise
• Fastinv plasma:>126 mg/dl
• 75 g OGTT 2 hour plasma glucose
»» Normal: <140 mg/dl
»» IGT: 140-199 mg/dl
»» Diabetes: >200 mg/dl

Hyperglycemia in pregnancy
HIP

75 gm 2 hour OGT (DIPSI) 6 weeks

postpartum

Impaired fasting glucose/

Diabetes Mellitus impaired glucose tolerances/
or both

Refer to Endocrinologist Consider referral for

management
Weight loss
Normal Planned physical activity
Consider metformin/glitazones
Medical nutrition therapy
Yearly glycemic status Yearly assessment of glycemic
status
Weight loss
Physical activity
Counseling

Postpartum contraception
Barrier IUD - Cu / LNG

POP/progesterone implant With due risk COC

Combined oral contraceptive/ Contraindicated with macrovascular disease
injectable/transdermal/intravaginal

9
MANAGEMENT OF
LABOUR

1
MANAGEMENT OF LABOUR
Moderators : Dr. Pratima Mittal, Dr. Shalini Rajaram
Panel Members : Dr. Veena Acharya, Dr. Prabha Luhadia, Dr.
Usha Shekhawat, Dr. Niranjan Chavan, Dr.
Mahesh Gupta

From left to right: Dr. Mahesh Gupta, Dr. Prabha Luhadia, Dr. Veena Acharya, Dr. Usha
Shekhawat, Dr. Pratima Mittal, Dr. Niranjan Chavan, Dr. Shalini Rajaram

1
 Preface
The World Health Organization (WHO) has defined normal birth as
“spontaneous in onset, low-risk at the start of labor and remaining so
throughout labor and delivery. The infant is born spontaneously in the vertex
position between 37 and 42 completed weeks of pregnancy. After birth,
mother and infant are in good condition.”
The process of labour and delivery has been divided into three stages and
each stage carries specific risks to both mother and infant if delay is not timely
identified. Hence, it is absolutely essential that management protocols are
followed closely.
For timely identification of complications, the available management tools
must be utilized effectively and in a manner that conforms to specific criteria.
These management tools are all based on regular clinical assessment of the
pregnant woman supplemented by expected progress of labour.
This management of labor algorithm provides recommendation for
intrapartum management of women who are expected to have a normal birth.
There are a number of options available for managing these women, but
have insufficient clinical evidence for making strong recommendations for a
specific approach. Hence, our approach is based on our clinical experience,
data from observational studies, international guidelines, and expert opinions.

Best wishes!

Dr. Rishma Dhillon Pai

President 2017 - Federation of Obstetrics & Gynaecological Societies of India (FOGSI)
President (Elect- 2018) – Indian Society for Assisted Reproduction (ISAR)
Hon. Gen. Secretary - Indian Association of Gynaecological Endoscopists (IAGE)
Hon. Gen. Secretary- Mumbai Obstetrics and Gynaecological Society
Board Member - World Endometriosis Society (WES)

This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
© 2018 Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for any errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.

2 These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systematic flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
INITIAL ASSESSMENT
Booked/unbooked
History
Calculate POG by LMP

Examination

General Exam Abdominal Per speculum if Per vaginum exam

including blood examination leaking/bleeding • Cervical
pressure/pulse • Height of uterus (Excessive effacement
rate and General as per POG bleeding do not do • Consistency of
condition • Presentation PV do USG to R/O cervix
• Fetal lie placenta previa ) • Cervical dilatation
Chest/CVS • Fetal heart • Presenting part
Sound • Station of Head
• Uterine • Membrane +/_
contraction • Assess pelvis for
• Frequency, adequacy
duration, and
intensity

Investigations ANC Profile *

Patient in active Patient not in active

phase of labor phase of labor

Identify if
No Patient is for
any high
identifiable LSCS OBSERVE
risk factor
high risk absolute (not in LR)
maternal/
factor indication
fetal

Manage *ANC Profile Should

Individualize
active phase
include
management
of labor • Last Hb
• Blood Group &
Rh Factor
• Blood Sugar
• Hbs Ag
• HIV Testing
• VDRL
ANC: antenatal screening, CVS: cardiovascular system; Hbs Ag: hepatitis B surface antigen; HIV Testing: human immunodeficiency • Urine Alb/sugar
virus testing; LMP: last menstrual period; LSCS: lower segment caesarean section; POG: period of gestation; USG: ultrasonography;
VDRL: Venereal Disease Research Laboratory test. • USG Examinations

3
 MANAGEMENT OF 1ST STAGE OF LABOUR
1st Stage of labour: Till full dilatation of cervix
Goal: Watchful expectancy and careful monitoring

• Emotional support and assistance

• Upright position & ambulation is encouraged
• Perineum preparation: Clipping of hair, no shaving
• No need for routine enema (given only if rectum is loaded)
• Light fluid diet
• Secure IV line
• Encourage to empty bladder
• Pain management: Epidural anaesthesia/tramadol 1mg/kg IM Note: No routine use of antibiotics during labour

Re evaluate maternal and fetal condition

Partogram charting: Fetal condition/progress
of labor/maternal condition/Intervention • Absent FHR
»» Fetal heart monitoring Every 30 • Abnormal FHR
min »» Liquor Meconium / Clear »» • Malpresentation
• Cord presentation
Moulding 0/+ /++/+++
• Significant MSL
• Half hourly monitor frequency
• PROM
of contractions
• Maternal pyrexia
• 4 Hourly vaginal examination
• Fresh bleeding developing in labour
for »» Descent of head • Raised diastolic BP >90 mmHg,
»» Cervical dilatation systolic BP > 140 mmHg
• Any drugs if given • Oxytocin augmentation
• Maternal pulse/BP/temperature
• Monitor for output, proteins, and ketones
Criteria for continuous CTG
• Abnormal FHR
Active first stage of labour (>4cm) • Significant MSL
Delay: Non progress of dilatataion after 4 cm
• Maternal pyrexia
for 2 hr inspite of good uterine contractions
• Fresh bleeding in labour
and Arrest of labor is considered after 4 hrs
• Oxytocin augmentation
Dilatation < 0.5 cm/hour in primigravida
and < 0.5–0.7 cm/hour in multigravida • During establishing or adding bolus
of regional anaesthesia

Ruptured Membranes Intact Amniotomy

Oxytocin Watchful
Review progress after 4 hours
augmentation expectancy

No or delayed progress

CTG: cardiotocograph; FHR: fetal heart rate; MSL: meconium

Re evaluation stained liquor; PROM: prolonged rupture of membranes.

4
MANAGEMENT OF 2ND STAGE OF LABOUR
2nd Stage of labour: From full dilatation to delivery of the foetus

• Position: dorsal position with 15o lateral tilt

• Toileting of the external genitalia
• Aseptic precautions 3 C’s: Clean
hand, Clean surface, Clean cord
cutting & ligature

Re evaluate
Partogram charting • Absent FHR
• Hourly pulse, BP and temperature • Abnormal FHR
• Significant MSL
• Empty bladder if full
• Maternal pyrexia
• Half hourly monitor frequency
• Fresh bleeding developing in labour
of contractions
• Raised diastolic BP >90 mmHg,
• Hourly vaginal examination systolic BP > 140 mmHg
• Every 15 mins FHS • Oxytocin augmentation

Delayed 2nd stage: Primi >3 hours, (4

hrs with epidural)
Multi >2 hours If epidural (3 hrs with epidural)
only under strict maternal & fetal monitoring
and careful watch for descent of head

Evaluate: Contractions, Station, Rotation and FHR If not delivered by 3 hours in primi and by
Start oxytocin if uterine contractions inadequate 2 hours in multi

Delivery of head*
• Routine episiotomy not required Operative Vaginal Delivery / CS
• Maintain flexion of head by pushing
occiput downward with one hand &
other hand supports the perineum
• Encourage pushing with Valsalva manoeuvre ESSENTIAL NEWBORN CARE
• Fundal pressure should not be given
• Double set of sheets
• No suction to be done, if baby has cried
Delivery of shoulder
• Not to be hasty in delivery • Keep the baby on mother’s abdomen
• After restitution, hold the neck with
both hands, draw the head downward
• Delayed cord clamping after 60 sec
till anterior shoulder is delivered
• Next head is drawn upward to BP: blood pressure; FHR: fetal heart rate; MSL: meconium stained liquor; CS: Caesareans section.
deliver posterior shoulder *Look for loops of cord around the neck and release the cord if around the neck

5
 MANAGEMENT OF 3RD STAGE OF LABOUR

3rd Stage of labour: From delivery

of foetus till delivery of placenta

Administer oxytocin 10 units IM immediately

after birth of baby (Oxytocin to be kept
at <300C temp) Keep other uterotonics
(Misoprostol/Prostaglandin) ready if the
patient has PPH

Earlier cord clamping may be required:

Delayed cord clamping: Clamp and cut Need for neonatal resuscitation/Rh –
the umbilical cord after 1-2 minutes of birth ve pregnancy/FGR baby with
abnormal Doppler parameters

Controlled cord traction

If placenta is not delivered after 30

minutes of baby delivery SManual
removal of placenta

• Examine placenta and membranes

• Inspect vulva, vagina and perinuem
FGR: fetal growth restriction; PPH: postprandial hyperglycemia.

6
MANAGEMENT OF 4th STAGE OF LABOUR
(One hour after placental Expulsion)
• Maternal vital monitoring (pulse/blood pressure/respiratory rate/temperature)
• Breast feeding within 1 hr of delivery
• Inspection of perineum for blood loss and swelling, if episiotomy
• Look for uterine tone
• Advice contraception

POST PARTUM CARE

Observe:
• Maternal pulse/blood pressure/ Respiratory Rate/Temperature)
• Bleeding per vaginum
• Breast feeding given properly
• Uterine involution
• If patient has passed urine and stool
Counselling for:
• To report danger signs as pain/swelling of legs / excessive bleeding /
foul smelling discharge
• Contraception

7
 MALPOSITIONS
Occipito positerior position

• Assess pelvis, baby weight CS indicated if

and uterine contractions
• Inadequate pelvis
• Watchful expectancy
• Maternal/fetal indication
• Oxytocin augmentation if
needed
• Reassess the casein early
2nd stage

Anterior rotation of Persistent occiput posterior

occiput in 90% cases Reassess the pelvis and cause of
failure of anterior rotation

Spontaneous or
ventouse or forceps
assisted delivery

Partial Anterior
No rotation Malrotation
Rotation

Deep transverse Persistent Occipito Occipito sacral

arrest Posterior position

LSCS

Pelvis adequate Pelvis inadequate

• Ventouse can
Caesarean section
be tried Spontaneous face
Arrest in descent
• LSCS to pubis delivery
Give generous
Episiotomy

LSCS
LSCS: lower segment caesarean section.

8
PRETERM
LABOUR
 PRETERM LABOUR
Moderators : Dr. Rishma Dhillon Pai, Dr. Madhuri Patel
Panel Members : Dr. Punit Bhojani, Dr. Bipin Pandit,
Dr. Muralidhar Pai, Dr. Ranjana Khanna,
Dr. Sarita Bhalerao, Dr. Sonia Malik

From left to right: Dr. Sonia Malik, Dr. Muralidhar Pai, Dr. Ranjana Khanna, Dr. Rishma Dhillon
Pai, Dr. Sarita Bhalerao, Dr. Punit Bhojani, Dr. Madhuri Patelw

1
 Preface
Preterm labour is the labor that starts before 37 weeks’ of gestation. It is an
important problem in obstetrics that affects 23% of pregnancies in India. It is
considered as one of the most important risk factors for neonatal morbidity
and mortality.
Preterm labour is a multifactorial problem and it’s most common causes include
ascending infection, multiple gestations polyhydramnios, and uterine developmental
malformations. Although the improved ability of obstetric care providers to identify
pregnant women at risk for preterm delivery has increased, the overall incidence of
preterm birth has remained unchanged for the past 30 years.
Among the various risk factors such as nutritional status, chronic diseases, and
intrauterine malformation contributing to preterm labour, the strongest ones are
multiple pregnancies and previous incidence of preterm delivery. In order to identify
asymptomatic women at the risk of preterm delivery, cervical length assessment
has been recommended to be performed in the second trimester of pregnancy.
For a gynaecologist, knowledge of the molecular mechanisms responsible
for the process of preterm labour and its early diagnosis is important.
With a thorough review of the literature assessing the causes and
consequences of preterm labour, FOGSI presents the following algorithm of
diagnostic approach and possible preventive measures that provide a
framework to improve the outcomes of preterm delivery.

Best wishes!

Dr. Rishma Dhillon Pai

President 2017 - Federation of Obstetrics & Gynaecological Societies of India (FOGSI)
President (Elect- 2018) – Indian Society for Assisted Reproduction (ISAR)
Hon. Gen. Secretary - Indian Association of Gynaecological Endoscopists (IAGE)
Hon. Gen. Secretary- Mumbai Obstetrics and Gynaecological Society
Board Member - World Endometriosis Society (WES)

This is an independent publication owned by Science Integra ®. The advice, opinion, statements, materials and other information expressed and
contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant
for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Abbott or
Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for any errors, omissions or
inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. Opinions
expressed do not necessarily reflect the views of Abbott India.
The information in this book is meant only to supplement and not to replace the practice guidelines set by International, Nat ional Associations and
Government bodies. The author/s, Doctors, sponsor and publisher advise readers to take full responsibility before practicing any of the suggested
guidelines described in this book, be sure not to take risks beyond your level of experience, aptitude, training, and comfort level.

2 These of course are only opinions of our experts and not recommendations or guidelines and are only meant to give the readers a systemati c flow
chart to follow, using your own expertise to make final judgements. Any unauthorized reproduction or distribution of this publication is illegal.
Definition and Terminology
Delivery less than 37 weeks (WHO Fact sheet, Nov 2017)
Subcategory
• Extremely preterm : Less than 28 weeks
• Very preterm : 28-32 weeks
• Late preterm : 32-37 weeks
Suspected/threatened preterm labour: uterine contractions without cervical dilatation
Diagnosed preterm labour: uterine contractions with cervical changes
Established preterm labour: uterine contractions plus progressive cervical dilatation of
more than 4 cms

Assessment and management of

preterm labour (<37 weeks)

Review history
Medical, surgical, obstetric, social

Assess for signs and symptoms

Pelvic pressure, lower abdominal cramping, lower
back pain, vaginal discharge - mucous, blood, fluid,
Regular uterine activity

Physical examination
• Vital signs
• Abdominal palpation
• Fetal surveillance – FHR, CTG
• Sterile speculum exam
»» Identify if ROM
»» Visualize cervix/membranes
»» High vaginal swab for culture and GBS
»» Test for Fetal fibronectin (if available)
• Cervical dilatation
»» Sterile digital vaginal exam unless
ROM, placenta praevia
• Ultrasound – if available
• Fetal growth and well-being
• TVS for cervical length
Laboratory tests
• Midstream urine for M/C and S
• CBC, RBC, CRP

CTG: cardiotocography; CBC: complete blood count; CRP: C-reactive protein; EFM: electronic fetal monitor; GBS: group B
streptococcus; M/C and S: Microscopy/ culture and sensitivity; RBC: red blood cells; TVS: transvaginal ultrasound scan;
ROM: rupture of the membrane;

3
 Table 1. Common tocolytic agents

Agent Dose Maternal/fetal Contra- Remarks

side effects indications
Beta- 40 mg in 500 mg RL Maternal: Tachycardia, Tachycardia- DCGI
adrenergic 8 drops/min (0.04 mg/min) hypotension, tremor, sensitive approval for
receptor Drip rate will be set at 8 drops palpitations, shortness maternal PTL India
agonists per minute (0.04 mg/min). The of breath, chest cardiac disease
Isoxsuprine drop rate will be increased by discomfort, pulmonary and poorly
8 drops/min every 15 min till edema, hypokalemia, controlled
and hyperglycemia diabetes
uterus becomes quiet
mellitus
Isoxsurine drip will be continued
for 12 hrs after the uterine
quiescence. Maximum dose
should not exceed more than
0.5 mg/min.
Subsequently Isoxsuprine will be
given orally in the form of tablet/
retard capsules 60-80 mg in
divided dose.
Oxytocin 6.5 mg IV stat Headache, nausea, Beneficial
receptor Initial bolus dose 6.75 mg over vomiting, rash, in cardiac
antagonist one minute, followed by an hyperglycemia, disease
(Atosiban) Infusion of 18 mg/h for 3 h and injection site reaction
then 6 mg/h for up to 45 h.
PGSI 25 mg TID Maternal: Nausea, Platelet Oral route
(Indomethacin) Loading dose of 50 mg rectally esophageal reflux, dysfunction Useful
gastritis, and emesis; or bleeding
or 50–100 mg orally, then 25–50 platelet dysfunction disorder, in poly-
mg orally every 6 hr × 48 h. hydramnios
is rarely of clinical hepatic
cardiac
significance in patients dysfunction,
without underlying gastrointestinal disease
bleeding disorder ulcerative
disease, renal
Fetal: In utero
dysfunction,
constriction of
and asthma (in
ductus arteriosus*,
women with
oligohydramnios*,
hypersensitivity
necrotizing
enterocolitis in preterm to aspirin)
newborns, and patent
ductus arteriosus in
newborn†
CCBs 20 mg stat, repeat every Maternal: Dizziness, Hypotension Oral route
(nifedipine) 6 hourly (10–20 mg) tachycardia, flushing, and preload-
and hypotension; dependent
Note:
suppression of heart cardiac lesions,
Nifedipine is
rate, contractility, and such as aortic
not approved
left ventricular systolic insufficiency
in PTL by
pressure when used
DCGI in India with magnesium
sulfate; and
elevation of hepatic
transaminases

4
Neuroprotectives
Magnesium 4 g IV initially followed by Maternal: Causes Myasthenia Not very
sulfate 1 g/hour X 24 hours flushing, diaphoresis, gravis effective for
nausea, loss tocolysis but
of deep tendon has neuro-
reflexes, respiratory protective role
depression, and
cardiac arrest;
suppresses heart
rate, contractility
and left ventricular
systolic pressure
when used with
CCBs; and produces
neuromuscular
blockade when used
with CCBs
Fetal: Neonatal
depression
†Data are conflicting regarding this association. CCBs: calcium channel blockers; DCGI: Drugs Controller General of India;
PTL: preterm labour; PGSI: prostaglandin synthetase inhibitors.

Maintenance:
Indian evidence suggests that isoxsuprine is superior with regards to maternal and fetal
outcome when administered in appropriate doses.

Evidence 1
Jaju et al (Dec 2017), in a recently concluded study in Indian patients, reported that
patients receiving oral dose of isoxsuprine with a maximum daily dose of up to 40 mg
for an average of 23 days had a mean latency period of 37 days. Significant
improvement in prolongation of delivery beyond 48 hours and perinatal outcomes were
also noted amongst these patients on isoxsuprine versus other pharmacological agents.

Evidence 2
In study reported by V.K. Singh et al, isoxsuprine was initially administered intravenously,
which was followed by maintenance oral therapy till 37 weeks of gestation. In this study,
the mean latency period reported was 28 days, maximum being 70 days (Singh VK et al.,
J. Obstet and Gynecol of India).

In India, clinician should decide the maintenance based on patients response.

5
 In utero transfer
Aim for in-utero transfer whenever necessary after 1st dose of steroids

Initial treatment

Steroids
• Give dexamethasone/betamethasone 24–34 weeks mandatory unless active infection
• From 34–37 weeks recent data indicates reduction in respiratory morbidity
• Betamethasone 12 mg 24 hours apart (use bethamethasone propionate)
• Dexamethasone 6 mg 12 hourly 4 doses (preferred in patients with diabetes, hypertension,
PIH)

Rescue course
• If pregnancy continues beyond 7 days after primary dose and if you suspect she will
deliver within 7 days (delivery is imminent) then rescue course of betamethasone or
dexametha-sone can be given up to 34 weeks of gestation
• Repeated doses are not recommended

Tocolysis
Need to be considered in threatened and diagnosed preterm labor
• Isoxsuprine. Refer Table 1.

Antibiotics
• If established labor (or imminent risk of PTB) give intrapartum GBS prophylaxis regardless of
GBS status or membrane status
• If chorioamnionitis (membranes intact or ruptured)
»» Ampicillin (or Amoxycillin) 2 g IV initial dose, then 1 g IV every 6
hours »» Gentamicin 5 mg/kg IV daily
»» Metronidazole 500 mg IV every 12 hours
• If penicillin hypersensitivity and chorioamnionitis:
»» Clindamycin 600 mg IV every 8 hours and
»» Gentamicin 5 mg/kg IV daily and
»» Metronidazole 500 mg IV every 12 hours
• If labor does not ensue (and no evidence of chorioamnionitis) and membranes intact then
cease antibiotics
• Coamoxyclav not to be given

Neuroprotection
1. Magnesium Sulfate
• Gestational age 24–32 weeks
• Labor established or birth imminent
Loading dose: 4 g IV bolus over 20 minutes
Maintenance dose: 1 g/hour for 24 hours or until birth – whichever occurs first
2. Delayed cord clamping up to 30s not more than 3 minutes except Rh negative mother and
HIV+

Prepare for birth

• Recommend vaginal birth unless there are specific contraindications to vaginal birth or
maternal conditions necessitating caesarean section
• Vacuum extraction is contraindicated due to risk of IVH

GBS: group B streptococcus; HIV:human immunodeficiency virus; IVH: intraventricular hemorrhage; PIH: pregnancy induced hypertension;
PTB: preterm birth.

6
Management algorithm for preterm
premature rupture of membranes
Symptoms and/or signs
suggestive of preterm PROM

Initial management
• Admit for labor and delivery
• Confirm the diagnosis
• Exclude other diagnoses
• Confirm gestational age
• Document fetal well-being

Contraindications to expectant NO contraindications to

management expectant management

Proceed with immediate delivery Expectant management

Continuous Fetal Heart Rate Monitoring, If • Review risks/benefits
of expectant
Fetus is Viable
• Management, including
• Consider neonatology, MFM,
likely latency period
and anesthesia consults
• Consider neonatology, MFM,
• Send CBC, T&S, coagulation
and anesthesia consultations
studies administer antenatal
corticosteroids, If indicated
• Administer GBS
chemoprophylaxis, If indicated Further management depends
• Broad-spectrum antibiotics to treat on gestational age
intra-amniotic infection, If present
• Cesarean delivery should be reserved
for the usual obstetric indications

≥34 weeks 32–34 weeks <34 weeks

Offer elective
delivery ± FLM

• Administer antenatal
corticosteroids, if indicated
• Neonatal complications related broad-spectrum antibiotics
Offer elective
primarily to prematurity to prolong latency
delivery at or after
• Postpartum endometritis is • Consider tocolyis therapy
32 weeks± FLM
increased after preterm PROM in threatened and
diagnosed preterm labor
• Consider Fetal Surveillance

CBC: complete blood count; FLM: fetal lung maturity test; GBS: group B beta-hemolytic Streptococcus; MFM: maternal-fetal medicine;
PROM: premature rupture of membranes; T&S: type and screen test.

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 Prediction and prevention of preterm birth
Progesterone for the prevention of preterm birth

History of previous singleton Selective or universal screening

preterm birth (16 to 37 weeks) (18 through 24 weeks)

17-α-hydroxy progesterone caproate Transvaginal cervical length

250 mg IM at 16 to 20 weeks and ≤20mm
weekly until 36 weeks

Vaginal progesterone: 200 mg,

suppositories or 90 mg, vaginal gel
until 36 weeks
No proven benefit in twins or triplets

Sonographic cervical length measurement

Detection of a short cervix by transvaginal ultrasound at 18 to 24 weeks gestation is the
most powerful predictor of spontaneous birth.

Cervical length and preterm labour

prediction

Detection of short cervix (18 to 24 weeks): most powerful predictor of

spontaneous preterm birth
Most common cut off: <25 mm to predict preterm birth at <35 weeks gestation

Indication for cervical cerclage

History of 1 or Prior cerclage for Cervical dilation in the Prior spontaneous
>2nd trimester losses painless dilation 2nd trimester (present preterm birth, cervical
(painless dilation, pregnancy) length of <25 mm
without labor or before 32 weeks
abruptio placenta)

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CONCLUSION
• Preterm labor is an improtant factor for neonatal morbidity and mortality.
• Antenatal corticosteroids are recomended to reduce neonatal morbidity and mortality.
• Tocolytics have been found to be useful in delaying preterm labor.
• Beta-adrenergic receptor agonists, isoxsuprine, has been approved by DCGI for use
in preterm labor in Indian women.