Obgyn Protocol 2016

OBSTETRICS AND
GYNAECOLOGY
PROTOCOL
STATE OF KEDAH
2017
1
KATA PENGANTAR PENGARAH KESIHATAN NEGERI
Obstetric and gynaecological services are one of the important services made
available in every public hospital in the country including nine hospitals in
Kedah. Not forgetting, our health clinics are also providing Obstetric and
gynaecological services whereby the family medicine specialists will be the
gatekeeper for patient referral to the hospitals. In providing primary, secondary
and tertiary care to our clients, it has and will always be our aim to ensure that
services rendered to our clients is of high quality and reputable services. As
such, the Kedah State Health Department, has conducted a three days workshop
reviewing its existing protocol in view of the need to update the protocol taking
into account current evidence based practices. It is hoped that this protocol will
harmonise and standardize the clinical management of obstetric and
gynaecological conditions hence reduces inconsistencies and substandard care
by our practitioners. This newly revised protocol should also be shared with
our practitioner from the private institutions to ensure that tireless effort in
crafting this valuable protocol is not put to waste. And, it is my sincere
expectation that all practitioners will adhere to this new protocol.
I would like to congratulate and express my sincere thanks and

gratitude to each and every individual in our team who have contributed one
way or another to the production of this Obstetrics & Gynaecology Protocol for
the State of Kedah.
Dato’ Dr. Norhizan bin Ismail

State Health Director
Kedah State Health Department
2
PRAKATA PENYELARAS O&G NEGERI KEDAH
The Kedah State Obstetrics & Gynaecology protocol was made possible with the
hard work and involvement of many parties namely the O&G specialists, Family
Medicine specialists and the Kedah State Health Department.
The development of this protocol started off with a brainstorming workshop

that enabled us to prepare and complete within a period of 3 days. During the
preparation stage, we ensured that all the acquired information are from
reliable sources such as the National CPG, CPG from the international
organizations and/or institutes namely RCOG, NICE, ACOG, RANZCOG and
others.
The preparation and production of this protocol would not been possible
without the input and contribution from the experienced Obstetrics &
Gynaecology specialists and sub-specialists.This new protocol was primarily
developed with the means to provide accessibility and information to all public
and private medical practitioners throughout the country on the effective
management of female patients. My main intention for producing this protocol
is to serve as a guideline on practical issues for all Obstetrics & Gynaecology
medical practitioners throughout the country. In order to ensure that this
protocol stays relevant at all times, amendments to its contents will be carried
out from time to time.
In conclusion, I would like to express my heartfelt gratitude to each and every

one who was involved directly and indirectly contributing to the production of
this Kedah State’s Obstetrics & Gynaecology Protocol.
Thank You.
Dato’ Dr. Mohd Rushdan bin Md Noor

State Obstetrics & Gynaecology Coordinator
Kedah
3
PENGHARGAAN
Penghargaan kepada semua yang terlibat samada secara langsung ataupun tidak
langsung di dalam penyediaan Protokol O&G Negeri Kedah termasuk Pengarah
Kesihatan Negeri Kedah, Kakitangan JKN, Pengarah-pengarah Hospital, Ketua-
ketua Jabatan O&G, Pakar-Pakar O&G, Pakar Perubatan Keluarga, Pegawai
Perubatan, Penyelia Jururawat dan lain-lain.
4
PENYUMBANG (CONTRIBUTORS)
PAKAR OBSTETRIKS & JAWATAN/HOSPITAL

GINEKOLOGI
Dato’ Dr.Mohd Rushdan Md Noor Ketua Jabatan O&G, HSB
Penyelaras Perkhidmatan O&G Negeri Kedah
Pengerusi penyediaan O&G State Protocol
Dato’Dr.Mohd Rouse Abd Majid Pakar Perunding Maternal-Fetal HSAH
Dato’ Dr.Bavanandan Naidu Gopal Pakar Perunding Maternal-Fetal HSB
Dr.K. Sushilnathan Pakar Perunding O&G, HSAH
Dr.Murizah binti Mohd Zain Pakar Perunding Perubatan Reproduktif HSB
Dr. Ismail bin Aliyas Pakar Perunding Ginekologi Onkologi HSB
Dr.Zubaidah binti Md Sani Pakar Perunding O&G HSB
Dr.Norlida binti Mansor Pakar Perunding O&G HSB
Dr.Zainol bin Ishak Pakar Perunding Uro-ginekologi HSB
Dr Haliza binti Ghazali Pakar Perunding Maternal-Fetal HSAH
Dr Rohani binti Aziz Pakar Perunding Obstetrik dan Ginekologi HSB
Dr.Aw Lin Da Pakar Perunding Reproduktif HSB
Dr. Lee Saw Joo Pakar O&G HSB
Dr.Asninda binti Bin Yamin Pakar O&G Hospital Kulim
Dr.Norul Akhma bt Abdul Hamid Pakar O&G Hospital Langkawi
Dr.Mazniza’in bt Mohamad Pakar O&G Hospital Sultanah Bahiyah
PAKAR PERUBATAN KELUARGA JAWATAN/TEMPAT BERTUGAS
Dr. Abdul Jalil bin Ahmad Pakar Perunding Perubatan Keluarga KK

Tunjang
Dr. Mohd Faudzi bin Abdullah Pakar Perunding Perubatan Keluarga KK Kuah
Dr. Sri Wahyu binti Taher Pakar Perunding Perubatan Keluarga KK
Simpang Kuala
Dr. Zamri bin Mansor Pakar Perunding Perubatan Keluarga KK Kuala
Ketil
Dr. Abdul Jamil bin Ahmad Pakar Perunding Perubatan Keluarga KK Kulim
Dr. Jamilah binti Abdullah Pakar Perunding Perubatan Keluarga KK
Pendang
Dr. Siti Aishah binti Johari Pakar Perubatan Keluarga Klinik Kesihatan
Bandar Alor Setar
Dr. Arfah binti Ahmad Pakar Perubatan Keluarga KK Naka
5
PEGAWAI PERUBATAN JAWATAN/TEMPAT BERTUGAS
Dr Siti Sarah binti Ahmad Pegawai Perubatan UD48 HSB

Dr Tan Yi Pin Pegawai Perubatan UD44 HSB
Dr Rajavel A/L Neelamekan Pegawai Perubatan UD44 Hospital Kulim
Dr Shiham bin Mohamud Fouzi Pegawai Perubatan UD41 HSB
Dr Mohamad Mukhlis bin Abd Pegawai Perubatan UD41 HSB
Talib
Dr Nur Faradilla binti Mohamad Pegawai Perubatan UD41 HSB
Bakri
Dr Abdul Khaliq bin Abdul Jalil Pegawai Perubatan UD41 HSB
Dr Farah Hazirah binti Mohd Nasir Pegawai Perubatan UD41 HSB
PENYELIA JURURAWAT
Sharifah binti Yahaya Penyelia Jururawat HSB U36

Saleha binti Awang Besar Penyelia Jururawat HSAH U36
Roslah binti Bakri Penyelia Jururawat Hospital Kulim U36
Che Dalilah binti Ishak Penyelia Jururawat PKD Kuala Muda U42
Chan Siew Hong Penyelia Jururawat KK Simpang Kuala U41
Salmah binti Ahmad Penyelia Jururawat PKD Baling U36
HSB: Hospital Sultanah Bahiyah, Alor Setar, Kedah

HSH: Hospital Sultan Abdul Halim, Sungai Petani, Kedah
6
KANDUNGAN
Kata Pengantar Pengarah Kesihatan Negeri 2

Prakata Penyelaras O&G Negeri Kedah 3
Penghargaan 4
List of Contributors 5
Contents 7
CONTENTS
OBSTETRICS PROTOCOL PAGE

SECTION A: PRE-PREGNANCY CARE 11
SECTION B: PROBLEMS IN EARLY PREGNANCY 15

Dating of Pregnancy 16
Late Booker 17
Miscarriages 20
Ectopic Pregnancy 28
Molar Pregnancy 32
SECTION C: ANTENATAL CONDITIONS AND PROBLEMS 36

Obesity in Pregnancy 37
Vomiting in Pregnancy 39
Multiple Pregnancy 48
Preterm Labour 51
Preterm Prelabour Rupture of Membrane (PPROM) 53
Prelabour Rupture of Membrane (PROM) 53
Intrauterine Growth Restriction (IUGR) 55
Rhesus Isoimmunisation 57
Post Date Pregnancy 60
Intrauterine Death 62
Antepartum Hemorrhage 64
Cervical Incompetence 73
Breech Presentation 76
Abnormal Lie (transverse, oblique, unstable) 79
SECTION D: MEDICAL DISORDERS IN PREGNANCY 82

Heart Disease in Pregnancy 83
7
Diabetes in Pregnancy 87
Hypertension in Pregnancy 97
Renal Disease in Pregnancy 104
Anemia in Pregnancy 105
Epilepsy in Pregnancy 110
Thyroid Disease in Pregnancy 112
Bronchial Asthma in Pregnancy 114
Jaundice in Pregnancy 116
Thrombophilia in Pregnancy 118
SECTION E: ASSESSMENT OF FETAL WELL BEING 120
SECTION F: PRENATAL SCREENING 124

Prenatal Diagnosis 125
SECTION G: INDUCTION OF LABOUR 128
SECTION H: INFECTIONS IN PREGNANCY 133

HIV 134
Sexually Transmitted Disease 141
Group B Streptococcus Infection 147
SECTION I: OBSTETRICS EMERGENCIES 148

Post Partum Collapse 150
Post Partum Hemorrhage 152
Retained Placenta 156
Morbidly Adherent Placenta 158
Uterine Inversion 160
Obstetrics Thromboembolism 162
Cord Prolapse 166
Shoulder Dystocia 169
SECTION J: PUERPERIUM CONDITION 174

Puerperal Sepsis 175
Secondary Post Partum Hemorrrhage 177
Puerperal psychosis 180
SECTION K: INTRAPARTUM CONDITIONS AND PROBLEMS 182

Normal and Abnormal Labour Progress 183
Operative Delivery ( C Section and Instrumental Delivery) 189
SECTION L: VAGINAL BIRTH AFTER CAESEREAN SECTION 198
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SECTION M: DRUGS IN PREGNANCY AND LACTATION 200
SECTION N: CONTRACEPTION 207
SECTION O: THROMBOPROPHYLAXIS IN O&G 209
SECTION P: REFERRALS 217

In Utero Transfer 218
Transfer of Critically Ill Obstetrics Patients
Interdepartmental Referral 219
APPENDIX 221
REFERENCES 222
GYNAECOLOGY PROTOCOL PAGE

CHAPTER 1 : ABNORMAL VAGINAL BLEEDING 225
CHAPTER 2 : ABNORMAL VAGINAL DISCHARGE 228
CHAPTER 3 : LOWER ABDOMINAL PAIN 238
CHAPTER 4 : FUSED LABIA IN CHILDREN 241
CHAPTER 5 : LABIA / VULVAL SWELLING 244
CHAPTER 6 : DYSMENORRHEA 248
CHAPTER 7 : PRIMARY AND SECONDARY AMENORRHEA 252
CHAPTER 8 : POLYCYSTIC OVARIAN SYNDROME 259
CHAPTER 9 : ENDOMETRIOSIS 266
CHAPTER 10: INFERTILITY 272
CHAPTER 11: CLIMACTERIC SYMPTOMS AND MENOPAUSE 277
CHAPTER 12: ABNORMAL PAP SMEAR 283
CHAPTER 13: CIN 290
CHAPTER 14: CERVICAL CARCINOMA 293
CHAPTER 15: ABDOMINAL SWELLING/MASS 298
CHAPTER 16: OVARIAN CARCINOMA 301
CHAPTER 17: ENDOMETRIAL HYPERPLASIA/EIN 307
CHAPTER 18: ENDOMETRIAL CARCINOMA 311
CHAPTER 19: VULVLAR CARCINOMA 315
CHAPTER 20: GESTATIONAL TROPHOBLASTIC NEOPLASIA 321
CHAPTER 21: URINARY INCONTINENCE 325
CHAPTER 22: UTERO-VAGINAL PROLAPSE 329
CHAPTER 23: MANAGING RAPE VICTIM 333
REFERENCES 338
9
OBSTETRICS
PROTOCOL
10
SECTION A
PRE-PREGNANCY CARE
11
PRE PREGNANCY CARE
Introduction Making pregnancy safer is an important component of maternal and

child health services. As our nation develops, the profile of a woman
embarking upon pregnancy changes. A greater number of them are being
categorized as high risk pregnancies. Early intervention and treatment
can reduce the incidence of maternal and neonatal complications in
these women.
Definition A set of intervention that aim to identify and modify biomedical,

behavioural and social risks to a woman’s health or pregnancy outcome
through prevention and management, emphasizing those factors that
must be acted on before conception or early pregnancy to the mother
and baby.
Criteria for referral 1. General

a) Prospective couples intending to get married
b) Women who are married, planning a pregnancy
c) Women in reproductive age group (15-44)
2. Specific
a) women above 35 years old without medical illness, planning a
pregnancy
b) Women with obesity
c) Women with medical illness
d) Women with pervious miscarriages/stillbirths/ early neonatal
death
e) Women with inherited abnormalities
f) Women with babies who have inherited abnormalities
g) Women with congenital structural abnormalities
h) Women with babies with congenital structural abnormalities
i) Women with family history of genetic disorders
Sources of referral 1. Outpatient Department (OPD)
A. Wellness clinic
B. Premarital HIV screening program
C. Thalassaemia screening program
D. Adolescent clinic.
E. Referral from GP or Private Medical Centre (PMC)
F. Community outreach program e.g. Klinik 1 Malaysia,
G. Non communicable diseases clinic
12
2. MCHC services- e.g. Family Planning, Child Health Services, Postnatal
services
3. Specialist clinic- e.g. Cardiology clinic, Nephrology clinic, General
Medical clinic, Paediatric clinic, O&G clinic and other specialist clinic
4. Hospital In-Patient (all discipline)
5. Ambulatory care centre
6. Others- e.g. LPPKN, RSAT, PLKN, FPA(Family Planning association),
FFPAM, University Hospital, GP, PMC
Place of Pre- 1. O&G Specialist clinic- at hospital level and under supervision of
pregnancy Care Maternal Foetal Medicine Specialist
Services 2. Other specialist clinic (medical, surgical, Psychiatric etc)
3. Hospital without specialist as outpatient department- all
disciplines
4. Health Clinic- should integrated into current MCH/OPD services
headed by Family Medicine Specialist/ Medical & Health
Officers
Activities during the 1.Screening for risk factors eg history taking, Physical examination and
pre-pregnancy visit clinical laboratory test
2.Identification of pre pregnancy risk factors
3.Appropriate management according to identified risk factors
4.Referral to pre pregnancy care clinic eg health education, counselling,
investigation, appropriate treatment and management and appropriate
referral
SOP 1-Preexisting chronic medical illness

SOP 2-Thalassaemia
MANAGEMENT/SOP SOP 3- History of Congenital anomalies
SOP 4- Previous Surgical History
SOP 5-Recurrent Miscarriages
SOP6- History of unexplained Perinatal Death
SOP 7-Medication and Substance Abuse
SOP 8-Sexually Transmitted Illnesses
SOP 9-Subfertility
Notes Refer flow chart
13
FLOWCHART OF PRE-PREGNANCY CARE AT PRIMARY LEVEL
Walk in referral
Screening and history taking

using pre pregnancy screening 1.Maternal and child health
format (PARAMEDICS) services
Family planning
Child Health Services
Postnatal service
2. Outpatient service
Wellness services
Any risk factors Premarital screening
Thalassemia screening
Adolescent Services
Referral from GP/NGO
3. Specialist Clinic
NO YES Physician
Cardiology
Give advice/ Refer MO/FMS Nephrology
health education Paediatrics
Other Specialist clinic
YES
Request
counselling
Pre pregnancy
care and 1. History taking
management 2. Physical examination
NO
3. Diagnosis and
confirm possible
END risk
4. Counselling
Conduct further
5. Investigation
investigations
(MO/FMS)
NO
YES
Refer pre pregnancy
Any risk factor service to secondary/
tertiary level 14
(Specialist/Consultants
PROBLEM IN EARLY PREGNANCY
SECTION B
15
EARLY PREGNANCY CONDITIONS AND
PROBLEMS
Dating of Pregnancy
Introduction Determination of the gestational age of the pregnancy is important in re-
establishing the EDD particularly in patients with irregular menstrual
cycles, unsure of date, lactating and also establishing the number of
fetuses. Furthermore accurate dating decreases the number of labour
induction for post term pregnancies and is important in the cases of
planned deliveries to prevent iatrogenic prematurity.
Definition Accurately establishing the period of gestation by various modalities.
Presentation 1. Amenorrhea - > 4 weeks

2. Nausea and vomiting
3. Breast swelling/soreness
Clinical Findings Breast tenderness

Cutaneous change to the breast
Differential 1. Amenorrhea due to other causes besides pregnancy
Diagnosis 2. Pseudocyesis (false pregnancy)
Investigations Blood: FBC, β-HCG
Urine: UPT
Imaging: USG (TAS/TVS)
Healthcare Refer to flow chart

centre
MANAGEMENT
District Refer to flowchart
Hospital
16
Hospital with Refer to flow chart
Specialists
Notes Ectopic pregnancy should be considered if IUGS not see
LATE BOOKER
Late booker is defined as pregnant woman who booked her antenatal check-up
at or after 22 weeks period of gestation.
Management of late booker is as followed:
1. Late bookers should be tagged as green in their red antenatal card if this is
the only risk factor they have.
2. Late booker should be referred to O&G Specialist to decide EDD, timing and
mode of delivery.
3. Late booker should not be routinely induced unless if they have other
obstetrics indications
4. The decision for induction of labour should be made by O&G Specialist.
17
FLOWCHART MANAGEMENT OF DATING PREGNANCY
Suspect pregnancy
UPT
Positive Negative
USG Gynae scan

TAS/TVS
Uterus empty
Empty Fetal measure

BPD/HC/FL/AC
IUGS seen but no
fetal pole > 13 weeks *
Refer to ectopic Refer to

chapter amenorrhea
chapter
Fetal pole seen

Repeat scan after 2
-Measure CRL (6-
weeks
12 weeks)
*A repeat scan 2-4 weeks later is

required to reestablish EDD in Repeat scan after
cases where patient is USOD or 2-4 weeks *
has irregular menstrual cycle
18
NOTES
1.Measurement of gestational sac diameter should not be used in estimation of gestational age
2.The gestational age measurement based on CRL as an accuracy of +/- 5 to 7 days up to the
gestation of <14 weeks
3.Gestational age assessment by US based on composite fetal biometric measurement has an
accuracy of +/- 7 to 10 day between 14-22 weeks
4.Between 22-28 weeks, the US dating has accuracy of +/- 10 to 14 days
Re-dating based on ultrasonography
Gestational age range Method of Discrepancy between

( by LMP) measurement US dating and LMP
dating that support
redating
* management
<14 weeks decision based on
third trimester
i. <9 weeks CRL >5 days scanning is
ii. 9 - <14 weeks >7 days problematic and need
to be guided by careful
14 till <16 weeks BPD,AC,HC,FL >7 days consideration of entire
full clinical picture and
16 till <22 weeks BPD,AC,HC,FL > 10 days
close surveillance due
to the risk of redating
22 till < 28 weeks BPD,AC,HC,FL > 14 days
a small fetus with
> 28 weeks * BPD,AC,HC,FL > 21 days IUGR
19
EARLY PREGNANCY PROBLEMS
Miscarriages
Introduction Commonest admission to the gynae ward. The loss rate among clinically
recognized pregnancies is about 15%. It may rise to 50% if unrecognized
pregnancies are included.
Definition Expulsion of the conceptus /fetus weighing < 500g or at < 22 weeks gestation
Presentation 1. Amenorrhea
2. PV bleeding
3. Abdominal pain
4. Recent post coital bleed
Clinical Findings
Features Threatened Inevitable Incomplete Missed Septic
PV Fresh / Fresh/nil fresh +/- +

bleeding brownish
Abdominal nil nil + nil +

pain
Passage of nil nil + nil +

POC
Cervical os closed open open closed open
Uterine = date =date < date < date <

size date
Fever nil nil nil nil +
Differential 1. Ectopic pregnancy

Diagnosis 2. Molar pregnancy
3. Heterotopic pregnancy
20
Investigations Blood: FBC, β- HCG, Sr. Progesterone, Coagulation profile, Blood grouping,
Urine: UPT
Imaging: USG (TAS/TVS)
Others: swab C&S
Healthcare centre Refer to flow chart
MANAGEMENT District Hospital Refer to flowchart

Specialists
Notes Anti-D Rhesus prophylaxis for Rhesus negative patients - To refer Rh-
isoimmunization chapter
21
FLOWCHART OF MISCARRIAGE
PV BLEEDING
History, examination
(as per table)
Ultrasound (TAS/TVS)
NO
Fetus
SEEN
Fetal Heart activity POC Empty
Fever + Complete
abdominal miscarriage
pain + fever
Present
Absent
Missed
VE (Os) miscarriage
PRESENT ABSENT
Open Closed
Inevitable Threatened Septic Incomplete

miscarriage miscarriage miscarriage miscarriage 22
1. THREATENED MISCARRIAGE
Management:
1. Advise adequate rest at home/hospital
2. Indication for admission is excessive PV bleeding or lower abdominal pain.
3. Observed for progression to inevitable, incomplete or missed miscarriage
4. T. Duphaston (dydogesterone) 40mg stat and 10mg tds until bleeding stops may be considered
in selected cases after discussion with O&G Specialist.
5. Discharge if no per vaginal bleeding for 12-24 hours
6. Medical leave for 7 days.
7. Repeat scan USG after 2 weeks of discharge for reassurance
8. Counselling:
Reassure patient that pregnancy will progress well in 95% of cases if fetal heart is seen
Return immediately if increasing per vaginal bleeding and abdominal pain, foul smelling
vaginal discharge or fever
to bring the POC if passed out for confirmation
abstinence from coitus for 2 weeks after cessation of bleeding
Patients with threatened miscarriage has increased risk of preterm delivery and abruptio
placenta.
2. INEVITABLE MISCARRIAGE
Management:
1. Keep in the ward until expulsion has occurred completely
2. Vital signs monitoring and pad chart
3. Analgesic e.g. IM Pethidine 1mg/kg.
4. Repeat pelvic examination if PV bleeding and abdominal pain increasing.
5. If expulsion has not occurred within 12 hours, prostaglandin or oxytoxics may be given to
hasten the process.
6. To repeat scan after expulsion of conceptus. If there is presence of residual POC to treat as
incomplete miscarriage.
3. INCOMPLETE MISCARRIAGE
Management:
1. Assess the degree of per vaginal bleeding, set IVD, resuscitation if necessary and vital signs
monitoring.
2. Intramuscular ergometrine 0.5 mg or syntometrine if no contraindication in patient with
continuous vaginal bleeding. Use intravenous syntocinon 10 units bolus if patient has
contraindications to ergometrine.
3. Remove any POC seen at the Os with the sponge forcep but DO NOT insert sponge forcep in the
uterine cavity.
4. Repeat scan for residual tissue within uterus.
A. If heterogeneous tissue > 15mm:
a) Arrange for evacuation of retained POC in OT under General Anaesthesia. (All POC should be
23
sent for HPE.)
b) Medical evacuation - with Misoprostol 800microgram vaginally daily. However surgical option
may still be necessary if bleeding becomes heavier or persistent beyond a reasonable time.
c) Conservative management- to allow tissue to be expelled spontaneously provided there is no
signs of infection, heavy vaginal bleeding, pyrexia or lower abdominal pain. A follow up scan at 2
weeks interval is necessary until a diagnosis of complete miscarriage is made.
B. If heterogeneous shadow < 15mm either for conservative management or medical evacuation
with Misoprostol.
5. Patient can be discharged after 6 hours of ERPOC if she is stable.
6. Medical leave for 2 weeks.
7. Counselling before discharge:
Probable cause of miscarriage
Resumption of coitus -once bleeding stops or after 1-2 weeks of evacuation.
TCA stat if having abdominal pain, increasing vaginal bleeding, having foul smelling vaginal
discharge, fever or fainting episode
Contraception for 3 months
Follow up in pre-pregnancy clinic
Analgesia and Haematinics if necessary
8. Complications:
Incomplete evacuation
Post evacuation uterine bleeding
Sepsis
Uterine perforation
Ashermans syndrome
Recurrent miscarriages
Psychological dysfunction.
4. COMPLETE MISCARRIAGE
Management:
1.Reassurance and discharge

2.For adequate analgesia
3.Medical leave for 2 weeks
4.Counselling before discharge:
Probable cause of miscarriage
Resumption of coitus -once bleeding stops or after 1-2 weeks of evacuation.
TCA stat if having abdominal pain, increasing vaginal bleeding,
having foul smelling vaginal discharge, fever or fainting episode
Contraception for 3 months
Follow up in pre-pregnancy clinic
24
5. SEPTIC MISCARRIAGES
This miscarriage is complicated by infection of the uterine contents. The commonest organisms
are E.coli, streptococci and anaerobes.
Management:
1. Resuscitate with IV fluid and blood if necessary.
2. Send FBC, BUSE, Blood culture, Urine C&S, Endocervical and HVS swabs for C&S, coagulation
screening (PT/aPTT).
3. To transfer to hospital with specialist immediately after resuscitation.
4. Start antibiotics: Broad spectrum antibiotics + Metronidazole +/- Aminogylcosides (if patient
has severe infection or septicimic shock)
IV Cefoperazone 1 gm 12 hourly or IV Cefuroxime 750 mg 8 hourly plus IV
Metronidazole 500 mg 8 hourly.
Or
IV Augmentin 1.2 gm 8 hourly or IV Unasyn 1.5gm 8 hourly plus IV Gentamicin 1mg/kg 8
hourly plus IV Metronidazole 500 mg 8 hourly.
Alternative antibiotics (2nd Line)

IV Ceftriaxone 1-2gm 12 hourly or IV Ceftazidime 1gm 12 Hourly + IV Metronidazole 500mg 8
hourly.
5. Parenteral antibiotics should be continued until patient is
afebrile for 24-48 hours, then oral antibiotics can be instituted for 10 days. Adjust the antibiotics
according to the C&S result.
6. Arrange for evacuation of uterus after at least 12 to 24 hours after commencement of
antibiotics and once patient’s condition is stable.
7. Evacuation must be done at least by a senior medical officer.
Notes: Complications of septic miscarriages:
1. Pelvic abscess
2. Septic shock
3. Chronic PID
4. Uterine synechae
6. MISSED MISCARRIAGE
Management:
1. Establish the diagnosis by history, examination, UPT and ultrasound.
2. Sonographic diagnostic criteria for early pregnancy loss
a) absence of cardiac activity with CRL of 6mm
b) gestational sac diameter of 21mm without embryo (+/- yolk sac)
c) gestational sac empty on initial scan and continued absence of a yolk sac or embryo 7 days later
3. Investigation: FBC, Screening for Coagulopathy, GSH
25
4. Treatment option:
A) Expectant management - indicated only in medically stable patient with first trimester
pregnancy loss
B) Medical Management -
I) 5-12weeks:
Mifepristone 600mg PO plus 24-48H later vaginal misoprostol 800 microgram (may be
followed by a smaller vaginal misoprostol 3-6 hours if needed)
Mifepristone 600mgPO plus Gemeprost 1mg vaginally between 1-3 days later.
Gemeprost 1mg vaginally every 3-6 hours up to 3 doses in 24H or Misoprostol 800
microgram vaginally daily up to 5 days until abortion occurs or a total of
2400microgram Misoprostol vaginally every 3-12H
II) 13-22 weeks:
Gemeprost 1mg 3-6 hourly up to 3 doses in 24H

IM carboprost 250microgram deep IM can be repeated every 2 hours up to a total of
1200microgram
Mifepristone 200mg PO followed by 24-48 hours by Misoprostol 800 microgram
vaginally and repeated misoprostol 400 microgram 3 hourly up to 4 doses orally
Misoprostol 400 microgram vaginally every 3 Hourly for 5 doses.
Serial β-HCG evaluation or USG within 7-14 days is necessary to confirm an empty uterus. If
medical treatment fails surgical evacuation is indicated.
Medical management is contraindicated in the presence of infection, haemorrhage, severe anemia,

bleeding diathesis and allergic to prostaglandin.
C) Surgical evacuation
I) 5-12 weeks
Suction evacuation (vacuum aspiration/suction curretage) under local or GA preceded

by priming of cervix with prostaglandin or hydrophilic/osmotic dilator
Manual vacuum aspiration (<10 weeks) using Carmen cannula 50ml IPAS syringe with
paracervical block using 1% lignocaine.
II) 13-22 weeks
Medical therapy should be initiated as above until fetus is aborted followed by suction
curettage for incomplete miscarriage.
III) Counsel before discharge as above as in incomplete.
Note: a) Exclude contraindication to prostaglandin e.g.: severe bronchial Asthma or known allergy
to prostaglandin.
26
b) Monitoring of patients on prostaglandins should include
vital signs
pad chart
vomit chart
diarrhea chart
7.RECURRENT MISCARRIAGES
Definition: Three or more consecutive miscarriages.
Incidence: 0.34 %
Aetiology:
1. Endocrine
2. Genetic - parental chromosomal abnormalities, embryonic chromosomal abnormalities
3. Infective
4. Anatomical - congenital uterine malformation, cervical weakness
5. Immunological
6. Antiphospholipid syndrome
Investigations:
1. MGTT if diabetes is suspected
2. Connective tissue screening i.e,; ANA, ANF , dsDNA, RF
3. Screening for antiphospholipid syndrome
4. Blood: TFT, thrombophilia screening, Karyotyping only if indicated.
5. HSG, laparoscopy and hysteroscopy to rule out uterine abnormalities
Management:
Refer to centre with O&G Specialist/ pre pregnancy clinic
1.For habitual miscarriage T. Dydogesterone 10mg BD up to 20 weeks

2.Commencement of T. Apirin with unfractionated Heparin in patients with antiphospholipid
syndrome or inherited thrombophilia.
3. Prior optimization of the medical condition (exp: Diabetic patients should be changed to
injectable insulin prior to pregnancy)
Notes: 60% will conceive without any treatment.
27
Ectopic pregnancy
Introduction Ectopic pregnancy is a potentially life threatening condition. The rate of

ectopic pregnancy is 11 per 1000 pregnancies, with maternal mortality
of 0.2 per 1000 estimated ectopic pregnancies.
Definition Any pregnancy where the fertilised ovum gets implanted and develops in
a site other than uterine cavity
Risk factor 1. Tubal diseases due to previous pelvic infection secondary to STI
2. Previous ectopic pregnancy
3. Previous tubal surgery
4. Subfertility
5. Use of assisted reproductive techniques
Presentation 1. Abdominal pain
2. Amenorrhoea
3. Vaginal bleeding
4. Breast tenderness
5. Gastrointestinal /Urinary symptoms
6. Shoulder tip pain
7. Passage of tissue
8. Rectal pressure or pain on defecation
9. Dizziness, fainting and syncopal attack
Clinical Findings 1. Abdominal tenderness
2. Pelvic tenderness
3. Adnexal tenderness
4. Cervical motion tenderness
5. Rebound tenderness or peritonism
6. Pallor
7. Abdominal distention
8. Hypovolemic shock (Tachycardia, Hypotension & pallor)
Differential 1.Pelvic abscess
Diagnosis 2.Heterotopic pregnancy
3.Pyosalphinx
4.Degenerated uterine fibroid
5.Salphingitis
6.Appendicitis/appendicular mass
Investigations Blood: FBC, Blood grouping and cross matching 4 pints whole blood,
Coagulation profile, RP, Sr. Progestrone, β-HCG,
Urine: UPT
Imaging:USG
Healthcare Refer to flow chart (optional)
28
MANAGEMENT centre
District Refer to flowchart (optional)

Hospital
Hospital with Refer to flow chart (required)

Specialists
Notes Patient who had treatment for ectopic pregnancy are at 20% risk
of recurrence of ectopic pregnancy. Hence they should be advised
for early scan in the next pregnancy
29
FLOWCHART FOR RECOGNITION OF ECTOPIC PREGNANCY
Suspected Ectopic Pregnancy
Stable Unstable (hypovolemic

shock)
Intrauterine Admit
to ward
See in A+E
Resuscitate
Excluded
Heterotopic
pregnancy& TAS/TVS
discharge
Urgent surgical
intervention
Adnexal mass, Fluid in POD, Evidence of - open salpingectomy
Empty Uterus Empty uterus ectopic fetus - laparoscopic
(pseudo sac) Adnexal mass with heart beat
Positive UPT
Indeterminate
Ectopic pregnancy Quantitative

β-HCG
>2000 <2000
USG -Empty Increasing

Uterus trend Repeat
HCG in
Serial β Reducing 48H
Expectant Mx HCG and trend
repeat scan 30
FLOWCHART FOR ECTOPIC PREGNANCY MANAGEMENT
Ectopic pregnancy
Expectant Medical Surgical
Serial serum B HCG Systemic
Monitor until achieve Methotrexate dose 1mg/kg

normal range
(unruptured ectopic
pregnancy with adnexal mass
<35mm)
conservative radical
Local infiltration salphingostomy salphingectomy
(laparoscopic
salphingocentesis)
-Methotrexate
-Potassium chloride
-Hyperosmolar
glucose
-Mifepristone
*Patient on expectant and medical management if become unstable should be managed
-Actinomycin-D
surgically
*Patient on expectant, medical management and salphingostomy should have serial
serum B HCG done until level returns to normal range
31
Molar pregnancy
Introduction Molar pregnancy is part of the Gestational Trophoblastic Disease.
About 1 of 1500 women with early pregnancy symptoms has a molar
pregnancy.
Definition Hydatidiform moles are abnormal pregnancies characterized
histologically by:
-Trophoblastic proliferation
-Edema of the villous stroma (Hydropic)
Types Based on the degree and extent of this tissue changes, hydatidiform
moles are categorized as either
-Complete hydatidiform mole
-Partial hydatidiform moles
Features Partial Complete
1.Karyotype Most commonly 69, Most commonly

XXX or XXY 46,XX or XY
2.Pathology
fetus -Often present -absent
Amnion, fetal RBC -usually present -absent
Villious edema -variable,focal -diffuse
Trophoblastic -focal, slight -diffuse, slight severe

proliferation moderate
3.Clinical
Presentation
Diagnosis
Missed abortion Molar gestation
32
Uterine size Small for dates 50% larger for date
Theca lutein cysts Rare 25-30%
Medical complication Rare 10-25%
Postmolar GTN 2.5-7.5% 6.8-20%
Risk Factors 1.Age <20 (2 folds),>40 yrs (10 folds)
2.Prior molar pregnancy-second molar 1%, third molar 20%
3.Diet –increase in low fat, Vit A ,or carotene diet
4.Contraception –COC double the incident
5.Previous spontaneous abortion double the incident
6.Different H. Moles in women with different partners
Clinical -Irregular painless per vaginal bleeding

Presentation
-Passing out grapelike vesicles
-Hyperemesis
-Abdominal pain
-Excessive uterine enlargement
-Hyperthyroidism, early onset preeclampsia
-Abdominal distension due to theca lutein cysts
Investigations Blood: FBC, RP,LFT, serial serum Beta HCG,TFT
Urine: Urinalysis, UPT
Imaging: Ultrasound- Snow Storm appearance, CXR
33
There are 2 important steps:
MANAGEMENT 1.Evacuation of the mole
-For complete mole is suction and curettage
-cervical preparation with prostaglandins or misoprostol should be

avoided to reduce the risk of embolization
-For partial mole depend on fetal parts- small fetal part suction and
curettage, large fetal parts for medical(oxytocics). In partial mole the
oxytocics is safe as risk for embolisation and dissemination of
trophoblastic issue is very low and the needing for chemotherapy is
0.1-0.5%.
2.Regular follow up to detect persistent trophoblastic disease
If both steps are done appropriately, mortality rates can be reduced to

zero.
(Refer Flow Chart)
34
FLOWCHART MANAGEMENT OF MOLAR PREGNANCY
MOLAR PREGNANCY
Suction and curettage

+
Serial B HCG
(pre and post evacuation)
HPE
Complete hydatidiform mole Partial hydatidiform mole
Follow up with serial B HCG

-2 weekly for 2 months
-monthly for 3 months
-3 monthly for 9 months
-then 6 monthly for 1 year
Patient with normal B HCG in 8 1.Persistent elevation of

weeks post evacuations low B HCG >6 months
risk allow pregnancy in 6 month 2.Plateau or rising B HCG in 2
occasions 2 weeks apart
GTN
*refer section GTN
35
SECTION C
ANTENATAL CONDITIONS AND PROBLEMS
36
OBESITY IN PREGNANCY
Introduction Maternal obesity is one of the most common risk factors in obstetric.
Adverse outcomes include miscarriage, fetal congenital anomaly,
thromboembolism, gestational diabetes, preeclampsia, dysfunctional
labour, PPH, wound infection, stillbirth and higher caesarean section
rate.
Definition Body mass index (BMI) of 30 kg/m2 or more at the first antenatal visit
BMI 30.0 – 34.9 (Class 1)
BMI 35.0 – 39.9 (Class 2)
BMI 40 and over (Class 3 or morbid obesity)
Investigations Blood: FBC, MGTT
Imaging: Ultrasound limited by maternal obesity.

Estimated fetal weight at term to rule out macrosomic baby.
Healthcare Pre Pregnancy Care

MANAGEMENT centre 1. To optimise weight before pregnancy.
2. Advice the risks of obesity during pregnancy
and birth.
3. Folic Acid before conception.
Antenatal Care
1. To check BMI and record in the red card.
2. Appropriate size of arm cuff for BP
measurements. The cuff size should be
documented.
3. To identify risks such as preeclampsia and
GDM.
4. To refer FMS.
5. To refer O&G clinic after risks identification
and decision for antenatal VTE prophylaxis.
District To identify patient with obesity as antenatal care

Hospital above and referral to O&G Specialists.
Hospital with 1. Pregnant woman with booking BMI ≥ 40

Specialists should be referred to anaesthetist before
delivery for potential difficulties with venous
access, regional or GA.
37
2. Thromboprophylaxis
- Women with BMI ≥ 40 who has 2 or
more additional risk factors for VTE
should be considered antenatal
prophylaxis until 6 weeks postpartum.
- Women with BMI ≥ 40 should be
considered postnatal
thromboprophylaxis regardless of mode
of delivery.
- Women with BMI ≥ 30 with one or more
additional risk factors should be
considered postnatal
thromboprophylaxis for 7 day.
- Compression stockings.
3. Intrapartum
- Continuous midwifery care.
- To inform anaesthetist when a women
with BMI ≥ 40 in labour.
- To ensure venous access established
early when in labour.
4. Post delivery
- Anticipate for PPH.
- Anticipate for shoulder dystocia.
5. LSCS
- Prophylactic antibiotics
- If subcutaneous fat >2 cm, suture
subcutaneous tissue space to reduce
risk of wound infection and wound
breakdown.
Notes 1. Postnatal care

- Advise early mobilization after delivery.
- Nutritional advice and weight management.
2. Delivery for women with BMI ≥ 35, at hospital with specialists.
38
VOMITING IN PREGNANCY
Introduction Nausea and vomiting are common in pregnancy, affecting 70% of women
in the first trimester (NICE 2013).
Severe vomiting requiring hospitalization occurs in less than 1% of all
pregnant women (Jarvis 2011).
Symptoms manifest between 4-7 weeks’ gestation, the peak severity for
hyperemesis is around 11 weeks with 90% of cases resolved by 20
weeks’ gestation (NICE 2013; Bottomley 2009).
The cause of nausea and vomiting in pregnancy is unknown, but may be
due to the rise in human chorionic gonadotrophin concentration (Festin
2009).
Definition Hyperemesis gravidarum is a severe form of morning sickness, with

excessive pregnancy-related nausea and/or vomiting that prevents
adequate intake of food and fluids.
Morning sickness symptoms include nausea and vomiting. For most

women, morning sickness begins around the sixth week of pregnancy
and resolves by the 12th week.
However, one in five women endure morning sickness into their second
semester, and an unfortunate few experience nausea and vomiting for
the entire duration of their pregnancy.
Presentation Hyperemesis is associated with:
Weight Loss
Ketonuria
Electrolyte imbalance and dehydration
Vitamin and mineral deficiencies
Thyroid/renal/hepatic dysfunction
Clinical Findings The PUQE (Pregnancy Unique Quantification of Emesis and Nausea)
scoring index is a validated assessment tool to determine the severity of
nausea vomiting in pregnancy (NVP), taking into account feelings of well-
being (Lacasse 2008; Ebrahimi 2009). It is a useful tool for determining
treatment course.
Diagnosis of Hyperemesis Gravidarum is by exclusion.
A thorough clinical assessment should be carried out. Women who

experience nausea and vomiting for the first time after 10 weeks’
gestation are more likely to have an alternative diagnosis to NVP
(Ebrahimi 2010).
39
Differential Be Aware of Potential Differential Diagnoses or Predisposing Conditions
Diagnosis Urinary tract infection
Multiple pregnancy
Gastrointestinal (for example, infection including Helicobacter
pylori, reflux oesophagitis, gastritis, cholecystitis, peptic
ulceration, hepatitis, appendicitis, pancreatitis, complications
after bariatric surgery)
Neurological (for example, migraine, raised Intracranial
pressure, central nervous system diseases)
Molar pregnancy
Ear, nose, and throat disease (for example, labyrinthitis,
Ménière’s disease, vestibular dysfunction)
Drugs and supplements (such as opioids and iron- some
prenatal multivitamin preparations contain iron which may
exacerbate NVP)
Metabolic and endocrine disorders (such as hypercalcaemia,
Addison’s disease, uremia, and thyrotoxicosis)
Persistent vomiting in diabetic women which may suggest
autonomic neuropathy
Psychological disorders (such as eating disorders)
Investigations Blood:
Full blood count (FBC),
Urea and electrolytes for hypokalaemia and hyponatraemia,
Liver function test, (LFT)
Thyroid function (TFT)
Urine:
Urine dipstick for ketonuria
MSU to the laboratory for culture and sensitivity
Health General Management

MANAGEMENT Clinic Correct dehydration and electrolyte imbalance
Provide symptomatic relief (Appendix 1- see
treatment algorithm)
Provide psychological support
Complete assessment and management checklist
for each treatment day and re-admission and
place in chart (Appendix 1- see attached
checklist).
Outpatients Department (mild NVP)

PUQE score ≤6
Weight patient and record in chart
40
Advise on dietary management and adequate
fluids
Provide diet information leaflet (see Appendix 1)
and discharge home
District Day Care or Out-patient Management (moderate

Hospital hyperemesis)
PUQE score 7-12 will require management as per

algorithm. Adequate hydration is crucial for optimal
management
If the woman is unable to tolerate oral fluids and
ketotic, commence intravenous fluids
(Hartmann’s or sodium chloride 0.9%).
Infuse first litre over 1-2 hours and then reassess
the patient, including urine ketone testing.
Further IV fluids if required should be run at
1000mls over 4 hours, followed by further
assessment.
Commence fluid balance chart
Reassure the woman and allow to rest
Encourage oral fluids and dietary intake of small,
frequent amounts of preferred foods
IV fluids should be discontinued when ketonuria
has resolved and preferably when the woman is
able to maintain oral fluids
See treatment algorithm for prescribing
antiemetic medications
Arrange an ultrasound to confirm single, viable
pregnancy and rule out molar or multiple
pregnancy (nausea and vomiting is more common
in multiple and or molar pregnancy)
Weigh the woman and record in the assessment
and management checklist. If urinalysis is
negative for ketones and the woman is fully
hydrated, she can be discharged from day- care
with advice on nutrition and lifestyle
management.
The woman should be informed to continue
taking the antiemetic prescribed and the need to
return to hospital if still unwell.
Hospital with
Specialists In-patient management (severe
NVP/hyperemesis)
41
PUQE score ≥13 or if insulin dependent diabetic,
patient requires admission and management as per
algorithm or to tertiary unit if diabetes services do not
exist
Correct hydration as above with IV fluids, whilst

maintaining strict fluid balance record.
Check each urine sample for ketones
Insulin-dependent diabetics must be managed
carefully to prevent hypo- and hyperglycaemia.
Seek advice from an endocrinologist or refer to
local guidelines for the management of diabetes in
pregnancy.
IV vitamin supplementation (Pabrinex I/II) will
be required for all women with prolonged
vomiting (e.g. women requiring IV fluids for more
than 24 hours) and should be repeated at weekly
intervals if the patient remains admitted for
treatment of NVP or is readmitted with severe
NVP. Mix ampoule 1 and ampoule 2, dilute with
50ml-100ml of normal saline or glucose 5% and
administer over 30 minutes.
Caution: anaphylactic reactions have been
reported rarely during, or shortly after,
parenteral administration of Pabrinex.
Resuscitation facilities should be available
Diabetics requiring glucose infusion must be
given Pabrinex I/II concurrent with or
immediately after commencing dextrose/glucose
infusion. Thiamine deficiency followed by glucose
infusion precipitates Wernicke’s encephalopathy.
Encourage small, frequent oral fluids and foods
based on the patient’s personal preferences
If the serum potassium level is found to be less
than 3.2mmol/l, potassium supplements should
be given. Potassium is a high alert medication.
Ready-mixed potassium infusions should be used.
Refer to dietitian for assessment of nutritional
needs
Provide psychological support
Administer antiemetics as prescribed. Note
patients with severe hyperemesis may require
more than one antiemetic to control symptoms.
See treatment algorithm
Apply anti-embolic stockings for women who are
bed ridden, risk assess as per hospital guideline
42
for venous thromboembolism (VTE)
Daily U & E to assess electrolyte balance
Assess bowel function daily
Notes Criteria for discharge:

No ketones in the urine
Tolerating oral fluids and food without vomiting
Appropriate antiemetic prescription provided
Patient given information leaflet on diet and lifestyle management
Suggestion:
Intravenous administration of Pabrinex I/II vitamin solution as prophylaxis against
Wernicke’s encephalopathy (NICE 2010)
43
APPENDIX
Practical tips for coping with nausea and vomiting

Nausea and vomiting is common during the first three months of pregnancy. It usually eases by 16
weeks but can lead to weakness, weight loss and poor nutrition.
The following tips may help you cope and get the benefit of some nutrition, even when you are
feeling unwell.
1. Eat little and often:
Take small snacks and meals every 2 to 3 hours. Try to take food and drinks separately. Often
dry meals are better tolerated.
Try to eat something light such as dry toast, crackers or plain biscuits before getting out of
bed in the morning. Then wait about 15 to 20 minutes before getting out of bed.
Try cold foods or easy to prepare foods such as sandwiches and ready meals until symptoms
settle.
Take whatever food you are drawn to. Think of what flavours, temperature and textures that
appeal to you:
Sweet, salty, bitter or sour
Hot, warm or cold
Crunchy, dry or soft
Thin, wafer-like slices or small cubes
Ideas for snacks:

Breakfast cereals with or without milk
Toast or crackers
Thinly sliced fruit
Plain digestives, Marietta or rich tea biscuits
Hot or cold milky drinks: hot chocolate, Horlick’s, Ovaltine, Complan
Sandwiches made with wafer-thin chicken, ham, or cheese
Light, broth-base soup, Bovril or Oxo
Baked beans on toast or a baked potato
Plain thin spaghetti, noodles or rice
Rice pudding
Yogurt
1. Take plenty of fluids:
Aim to drink at least 8 cups of fluid per day.

If you cannot tolerate tap water, try bottled water, flavoured water, weak tea, diluted fruit
juice or fizzy drinks allowed to go flat.
Try ice pops, ice lollies, jelly or ice cream if you cannot take fluids.
Clear soups or broth and juicy fruits can add to your fluid intake.
44
2. Other helpful tips:
Take your folic acid every day until you are 12 weeks’ pregnant. It may be best to take a
complete vitamin and mineral supplement made for pregnant women after the first 12
weeks.
Avoid having to rush in the morning, when symptoms are often worse. Prepare your clothes
and shower before bed time rather than in the morning if it is easier.
Avoid strong smells such as perfumes and cooking odours.
Get some extra rest. You need more sleep during the first 3 months of pregnancy and
becoming
overly tired can make the nausea worse.
Ask for help from others. Your partner, family and friends can help by doing some shopping,
cooking and cleaning to allow you to get more rest.
Do not worry if your diet is not the best while you are sick. Try to eat enough to keep
your energy up and prevent weight loss.
Once the sickness fades, aim to eat a healthy, balanced diet. You can read more
about healthy eating for pregnancy and food safety advice in the maternity information
pack from the outpatient appointments desk.
You should see your doctor if you cannot keep any fluids down and are losing weight.
You can ask your doctor or midwife for a referral to see the dietitian as well.
45
46
47
MULTIPLE PREGNANCY
Introduction The incidence of multiple pregnancy is increasing in trend.
Definition Pregnancy where more than one fetus in the uterus.
Presentation 1. Exaggerated symptoms of pregnancy such as hyperemesis

gravidarum.
2. Uterus larger than date.
3. Premature contraction.
Clinical Findings Uterus larger than date.
Differential 1. Polyhydramnios
Diagnosis 2. Macrosomic baby
Investigations Blood: FBC, MGTT
Imaging: Early Ultrasound to determine chorionicity if necessary to refer

O&G team for confirmation. To refer early if unable to identify
separating membrane.
1. Dichorionic Diamniotic (DCDA): 3-4 weeks ultrasound
until 28 weeks then 2 weekly.
2. Monochorionic (MCDA & MCMA): 2-3 weekly after 16
weeks. Detailed ultrasound at 18-22 weeks. To detect
TTTS before 26 weeks, ultrasound to detect IUGR after 26
weeks.
Healthcare 1. Identify multiple pregnancy and chorionicity

MANAGEMENT centre as early as possible. Refer to Specialist
2. Identify complications and manage
accordingly.
District Identify problems and refer tertiary centre for further

Hospital management.
Hospital with Dichorionic Diamniotic (DCDA)-

Specialists 1. If no complications, 3-4 weekly follow up
2. Delivery at 38 weeks.
Monochorionic Diamniotic (MCDA)

1. If no complications, 2-3 weekly follow up
48
2. Delivery at 37 weeks.
3. To identify complications such as TTTS and
manage accordingly.
4. Mode of delivery depends on fetal
presentations and complications.
5. Ideally to be managed by MFM specialist.
Monochorionic Monoamniotic (MCMA)

1. Antenatal follow up same as MCDA.
2. Delivery at 32-34 weeks by caesarean
section.
Notes A. Look for complications of multiple pregnancy in every follow

up
1. Anaemia, PIH, DM
2. Preterm labour
3. IUGR
4. Twin to twin transfusion syndrome (TTTS) for MCDA
B. Suggest IM Dexamethasone 12 mg daily for 2 doses (out

patient).
C. Intrapartum
1. Consult specialist before induction of labour or
augmentation.
2. Continues CTG monitoring of both fetus.
3. Senior Medical Officer must be present at delivery.
4. After delivery of 1st twin
- Determine lie and presentation of second twin.
- If longitudinal lie, to start oxytoxin after stabilising the
second twin.
- Perform ARM once presenting twin is in pelvis and
longitudinal lie.
- External Version and Internal Podalic Version can
only be done by Senior MO/ Specialist.
D.
1. Anticipate PPH.
2. Continue oxytoxin infusion of 40 unit for 4-6 hours.
3. To identify atonic uterus early.
E.
1. For higher order multiple pregnancy (triplet etc.) to be
managed under O&G/MFM Specialist care.
49
MANAGEMENT OF MULTIPLE PREGNANCY
Early Ultrasound To Confirm Chorionicity Ideally 1st Trimester
DCDA MCDA MCMA
Follow up 3-4 2-3 weeks follow up

weeks
Detailed ultrasound Detailed

ultrasound
With complications No complications
TTTS
Selective IUGR
Delivery at To be managed by Delivery at Delivery at

38/52 O&G/MFM Specialist 37/52 32-34/52
50
PRETERM LABOUR
Introduction Prematurity is the commonest cause of perinatal mortality / morbidity in

Malaysia.
Definition Preterm birth at less than 37 weeks of gestation.
Presentation Diagnosis may be difficult. It is suspected when there is regular uterine

contractions. Other symptoms are leaking liquor and show.
Clinical Findings Regular uterine contractions occurring every 10 mins or less, lasting at
least 30 second. Other signs are ruptured membranes, show, cervical
dilatation and effacement.
Differential 1. Urinary Tract Infection (UTI)

Diagnosis 2. Braxton Hicks contraction
3. Chrioamnionitis/Abruptio
Investigations Blood: FBC
Urine: UFEME/Urine dipstick if need to rule out UTI
Imaging: Ultrasound to confirm viability, presentation, estimated fetal

weight and to exclude fetal anomalies.
Others: HVS for Culture and Sensivity
Healthcare Refer to nearest hospital.

MANAGEMENT centre
District Refer hospital with Paediatric backup. To start
Hospital Nifedipine protocol after discuss with specialist.
Hospital with Tocolysis

Specialists
1. Nifedipine
20 mg orally stat and 2nd dose of 20 mg if
contractions persist after 30 minutes. 3rd
dose of 20 mg if contractions still persist
after 30 minutes.
If indicated, to continue with maintenance
dose 20 mg TDS for 48 hours.
Maximum Nifedipine is 120 mg per day.
51
1. Sulbutamol (Ventolin)
Ventolin 5 mg in 1 pint D5%, Titrate at 5
drop per minute and increase every 20
minute, maximum 40 dpm.
2. Ritodrine (Yutopar)
2 x 5 ml amp in 1 pint D5%, Titrate at 5 drop
per minute and increase every 20 minute,
maximum 35 dpm.
Treatment is discontinued
1. Maternal side effects such as palpitations,
chest pain and SOB.
2. Maternal tarchycardia.
3. Hypotension.
4. Fetal tachycardia.
5. Hypokalemia.
6. Persistant Uterine Contraction.
IM Dexamethasone 12 mg BD x 1 day.
For premature labour at 26-30 weeks, to consider IM
Magnesium Sulphate for fetal neuro protection. The
dose is IV 4 gm loading dose (slowly 20-30 min) and 1
gm /hour maintenance dose. Continue for 24 hours or
until birth.
Notes Contraindications to Tocolytic Therapy
Absolute:-
1. Cardiac Disease
2. Thyrotoxicosis
3. Intra Uterine Death
4. Fetal anomalies
5. Fetal Distress
6. APH
7. Chorioamnionitis
Relative ( to discuss with specialist )

1. Pre Eclampsia/PIH
2. Diabetes
3. Advance Cervical Dilatation
52
.
PRETERM PRELABOUR RUPTURE OF MEMBRANE

(PPROM) AND PRELABOUR RUPTURE OF
MEMBRANE (PROM)
Definition Rupture of fetal membrane with a latent period (at least 6 hours) before
onset of spontaneous uterine activity:
- PPROM: POA < 37 weeks
- PROM: POA > 37 weeks
Confirmation 1. History of leaking liquor
diagnosis 2. Pooling of liquor during speculum examination
3. Litmus paper test
4. Ultrasound evidence of oligohydramnion
Urine: UFEME
Imaging: Ultrasound abdomen
Others: High vaginal swab C&S
Healthcare Refer to hospital with specialist
MANAGEMENT centre
District Refer to hospital with specialist after 12 hours of
Hospital leaking
Hospital with 1. If presence of chorioamnionitis or fetal distress,
Specialists immediate delivery is indicated.
2. If no evidence of infection, refer flowchart.
3. DO NOT PERFORM VE IF CONSERVATIVE
MANAGEMENT IS PLANNED
53
MANAGEMENT OF PROM
PROM
< 36 WEEKS ≥ 36 WEEKS
1. If no spontaneous
1. Monitor for signs and labour after 12
symptoms of chorioamnionitis hours, to start IV
e.g. maternal and fetal heart rate, Ampicillin 2g stat
temperature, uterine tenderness, and 1g 6 hourly till
foul smelling vaginal discharge delivery
2. Steroid for lung maturation 2. If still not in labour

after 24 hours, to induce
3. Initiate EES 400mg BD for 10 labour.
days
4. Weekly ultrasound for AFI
Intrapartum
1. IV Ampicillin till delivery
2. Continous CTG
3. Paediatrician need to be informed
Postpartum
1. Monitoring for infection for mother and neonate
54
INTRAUTERINE GROWTH RESTRICTION
Introduction Fetus failed to achieve appropriate growth potential.
Definition Fetal abdominal circumference and estimated fetal weight below tenth
centile.
Presentation Uterus smaller than date

Reduce fetus movement
Clinical Findings 1. Abdominal palpation and measurement of symphyseal fundal

height (SFH)showed uterus smaller than date
Differential 1. Wrong date

Diagnosis 2. Oligohydramnious
Investigations Blood: FBC, TORCHES
Imaging:
1. Ultrasound for fetal biometry, Estimated Fetal Weight, AFI.
2. Ultrasound for Doppler flow velocimetry.
Others: CTG after 28 weeks
Healthcare 1. To confirm date

MANAGEMENT centre 2. Early scan for dating
3. To check SFH during antenatal follow up
from 20 weeks onwards
4. To refer FMS or O&G clinic if uterus smaller
than date
5. Growth chart
District 1. To confirm date by ultrasound if patient

Hospital admitted in 1st trimester (eg: for
hyperemesis).
2. To refer O&G Specialist if uterus smaller than
date.
3. CTG.
Hospital with 1. Fetal surveillance by CTG and AFI.

Specialists 2. Ultrasound by MFM Specialist, to assess for
risk of chromosomal defects structural
abnormalities and soft markers.
55
3. Umbilical Artery Doppler.
Notes 1. When anomaly scan and Umbilical Artery Doppler are normal
and Growth Chart shows fetus is growing, likely SGA (Small for
Gestation Age).
2. Delay delivery until 37 weeks when End Distolic Flow is
present and other surveillance findings are normal.
3. When End Distolic Flow is absent or reversed, admission and
administration of steroids (Dexamethasone) are required. If
gestation is over 34 weeks, for delivery.
4. If less than 34 weeks, delivery to be decided by Senior O&G /
MFM Specialist.
5. Antenatal steroids if gestation 24-36 weeks.
6. Delivery in tertiary centre with Neonatology backup.
7. Intrapartum : continous CTG.
56
RHESUS ISOIMMUNIZATION
Introduction Rhesus isoimmunization against Rhesus antigen may result in hemolytic

disease of the fetus and newborn. With the development of RhD
immunogolubulin, severe Rhesus isoimmunization is rarely seen today.
There is a risk of isoimmunization in any situation in which Rhesus

positive red blood cells enter the circulation of a Rhesus negative
woman. The degree of the risk will vary with the amount of Rhesus
antigen to which she is exposed.
During pregnancy, a small proportion of women (1.5%) develop Rhesus

antibodies during their first pregnancy; most such immunization take
place after 28 weeks of gestation.
The combination of antenatal administration of 100 mg (500IU) anti-D

immunoglobulin to all unsensitized Rhesus negative women, and a
further dose administered after birth to all such women who give birth
to a Rhesus positive child, would reduce the remaining incidence of
Rhesus isoimmunization from 0.2 to 0.06%.
Healthcare Refer to flowchart
MANAGEMENT centre

Specialists
57
MANAGEMENT OF RHESUS ISOIMMUNIZATION IN HEALTHCARE CENTRE
Rhesus negative mother
Coomb’s test
Indirect positive Indirect negative
Arrange for Anti-D Refer O&G for

antibody in titre at Rhogum at 28
nearest hospital weeks
Result to be traced urgent
Refer O&G clinic for

earliest appointment
58
MANAGEMENT OF RHESUS ISOIMMUNIZATION IN HOSPITAL WITH SPECIALIST
Rhesus negative mother
Coomb’s test
Indirect positive Indirect negative
Anti-D antibody titre Administer Rhogum at 28

weeks
2 regimes:
Anti-D antibody Anti-D antibody
- two doses of 500 IU anti-D Ig
positive negative
at 28 and 34 weeks of
gestation
or
- a single dose of 1500 IU at 28
Refer Maternal Fetal weeks of gestation
Medicine specialist
Indications of administration of anti-D immunogolobulin to

unsensitised RhD negative women:
1. Miscarriages require surgical evacuation regardless of period of gestation
2. Induced miscarriage
3. Ectopic pregnancy
4. Chorion villious sampling
5. Fetal blood sampling
6. Amniocentesis
7. External cephalic version
8. Closed abdominal injury
9. Intrauterine death
10. Placenta abruptio
11. Manual removal of placenta
*Post-delivery, if baby Rhesus D positive, to give mother second dose Rhogum up to 72

hours 59
POST-DATE PREGNANCY
Definition Pregnancy beyond 40 weeks, up to 42 weeks

MANAGEMENT centre

Specialists
MANAGEMENT OF POST-DATE PREGNANCY IN HEALTHCARE CENTRE
POA
> 40 week to 41 week
Ensure correct date

No additional risk factor
Ultrasound for fetal well

being and AFI
AFI < 7 AFI normal
Refer to hospital with Admit at 40 weeks + 7

specialist. days
60
MANAGEMENT OF POST-DATE PREGNANCY IN HOSPITAL WITH SPECIALIST
POA
> 40 week to 41 week
Ensure correct date*

No additional risk factors
Cervical score
Favourable Unfavourable
Artificial rupture of Vaginal prostaglandin

membrane + pitocin 3-5 doses
Unfavourable
*
For C-section
- determine LMP and regularly
- last child birth
- oral contraceptive usage
- breastfeeding
- date of UPT test
- early ultrasound scan for dating
- review ANC card (uterine size
corresponds to dates)
61
INTRAUTERINE DEATH (IUD)
Introduction This is a tragic event and requires sympathetic approach.

Definition Death of fetus after completed 24 weeks of pregnancy
Causes 1. Maternal: DM, hypertension, septicaemia
2. Fetal malformation
3. Infections
4. Immune disorders e.g. Rh incompactability, connective tissue disorder
5. Cord incident
6. Placental insufficiency, abruption
7. Twin-to-twin transfusion, fetal to maternal haemorrhage
Confirmation Ultrasound abdomen
Investigations Pre-delivery: FBC, PT/APTT (to detect coagulopathy)
IUD workout: TORCHES, HbA1c, MGTT, HVS C&S, placenta swab C&S, +/-
HPE for placenta
Healthcare 1. Confirm IUD via scan

MANAGEMENT centre 2. Refer to hospital with specialist
District 1. Confirm IUD via scan
Hospital 2. Refer to hospital with specialist
Specialists
62
MANAGEMENT OF INTRAUTERINE DEATH IN HOSPITAL WITH SPECIALIST
Intrauterine Death
Confirmation
- Ultrasound
Counselling
Await spontaneous delivery Induction of labour
1. Monitor for signs of If uterus size < 20 weeks:

coagulopathy and infection Gameprost vaginal pessary 1mg
3-6 hourly (max 3-5 doses/day)
2. Aim for vaginal delivery unless
there is absolute indications for C- If uterus size > 20 weeks:
section Prostin E2 vaginal pessary 6
hourly (max 2 doses/day)
Consult specialist if there is no

progression to labour after 1
cycle of induction agent
Intrapartum
- ensure adequate pain relief during labour
Postpartum
- provision of lactation suppression
- post natal follow up for review results and
acceptance of loss
- contraceptions
- discussion regarding plan for subsequent pregnancy
63
ANTEPARTUM HAEMORRHAGE
Definition Bleeding from the genital tract after 22 weeks of pregnancy to delivery of
the fetus
Causes 1. Placenta praevia
2. Abruptio placenta
3. Local causes
4. Indeterminate APH
Placenta Praevia
Definition Abnormally situated placenta encroaching or covering the internal os
Presentation Painless per vaginal bleeding
Clinical Findings Based amount of blood loss
MANAGEMENT centre
Hospital
Specialists
64
MANAGEMENT OF PLACENTA PRAEVIA IN HEALTH CARE
Placenta Praevia
Not bleeding Bleeding and Bleeding but

haemodynamically stable haemodynamically not
stable
Refer to O&G specialist

at 34 weeks
1. Resuscitation
- insert large bore
1. Insert large bore branula
branula. - fluid resuscitation
2. Refer to Hospital
with Specialists 2. Inform covering
O&G specialist on-call
3. Transfer to Hospital
with O&G specialist
65
MANAGEMENT OF PLACENTA PRAEVIA IN DISTRICT HOSPITAL
Placenta Praevia

stable
Refer to O&G specialist

at 34 weeks
1. Resuscitation
- insert large bore
1. Insert large bore branula, take FBC +
branula. GXM WB
2. Refer to Hospital - fluid AND BLOOD
with Specialists resuscitation
2. Inform covering
with O&G specialist
66
MANAGEMENT OF PLACENTA PRAEVIA IN HOSPITAL WITH SPECIALISTS
Placenta Praevia

stable regardless of POA
Admit at 34 weeks for

expectant
management
1. Resuscitation
(McCaffee regime)
- insert large bore
1. If < 34 weeks: branula, take FBC,
Pre-requisites: - administer PT/APTT + GXM WB
1. Minimal bleeding dexamethasone - fluid AND BLOOD
2. POA < 34-36 weeks - continue expectant resuscitation
3. Centres equipped management - correction of
with Obstetrician,
coagulopathy
Anaesthetist and 2. If > 34 weeks:
Operating Theatre, - consider delivery 2. Arrange for delivery
Paediatric backup and
once patient stable with
blood bank
Paediatric backup
Monitoring:
1. Maternal serial
haemoglobin Indications for delivery:
2. Weekly CTG 1. Achieved 37 completed weeks
3. Serial ultrasound for 2. Significant vaginal bleeding
fetal growth and 3. Fetal compromise
placenta 4. Symptoms of labour
localization/mapping
Mode of delivery:
1. Aim for vaginal delivery in PP minor
2. For Elective C-section at term fin PP minor
3. Examination under anaesthesia at term
when ultrasound is doubtful
67
Abruptio Placenta
Definition Bleeding following premature separationof a normally situated placenta
Presentation Painful per vaginal bleeding (concealed, revelaed or mixed)
Clinical Findings 1. General condition may not proportionate with amount of blood loss in
concealed type
2. Tense, tender, woody hard abdomen
3. Fetus may be viable or not
MANAGEMENT centre
Hospital
Specialists
68
MANAGEMENT OF ABRUPTIO PLACENTA IN HEALTH CARE
Abruptio Placenta
Mild abruptio placenta or Abruptio placenta with

stable
Insert large bore

branula 1. Resuscitation
- insert large bore
Refer to hospital with branula
specialist. - fluid resuscitation
2. Inform covering
with O&G specialist
69
MANAGEMENT OF ABRUPTIO PLACENTA IN DISTRICT HOSPITAL
Abruptio Placenta
Mild abruptio placenta or Abruptio placenta with

stable
Insert large bore

branula 1. Resuscitation
- insert large bore
Refer to hospital with branula
specialist. - take FBC, GXM WB
- fluid AND BLOOD
resuscitation
2. Inform covering
with O&G specialist
70
MANAGEMENT OF ABRUPTIO PLACENTA IN HOSPITAL WITH SPECIALIST
Abruptio Placenta
Mild abruptio placenta Abruptio placenta with

haemodynamically not
stable
If < 34 weeks, consider

expectant management 1. Resuscitation
- insert large bore branula
If > 34 weeks, consider - take FBC, GXM WB
delivery - fluid AND BLOOD resuscitation
- correction of coagulopathy
2. Mode of delivery depend on

severity, fetal viability or stage
of labour (decision to be made
by specialist)
3. Anticipate post-partum
haemorrhage
4. Paediatric team to be notified

on delivery if fetus still viable
71
Local causes
Causes 1. Cervix: erosion, trauma, polyps, varicosities, tumor
2. Vagina: trauma, tumor, varicosities
Based on diagnosis (investigations include):
MANAGEMENT 1. Cervical smear
2. Polypectomy
3. Tumor biopsy
Indeterminate APH
Diagnosis By exclusion
1. Expectant management
MANAGEMENT 2. Monitoring mother and fetus as outpatient on regular basis by
FMS/O&G
3. Aim for delivery at 40 weeks POA
72
CERVICAL INCOMPETENCE
Introduction Cervical Incompetence is and imprecise clinical diagnosis applied to

women with history of mid trimester loss and spontaneous preterm
birth.
Definition Mid trimester loss and spontaneous preterm birth with risk factors such
as multiple pregnancy, uterine anomalies and history of cervical trauma
(D&C and Cone Biopsy).
Presentation 1. Vagina discharge, show or sensation of pressure at perineum.
2. History of painless dilatation of the cervix.
3. History of rupture of membranes before onset of contractions.
Clinical Findings VE - cervical dilatation
Investigations Blood : FBC
Imaging: Transvaginal Ultrasound at 14-24 weeks of gestation for
cervical length shortening, of less than 25 mm. Ultrasound
indicated for women with suspected past history of
mid trimester loss secondary to cervical incompetence.
Others: HVS C&S

Healthcare 1. To identify history with previous preterm birth
MANAGEMENT centre and/or second trimester loss.
2. To refer O&G Clinic for further assessment and
management.
District As above
Hospital
Hospital with 1. Cervical cerclage should be offered to women
Specialists with history of recurrent (3) spontaneous mid
trimester loss or preterm birth.
2. Cervical cerclage should be offered to women

with history of one or more spontaneous mid
trimester loss or preterm birth, with TVS
surveillance of cervical length is 25 mm or less,
and before 24 weeks of gestation.
3. Serial TVS surveillance for women with history

of spontaneous mid trimester loss or preterm
birth suspected secondary to cervical
incompetence. Cervical cerclage should be
offered when cervical shortening of 25 mm or
less.
73
4. Rescue cerclage
- In cases of dilatation of the cervix 4 cm
or less without membrane prolapse
beyond the external Os.
- Decision by senior obstetrition
depending on period of gestation.
- To counsel couple, even with rescue
cerclage severe preterm delivery with
neonatal mortality and morbidity.
- Rule out chorioamniotis before
procedure.
5. Transvagina cervical cerclage should be

removed at 36-37 weeks.
6. If delivery by elective LSCS, suture removal

could be done together.
7. In PPROM at 24-34 weeks without infection or

preterm labour, can delay removal of cerclage
for 48 hours until complete prophylactic
steroids.
Notes 1. Cervical cerclage is not recommended in women with incidental
findings of cervical shortening of 25 mm or less and without
history of spontaneous mid trimester loss or preterm birth.
2. Cervical cerclage is not recommended for funneling of the cervix in

the absence of cervical shortening of 25 mm or less.
3. Cervical cerclage is not recommended in women with multiple

pregnancy since evidence suggest increase in preterm delivery and
pregnancy loss.
4. Contraindication for cervical cerclage

- Advanced preterm labour
- Chorioamnionitis
- APH
- PPROM
- Fetal distress
- Fetal abnormality
- IUD
5. No evidence to support the use of preoperative

tocolysis.
6. Decision for antibiotic prophylaxis should be decided

by the Surgeon. No studies done.
74
MANAGEMENT OF CERVICAL INCOMPETENCE
Patient with history of mid trimester loss

and spontaneous preterm birth
Recurrent (3 times) Less than 3 times
Cervical cerclage TVS 14-24 weeks
Cervical length Cervical length

more than 25 mm less than 25 mm
Serial TVS Cervical cerclage

until 24/52 if less 24/52
75
BREECH PRESENTATION
Introduction The incidence of breech presentation decreases from about 20% at 28

weeks of gestation to 3–4% at term, as most babies turn spontaneously
to the cephalic presentation. This appears to be an active process
whereby a normally formed and active baby adopts the position of ‘best
fit’ in a normal intrauterine space.
Persistent breech presentation may be associated with abnormalities of

the baby, the amniotic fluid volume, the placental localisation or the
uterus.
It may be due to an otherwise insignificant factor such as cornual

placental position or it may apparently be due to chance. There is higher
perinatal mortality and morbidity with breech than cephalic
presentation, due principally to prematurity, congenital malformations
and birth asphyxia or trauma.
MANAGEMENT centre
Hospital
Specialists
76
MANAGEMENT OF BREECH PRESENTATION IN HEALTHCARE
CENTRE/DISTRICT HOSPITAL
Preterm Breech
Ultrasound
No obvious causes Presence of abnormalities
Refer O&G clinic

Reassess at 36-37 weeks
Still breech
Refer O&G clinic Term Breech

with/without abnormalities
77
MANAGEMENT OF BREECH PRESENTATION IN HOSPITAL WITH SPECIALIST
Term Breech
3 options
External Cephalic
Version Vaginal Birth
SHOULD BE DONE Factors regarded as

AFTER 37 WEEKS
unfavourable for vaginal
breech birth:
Criteria to be fulfilled: ● placenta praevia,
- a mature normally
compromised fetal
grown singleton fetus
condition
- adequate amniotic ● clinically inadequate
Elective C-section
fluid volume
pelvis
- an unscarred uterus ● footling or kneeling
- a normally situated
breech presentation
placenta ● large baby (> 3.8 kg) ●
- no maternal
growth-restricted baby (<
hypertension or APH
2 kg)
- no other ● hyperextended fetal neck
contraindication for
in labour
vaginal delivery ● lack of presence of a
clinician trained in vaginal
breech delivery
● previous C-section
Successful Failed
Induction of labour
or
Spontaneous labour
78
ABNORMAL LIE
Types of Lie Transverse

Oblique
Unstable
Causes Prematurity
Polyhydramnions
Placenta praevia
Multiple pregnancy
Fetal or uterine anomalies
Cephalopelvic disproportionate
Investigations
Imaging: Abdominal ultrasound

MANAGEMENT centre

Specialists
79
MANAGEMENT OF ABNORMAL LIE IN HEALTHCARE CENTRE
Abnormal Lie
Evaluate after 34 weeks
Refer to FMS or O&G specialist

- investigate causes
If placenta praevia major, to Other causes of abnormal lie,

admit for expectant management follow up as outpatient
Reassess at 36-37 weeks
Persistent abnormal lie
Admit at hospital with specialist

for delivery
80
MANAGEMENT OF ABNORMAL LIE IN HOSPITAL WITH SPECIALIST
Reassess at 38 weeks
Persistent abnormal lie Unstable lie
REASSESS
If lie remains If cephalic for 24-48

unstable 24-48 hours
hours
Options:
1. Discharge and follow up as outpatient
till spontaneous labour
or
2. For induction of labour
For elective C-section
81
SECTION D
Medical Disorders in Pregnancy
82
MEDICAL DISORDERS IN PREGNANCY
Heart disease in pregnancy

Introduction Confidential Enquiry on Maternal Deaths (CEMD) reports since 1997
have shown that maternal deaths due to heart diseases are the main non
obstetric cause of maternal mortality in Malaysia. Pregnancy has been
known to aggravate cardiac haemodynamics and could compromise
functional capacity. Furthermore the presentation of cardiac disease
mimics the signs and symptoms of pregnancy making detection of
cardiac lesions by doctors running antenatal clinics not easy. The
consequences for such an omission can be considerable and prove fatal.
Examples of heart Chronic Rheumatic Heart disease (CRHD)
disease in Congenital heart disease
pregnancy Ischemic heart disease
Cardiomyopathy
Presentation Shortness of breath, cough, orthopnea, PND, reduce effort tolerance,
palpitation, edema, chest discomfort.
Clinical findings Dyspnoea
Cyanosis
Ankle edema
Lungs with basal crepitation
Hepatomegaly +/- ascities
Cardiac murmur
Tachycardia
Elevated JVP
Differential Acute exacerbation of bronchial asthma
Diagnosis Pulmonary embolism
Hyperthyroidism
FBC
Renal profile
TFT
UFEME
ECG
Imaging
Chest X-ray with abdominal shield
ECHO
US for fetus
MANAGEMENT Pre-pregnancy
Ideally all cardiac patient should have their cardiac status assessed prior
to pregnancy. Women with Eisenmenger Syndrome or primary
pulmonary hypertension should be advised against pregnancy.
83
Antenatal
JOINT MANAGEMENT
1. Suspected cases from history and examination refer to Cardiologist
2. Refer Obstetrician for antenatal follow-up.
3. Grade the severity (functional and structural):
a. New York Heart Association Class I - IV.

Class:
a. No symptoms or symptoms only on severe
exertion.
b. Symptoms on moderate exertion.
c. Symptoms on carrying out normal activities.
d. Symptoms at rest, presence of heart failure
b. Echocardiogram
4. Look for aggravating factors and treat accordingly in each visit:

- Screen for anaemia : serial FBC
- Screen for infections: URTI, UTI, dental caries.
- Screen for Hypertension and thyrotoxicosis.
5. Check for any deterioration in cardiac function (clinically) on each
visit.
6. First trimester scan for dating.
7. Anomaly scan at 18-20 weeks POA (mother with congenital heart
disease).
8. Serial scan for fetal growth.
Plan for delivery
i. Awaits spontaneous labour

- aim for vaginal delivery
- induction of labor if obstetrically indicated
ii. Caesarean section.
- Obstetric indication
- Severe heart disease for which planned delivery is required
(optimum backup to anticipate complication : ICU/CCU bed,
anesthetist, cardiologist)
- To get added risk consent under GA.
84
Intrapartum
A. First Stage
JOINT MANAGEMENT with physician/cardiologist and anaesthetist
1. Patient to be propped up.

2. Administer O2 by nasal prong 3L/min.
3. Provide adequate pain relief preferably epidural analgesia. Other
choice of analgesia are Pethidine and Phenergan or Nubain. (Refer
obstetric analgesia team if available)
4. Give Prophylactic antibiotics intrapartum
5. Strict intake/output chart.
6. Judicious use of fluid and oxytocin infusion.
7. ½ hrly BP, pulse rate
8. Auscultate lungs for evidence of pulmonary oedema every review.
9. Pulse oxymetry and cardiac monitor if available
10. Continuous CTG if possible
B. Second Stage
Shorten the second stage with forceps or vacuum may be necessary.
C. Third Stage
ONLY give syntocinon 10 units intramuscular at delivery of anterior
shoulder (do not use Ergometrine or Syntometrine).
Patient should be observed in CMR for first 24 hours after delivery
Puerperium
- Complete antibiotics
- Normal activities as tolerated.
- Encourage breast feeding.
- Assess for infection and anaemia
- Advise on appropriate contraception.
- Medical team review before discharge
- Hospital stay depends on clinical status. Generally observe patient
for 5-7 days. Patient to be discharged only by MO or specialist.
FOLLOW-UP
- Notify Klinik Kesihatan upon discharge for postnatal follow-up
- MO / FMS review at Klinik Kesihatan
- Ensure follow-up with Cardiac clinic.
85
Notes STANDARD REGIME
Ampicillin IV or IM Ampicilin 2.0gm +
Gentamicin IV or IM Gentamycin 1.5 mg/kg (not
to exceed 80 mg)
30 minutes before procedure,
followed by :
Amoxicillin 1.5 gm orally 6 hours
after initial dose or repeat parenteral
regime 8 hours after initial dose.
PENICILLIN ALLERGIC
PATIENTS
Vancomycin IV Vancomycin 1.0 gm over 1 hour +
Gentamycin IV or IM Gentamycin 1.5 mg/kg (not
to exceed 80 mg) 1 hour before
procedure and repeat 8 hours later.
86
Diabetes in pregnancy
Introduction Diabetes is a disorder of carbohydrate metabolism that requires immediate
changes in lifestyle. In its chronic forms, diabetes is associated with long-term
vascular complications, including retinopathy, nephropathy, neuropathy and
vascular disease. The incidence of diabetes in pregnancy was 8.83% (NOR
2012).
Approximately 87.5% of pregnancies complicated by diabetes are estimated to

be due to gestational diabetes, with 7.5% being due to type 1 diabetes and the
remaining 5% being due to type 2 diabetes.
Diabetes in pregnancy is associated with risks to the woman and to the

developing fetus. Miscarriage, pre-eclampsia and preterm labour are more
common in women with pre-existing diabetes. In addition, diabetic retinopathy
can worsen rapidly during pregnancy. Stillbirth, congenital malformations,
macrosomia, birth injury, perinatal mortality and postnatal adaptation
problems (such as hypoglycemia) are more common in babies born to women
with pre-existing diabetes.
Definition GDM - Abnormal OGTT after 20weeks gestation and resolved after
delivery
Pre-existing diabetes mellitus
Presentation Risk factors/indications for MGTT
a. Age > 35 years old, (consensus)
b. History of diabetes in a first degree relative
c. Glycosuria on 2 occasions or in a single fasting urine sample
d. Diabetes in precious pregnancy
e. BMI > 27 kg/m2 at booking or first visit
f. Previous baby > 4kg
g. Previous unexplained intrauterine death or early neonatal death
h. Congenital abnormality in a previous pregnancy
i. Polyhydramnios in present pregnancy
j. Recurrent UTI
k. Recurrent vaginal candidiasis
l. Recurrent miscarriages ( 3 consecutive in 1st trimester or 2
consecutive in 2nd trimester)
Diagnostic WHO criteria for diagnosis of diabetes and impaired glucose tolerance using a
criteria 75g oral glucose (WHO 1980)
87
Diagnosis FPG (mmol/L) 2H value (mmol/L)
Gestational DM ≥5.6 ≥7.8 (consensus)
75g 2hour OGTT as soon as possible after booking and repeat OGTT 24-28
weeks if the result of the first OGTT are normal. (NICE 2015)
Measure HbA1c levels in all women with gestational diabetes at the time of
diagnosis to identify those who may have pre-existing diabetes. HbA1C ≥ 6.3
Investigations Blood: HbA1c, Renal profile
Urine: UFEME
Imaging: Serial US scan,
Others: Fundus photography every trimester
MANAGEMENT Antenatal
Refer to Family Medicine Specialist or O&G Specialist
Refer dietician
Stabilise blood sugar
- serial BSP
- aim for 4 – 6 mmol/L
- BSP frequency
i. 2 weekly if on insulin
ii. 4 weekly on diet control
iii. Earlier if suboptimal control
- Initiate insulin therapy if suboptimal control
Serial scan to monitor fetal growth and fetal well being.
For patient with established DM :
- OGTT not required
- Convert OHA to insulin therapy
- Refer ophthalmologist if retinopathy for eye
assessment
- Combine clinic referral if required
- Detail scan at 18-20 weeks (ideally by Maternal-Fetal
Consultant)
- Screen for renal function and HbA1c
d. Consider low dose aspirin therapy 75mg OD in pre-existing diabetes
The choice of insulin therapy

a. Short acting insulin and basal intermediate insulin are preferred
based on the BSP.
Admission
a. Initiation of insulin to be started at health clinic except for certain
condition or circumstances where admission is indicated
b. Optimization of insulin therapy for poorly controlled diabetes.
c. Presence of serious complication which requiring multidisciplinary
care.
88
Delivery
a. Timing :
- well controlled diabetics with diet control alone - deliver at 40
weeks
- well control diabetics with diet controlled and insulin – deliver
at 38 weeks
- clinical evidence of suboptimal control (eg polyhydramnios,
macrosomia) – deliver at 38 weeks
- difficult glucose control with serious complication – consider
earlier delivery
b. Mode of delivery :
- Caesarean section for obstetric indication
Management in labour room (patient on insulin therapy)

a. GSH
b. RBS and BUSE (review result within 2 hours)
c. 4 hourly urine acetone
d. IVD D5% at 100mls/Hr .
e. Hourly capillary blood sugar.
f. Start insulin therapy according to sliding scale.
g. Other labour management applied.
**Patient on diet control are managed as normal delivery

Postpartum Management
a. Established diabetics - Recommence oral anti-diabetic agent (OAD) or

previous insulin therapy when the patient takes orally, according to BSP.
b. Gestational diabetics :
- resume normal diet.
- Stop insulin therapy
- appointment for MGTT after 6 weeks
Management of Infant
a. Capillary blood sugar

b. Refer paediatric team
c. Initiate early breastfeeding.
89
ANC/PNC management at Health clinic
Pregnant women at 1st booking
Risk factors / indications for OGTT ?
Screen patient for GDM at booking

and repeat at 24-28 week if first
OGTT normal
Abnormal OGTT
Refer to Family Medicine Specialist or

O&G Specialist
Refer dietician/nutritionist (Pegawai If any problems
Refer to family
Sains Pemakanan)
medicine
Stabilise blood sugar – serial BSP
specialist for
Serial scan to monitor fetal growth
reassessment and
and fetal well being.
Delivery management
For patient with established DM :
- OGTT not required
- Convert OAD to insulin therapy If unresolved
- Refer ophthalmologist for eye
assessment soon after booking if
diabetes retinopathy is detected Refer to Hospital
- Refer to antenatal clinic hospital at 34 with specialist
to 36 weeks
- Detail scan at 18-20 weeks (ideally by
Maternal-Fetal Consultant)
f. GDM on diet control with optimum BSP

need not refer to antenatal hospital
Repeat OGTT 6 weeks post-partum

90
ANC/PNC management at District Hospital
Risk factors / indications for

OGTT?
Screen patient for GDM at

booking and repeat at 24-28 week
if first OGTT normal
Abnormal OGTT
Refer to Family Medicine Specialist or O&G

Specialist If any problems
Refer dietician
Stabilise blood sugar – serial BSP Refer to Visiting
Serial scan to monitor fetal growth and fetal well O&G specialist
being. clinic/ Hospital
For patient with established DM : with specialist
- OGTT not required
- Convert OHA to insulin therapy
- Refer ophthalmologist for eye
assessment soon after booking
- Detail scan at 18-20 weeks (ideally
by Maternal-Fetal Consultant)
Delivery
91
ANC/PNC management at Hospital with Specialist
Risk factors / indications for

OGTT?
Screen patient for GDM at

booking and repeat at 24-28 week
if first OGTT normal
Abnormal OGTT
If any problems
Refer to Family Medicine Specialist or O&G Specialist

Reassessment and
Refer dietician
decision
Stabilise blood sugar – serial BSP
Serial scan to monitor fetal growth and fetal well being. 1. Conservative
For patient with established DM : and continue
- OGTT not required observation
- Convert OAD to insulin therapy
- Refer ophthalmologist for eye assessment 2 .Delivery –
soon after booking IOL/LSCS
- Detail scan at 18-20 weeks (ideally by
Maternal-Fetal Consultant)
Delivery
92
Intrapartum management at District Hospital
GDM on insulin/ Pre-existing DM

on insulin admitted in labor
Transfer out to Hospital with

Specialist for delivery
93
Intrapartum management at Hospital with Specialist
GDM/ Pre-existing DM on insulin

admitted in labor
a. GSH
b. RBS and BUSE (review result
within 2 hours)
c. 4 hourly urine acetone
d. IVD D5% at 100mls/Hr .
e. Hourly capillary blood sugar.
f. Start insulin therapy according to
sliding scale regime.
Delivery
Baby refer to paed team

a. Established diabetics - Recommence oral anti-
diabetic agent or previous insulin therapy when the
patient takes orally.
b. Gestational diabetics :
- resume normal diet.
- Stop insulin therapy
- Appointment for repeat OGTT after 6 weeks
94
MANAGEMENT OF DM DURING FASTING MONTH
Hari Biasa Hari Berpuasa

Ubat Insulin
Masa Dos Masa Dos
Kekalkan dos
Pagi ( sarapan) Dos Semasa Buka Puasa
Insulin Mixtard pagi
30 Kurangkan 20-
Petang ( Makan
Novomix 30 Dos Semasa Sahur 50% dos
Malam)
petang
Insulin Sahur
Pagi
Glargine Buka Puasa / Kekalkan Dos
atau Dos Semasa
Insulin Sebelum pukul Semasa
Malam
Levemir 10 mlm
Semasa/
Kekalkan Dos
Insulatard Sebelum Tidur Dos Semasa Selepas
Semasa
Terawih
Kurangkan
Pagi Dos Semasa Sahur 25% Dos
Insulin Semasa
Actrapid / Abaikan (
Tengahari Dos Semasa Tengahari
Novorapid tinggalkan dos)
Kekalkan Dos
Petang Dos Semasa Buka Puasa
Semasa
Kekalkan Dos
Pagi Dos Semasa Buka Puasa
Glucovance Semasa
(Selepas Kurangkan
Makan) Petang Dos Semasa Sahur 50% Dos
Petang
Kekalkan Dos
Gliclazide/ Pagi Dos Semasa Buka Puasa
Semasa
Glibenclamide
Kurangkan
(Sebelum
Petang Dos Semasa Sahur 50% Dos
Makan)
Petang
Metformin , Kekalkan Dos
Pagi Dos Semasa Sahur
Acarbose, Semasa
Rosiglitazone , Abaikan (
Tengahari Dos Semasa Tengahari
Repaglinide tinggalkan dos)
Gliclazide MR
Kekalkan Dos
( ambil selepas Petang Dos Semasa Buka Puasa
Semasa
buka puasa)
95
Panduan Pengubahsuaian Dos Insulin Semasa bulan Puasa
Masa Pemonitoran Paras Gula Pengubahsuaian dos

Insulin
Sebelum sahur <4.4 mmol/L @ symptom Kurangkan 2 unit dos buka
hypoglisemia puasa
>7 mmol/L Tambah 2 unit dos buka
puasa
2 jam sebelum buka puasa <4.4 mmol/L @ symptom Kurangkan 2 unit dos sahur
hypoglisemia
>7 mmol/L Tambah 2 unit dos sahur
Masa Pemonitoran Dan Sasaran Gula
Masa Julat Normal

Sebelum SAHUR 4.4-6.1
2 Jam Selepas SAHUR 4.4-8.0
2 jam atau sebaik sebelum Buka Puasa 4.4-6.1
2 jam selepas Buka Puasa 4.4-8.0
96
Hypertension in Pregnancy
Introduction Hypertension is the most common medical problem encountered during
pregnancy, complicating 2-3% of pregnancies worldwide. The National
Obstetrics Registry (NOR) 2012 reported the prevalence of HDP in
Malaysia was 3.83%. Hypertensive disorders in pregnancy remain a
major health problem. Pre eclampsia either alone or superimposed in
pre-existing (chronic) hypertension, present the major risk.
Definition Hypertension in pregnancy is defined as a systolic blood
pressure (BP) =140 mmHg and/or a diastolic BP = 90 mmHg.
Gestational hypertension is defined as hypertension detected
for the first time after 20 weeks pregnancy.
Pre-eclampsia / eclampsia clinically diagnosed in the presence
of de novo hypertension after gestational week 20 with
significant proteinuria.
.
Presentation Mostly asymptomatic
Presents with headache / nausea / giddiness / blurring of
vision / epigastric pain
Clinical Findings High BP with or without signs and symptoms of impending
eclampsia
Excessive weight gain
Differential Chronic hypertension with or without pre-eclampsia
Diagnosis Hyperthyroidism
Investigations PE Profile: FBC, RP, FBC, LFT, Uric Acid (frequency according to severity)
TSH / TFT if indicated.
Urine: UFEME / 24 hours urine protein
Imaging: Ultrasound for fetal wellbeing (serial)
Others: SFH (look for IUGR), BP monitoring, pulse rate, fetal growth
chart, reflexes. ECG and CXR (if indicated)
Healthcare Mild PIH:
centre DBP<100 mmHg without any complication
may not require any antihypertensive
treatment
Diastolic BP≥100 mmHg require anti-
hypertensive treatment
Referral to hospital if diastolic BP poorly
control>100 mmHg with symptoms of
impending eclampsia / severe proteinuria >
2+
97
Fetal surveillance:
- Fundal height
- Fetal heart
- FKC
- Serial USG (fetal growth & AFI)
Maternal surveillance:
- BP, urine protein, weight gain
- Signs and symptoms of impending
eclampsia
Severe PIH/Pre eclampsia (refer to hospital Mx at
KK level)
To stabilize patient and refer to hospital
Anti HPT agent to be given
Give IM MgSo4 5 gram each buttock
Treatment
(refer appendix)
District If BP > 150/100 and albuminuria >1+, refer to
Hospital Hospital with specialist.
Severe PIH/Pre eclampsia (hypertensive crisis SBP

> 170 and diastolic > 110)
Anti HPT agent for BP stabilization
Anticonvulsant therapy – MgSO4 IM 5 gram
for each buttock or IV slow bolus 4 gram
over 10-15 minutes
IV access
Refer hospital with specialist after
stabilization
If DBP > 110mmHg, optimize oral anti-
hypertensive and simultaneously start
parenteral anti-hypertensive
(Hydralazine/Labetalol).
Once BP is controlled to 140/90 – 140/100
immediately transfer to hospital.
Avoid parenteral anti-hypertensive infusion
during transportation.
Hospital with On admission, check the following
Specialists - History
- Physical examination: BP, CVS, Fundal
height for IUGR, reflexes
- Urine for albumin, Hb, Platelet count,
BUSE, Sr. Creatinine, uric acid, LFT, CTG
- Ultrasound for fetal well-being and
growth
- Monitor BP, pulse rate, I/O chart, daily
urine protein
98
Anti-hypertensive medication
- Treat if BP > 150/100 mmHg, aiming for
approximately systole 130 – 140 and
diastole 90 – 100 mmHg
- Treatment (Refer appendix)
- Methyldopa is preferred in patient who
requires treatment in early pregnancy.
- If second line needed use Labetalol
- Third line use Nifedipine
- For acute control of severe hypertension
use IV Hydralazine / IV Labetalol
(Please refer to appendix for dosage)
Chronic Hypertension
- Treat if BP > 150/100 mmHg aiming for
approximately systole 130 – 140 and
diastole 80 -90 mmHg.
Note:
- Long term use of beta blocker is
associated with IUGR.
- Avoid ACE inhibitors. Is was found to be
associated with high incidence of fetal-
renal impairment
PIH (BP well controlled)
- Can be managed as outpatient
- Considered delivery at 38-40 weeks
Mild Pre Eclampsia

- Can be managed as outpatient (decision
to be considered after D/W specialist)
- Consider delivery at 38 weeks
- Consider earlier delivery if BP not well
controlled, deteriorating biochemical
profile and underlying fetal
compromise.
Severe Pre Eclampsia

- Admit to HDU / close monitoring room
- Monitoring and Investigation:-
- Ask for symptoms of impending PE daily
- BP / pulse 4 hourly
- Check daily urine protein
- Auscultate lungs
- Daily fetal heart
- Daily fetal movement chart
- CTG monitoring
- Serial Renal profile, FBC, coagulation
profile, liver enzymes
99
- Consider IV MgSO4 prophylaxis therapy
(if indicated)
- Consider earlier delivery if BP not well
controlled, deteriorating biochemical
profile and underlying fetal
compromise.
Mode of delivery depending on:

Severity of disease (Maternal/Fetal state)
Gestational age
Cervical score
Presence of other obstetric risk
Intrapartum management and delivery

Monitoring is done as high risk
Strict I/O chart
Ensure adequate analgesia(Epidural
analgesia should be preferred)
Monitor fetal heart rate with CTG
First stage should not be prolonged
Shortened 2nd stage may be necessary
Avoid ergometrine/Syntometrine
Use syntocinon intravenously/IM as anterior
shoulder is delivered
Use hydralazine if BP > 110mg Hg diastolic
pressure
Paedatric referral for the baby if required
Consider the use of thromboembolism
prophylaxis if indicated.
Always watch for possible complications

Acute pulmonary oedema
RED ALERT
Admit to close monitoring room
O2 supplement
IV Frusemide
I/O chart
Restrict fluid
Regular arterial blood gases monitoring
Close monitoring of : BP,PR, O2 saturation
Refer medical team
Deterioration renal profile
100
Refer to medical team / Nephrology team for further
advice
ECLAMPSIA
RESUSCITATION AND GENERAL MANAGEMENT
1. Trigger RED ALERT

2. Maintain airway
3. Left lateral position
4. Head in extended and lower position.
5. Give O2 by mask
6. Abort fit, give loading dose of IV / IM MgSO4
stat (slow bolus for IV) or IV Diazepam
(Valium) 10mg bolus over 1-2 minutes.
7. Setup – 2 IV lines Branula, GXM 2 pint blood,
platelet count, coagulation profile, renal profile.
8. Level of consciousness and neurological status
need to be fully assessed after the fit.
9. Vital signs are closely monitored –
BP,PR,SPO2,RR,I/O chart
DELIVERY
All cases of eclampsia should have the baby delivered

immediately regardless of gestation once patient is
stabilised.
Mode of delivery by LSCS unless patient is in advanced

stage of labour.
Postpartum
1. Monitor closely in close monitoring room /

HDU at least 48 hours post event.
2. Complete IV MgSO4 for 24 Hours post-
delivery or from the last fit.
3. Optimize BP with oral anti hypertension
4. Keep 3-5 days
5. Upon discharged for high risk discharge
(ensure follow up visit and inform nearest
health clinic).
Notes Excessive weight gain in pregnancy is associated with gestational

hypertension, pre-eclampsia and gestational diabetes mellitus. It is
recommended to do biweekly BP monitoring if detected during antenatal
check-up and if BP ≥ 140/90 to check for proteinuria.
101
Appendix treatment of Hypertensive in Pregnancy
Table 1. Anti-hypertensive Drugs Commonly Used in Pregnancy
Drugs Remarks
Methyldopa Oral 250 mg tds, doubling every 48 hours (up to 1 gm tds) until BP well
controlled. Oldest anti-hypertensive agent used in pregnancy, with best
safety profile.
Labetalol Oral 100 mg tds, doubling every 48 hours (up to 400mg tds) until BP well
controlled.
Nifedipine Oral 10 mg tds, up to 20 mg tds, usually as second line antihypertensive,

when BP poorly controlled despite maximum doses of methyldopa +
labetolol.
Table 2. Anti-Hypertensive Drugs for Severe Preeclampsia with Acute Hypertensive Crisis
Drugs Remarks
Hydralazine 5 mg IV bolus or IM, then 5–10 mg every 20–40 minutes up to 30 mg, or IV

infusion of 0.5-10 mg per hour.
Labetalol 20 mg IV bolus, then 40 mg 10–15 minutes later, then 80 mg every 10–15

minutes, up to 220 mg; or continuous IV infusion of 1–2 mg/minute until BP
stabilizes, then stop or reduce to 0.5 mg/minute. May cause fetal bradycardia.
Nifedipine Oral 5–10 mg stat (repeat in 30 minutes if necessary), especially prior to

transferring a patient from a peripheral clinic to hospital. After the initial
emergency dose, 10–20 mg can be given every 3–6 hours until BP stabilizes.
* Hydralazine is no longer recommended as first line treatment for acute hypertensive crisis in
pregnancy.
102
Table 3. Anti-convulsant for Eclampsia (and Severe Preeclampsia)
Drugs Remarks
Magnesium IV: 4g slow bolus over 10 minutes, followed by 1-2 g/hour maintenance
Sulphate infusion given via a controlled infusion pump.
IM: 4g IV slow bolus over 10 minutes, followed immediately by 10g IM, then
5 g IM every 4 hours in alternate buttock.
Clinical monitoring is of utmost importance, looking for signs of toxicity

(especially loss of deep tendon reflexes, respiratory depression with rate
<16/minute) and renal impairment (hourly urine output <30 ml/hour).
Diazepam 10 mg IV bolus, followed by 40 mg in 5% dextrose slow infusion so that

patient remains sedated.
Table 4. Use of Aspirin in pregnancy for prophylaxis of pre-eclampsia
Aspirin Indication
75mg–100mg daily High risk patients:
(from 12 weeks gestation hypertensive disease during a previous pregnancy

until delivery) chronic kidney disease
autoimmune disease such as Systemic Lupus
Erythematosus (SLE) or anti-phospholipid syndrome
(APS)
type 1 or type 2 diabetes mellitus
chronic hypertension
75mg–100mg daily Two or more of below moderate risk factors:
(for optimal effectiveness primigravida

should be started before 16 age >40 years
weeks of gestation until pregnancy interval >10 years
delivery) body mass index of >35 kg/m at first visit
family history of preeclampsia
multiple pregnancy
103
MEDICAL DISORDERS
Renal Disease in Pregnancy

Introduction Pregnancy results in important alterations in acid-base, electrolyte, and
renal function due to pregnancy-associated physiologic changes in renal
and systemic hemodynamics. During pregnancy, the glomerular filtration
rate normally increases to up to 150% of the normal rate, peaking at
approximately the 13th week of pregnancy. Hence the levels of urea and
creatinine decrease as a result of the increase renal excretion.
Preexisting renal disease in pregnancy exposes to high risk of pre-term

delivery, fetal growth retardation, hypertension, proteinuria, pre-
eclampsia and perinatal deaths.
US stated the prevalence of 0.03–0.12% of all pregnancy and live birth

rate in women with chronic renal disease ranges between 64% and 98%
depending on the severity of renal insufficiency and presence of
hypertension. All pregnant women with CKD should be co-managed by a
multidisciplinary team comprising nephrologists/physicians and
obstetricians.
Definition Chronic kidney disease (CKD) is an irreversible loss of renal function
pre-existing prior to pregnancy
Presentation Mostly asymptomatic. Severe renal disease with complications may
present with ankle swelling, breathlessness, lethargy, anaemia and fetal
growth retardation.
Clinical Findings Sallow, oedema, facial puffiness
Differential Connective Tissue Disease / SLE / Nephrotic Syndrome
Diagnosis
Investigations Blood: Renal Profile, FBC,
Urine: UFEME, 24 hours urine protein
Imaging: USG KUB, USG Fetal well being
Others:
MANAGEMENT Healthcare centre Refer FMS for management
Monitor renal function, BP, proteinuria, fetal growth
monitoring
Screen for diabetes
Refer nephrologist
Use of medication permissible by guideline
UFEME
Renal function monitoring
Anti-hypertensive drugs
Dietary modification – refer dietician
104
Anemia in pregnancy
Introduction Anemia is one of the most frequent complications related to pregnancy.
Normal physiologic changes in pregnancy affect the hemoglobin (Hb),
and there is a relative or absolute reduction in Hb concentration. The
most common true anemias during pregnancy are iron deficiency anemia
(approximately 75%) and folate deficiency megaloblastic anemia, which
are more common in women who have inadequate diets and who are not
receiving prenatal iron and folate supplements.
Severe anemia may have adverse effects on the mother and the fetus.
Anemia with hemoglobin levels less than 6 gr/dl is associated with poor
pregnancy outcome. Prematurity, spontaneous abortions, low birth
weight, and fetal deaths are complications of severe maternal anemia.
Nevertheless, a mild to moderate iron deficiency does not appear to
cause a significant effect on fetal hemoglobin concentration. In an iron-
deficient state, iron supplementation must be given and follow-up is
indicated to diagnose iron-unresponsive anemias.
Definition Anemia in pregnancy is defined as (RCOG 2015) :

Hb < 11.0g/dl. In 1st trimester
Hb < 10.5g/dL in 2nd/ 3rd trimester
Hb < 10.0g/dL in postpartum
For management purpose the severity of

anaemia is classified as
mild >9-10gm/dl
moderate 8-9gm/dl
severe <8gm/dl
Causes a. Iron deficiency (Nutritional) anemia – the commonest

b. Hemorrhage – APH, hemorrhoids
c. Haemoglobinopathy – thalassemia
d. Chronic UTI, worm infestation
105
Presentation Shortness of breath, lethargy, dizziness, palpitation
Clinical findings Pallor, tachycardia, hepatosplenomegaly, signs of heart failure
Differential Heart failure, hyperthyroidism, renal failure

Diagnosis
FBC
FBP
Serum ferritin when iron deficiency is suspected
Hb electrophoresis when haemoglobinopathy is suspected
Urine: UFEME
Stools: Stools ova and cyst
MANAGEMENT Management - Depends on:
i. Type of anaemia
ii. Severity of anaemia
iii. Period of gestation.
Please refer to the following section for management regarding type,

severity and period of gestation
Prophylaxis
1. Iron supplement – given to all mothers as early as possible if
tolerable.
Consisting of :
T. Ferrous fumarate 200mg daily
T. Folic acid 5mg daily
T. Ascorbic acid
T. Vit B Complex
2. Refer for dietary advice (Nutritionist or dietician)

3. FBC monitoring monthly
Notes Patient with Thalassemia should not be given parenteral iron. Oral
hematinics can be considered in patient with thalassaemia minor. In case
of thallassaemia major, patient should be seen in combine care with
physician/ hematologist
All patient with Thalassemia - give prophylactic folic acid 5mg daily
106
Management of iron deficiency anemia in pregnancy
Yes No
FBC
FBP Iron supplementation
Hb < 11g/dl
Iron study to be given
Hb < 11g/dl
RBC
HCT
MCV < 80fl
No
MCH < 27pg Investigate for other causes of
MCHC < 32 gm/dl anemia including Thalassemia
RDW raised > 14.5%
FBP – hypochromic microcytic
Serum ferritin < 12µg/L
Soluble transferrin receptor
Transferrin saturation < 15%
Yes
Iron Deficiency
Anemia
Treat according to
gestation
107
Management at Health clinic/District Hospital/Hospital with specialist
Treatment
Antenatal
Mild [9 - 10gm%]: Oral ferrous fumarate 200mg tds,

Folic acid 5mg daily
Dietary advice
Treat underlying cause if present.
Moderate [8 - 9 gm%] Oral hematinics (eg: T. Iberet, T. Maltofer, T. Zincofer)
Consider IM Imferon (2 mls daily for 5 -7 days) or IV Iron
Sucrose(Venofer), if patient is unable to tolerate side effects of oral iron
or poor compliance
Severe [< 8gm%] Transfuse packed cells depending on Hb level. Consider IV Frusemide
20mg in between transfusion. Upon discharge continue oral iron
supplement
Intrapartum
Mild [9-10gm/dl] GSH
Moderate [8 - 9gm/dl] GXM 2 units packed cells, consider blood transfusion in patients at
higher risk of PPH
Severe [< 8 gm/dl] Transfuse blood with IV Frusemide 20 mg in between transfusion
Puerperium
Mild Oral iron, folate
Moderate Oral iron / IM imferon /IV Iron Sucrose, if poor compliance
Severe Blood transfusion followed by oral hematinics
108
IV Venofer (Iron Sucrose)
1 ampoule = 100mg/5ml
Dilution
1 ampoule Maximum 100ml NS

Administration
100mg Minimum 15mins
200mg Minimum 30mins
300mg Minimum 1.5hours
400mg Minimum 2.5hours
500mg Minimum 3hours
Please protect from light
109
Epilepsy in pregnancy
Introduction Epilepsy is the most commonly encountered serious neurological
problem in obstetrical practice. The incidence of epilepsy is 0.3–0.5% in
different populations around the world. Most women with epilepsy will
need to continue taking antiepileptic drugs in pregnancy to prevent the
harmful effects of seizures. The treatment goal in pregnancy is to
maintain a balance between an effective but low dose of a single
antiepileptic drug and the harmful effects of seizures
Definition Epilepsy is a disease characterized by an enduring predisposition to
generate epileptic seizures.
Diagnosis Epilepsy is a clinical diagnosis supported by EEG
Antenatal Joint management by an Obstetrician and a
MANAGEMENT Physician/neurologist/FMS between combined
and health clinic.
Continue anti-convulsant drug (carbamazepine,
phenytoin, sodium valproate co-administered
with folic acid)
Clear documentation of seizure history
Women should be advised about the importance
of proper sleep and medication compliance,
particularly in the last trimester, when anti-
epileptic drugs levels tend to be lowest
Detailed ultrasound assessment of the fetus at 18
– 20 weeks gestation
Monitoring Monitor plasma anticonvulsant levels, if there is
deterioration in seizure control, adjust dose
accordingly
Intrapartum Obstetric management of epilepsy patient is

generally similar to that in a normal patient.
Continue oral anticonvulsants.
Ensure intravenous access.
There should be readiness to deal with any
seizure activity; intravenous benzodiazepine (eg.
lorazepam or diazepam) is recommended for
seizure termination
110
Observe baby closely for signs of respiratory
depression. Examine baby for signs of
anticonvulsant and epilepsy-associated
dysmorphology
Post partum Continue antiepileptic drugs. As antiepileptic drugs

are excreted in breast milk only in low concentrations
encourage breastfeeding
111
Thyroid disease in pregnancy

Introduction Thyroid dysfunction frequently occurs in women of childbearing age.
Abnormal thyroid function during pregnancy causes premature birth,
miscarriage and toxemia of pregnancy. Furthermore, it also influences
the thyroid function of newborn infants.
Definition Thyrotoxicosis/hyperthyroidism-. (suppressed serum TSH and elevated
serum free T4 and triiodothyronine (T3) concentrations)
Hypothyroidism-(elevated serum thyroid stimulating hormone (TSH)

concentration and reduced free Thyroxine (T4) concentration)
Subclinical hypothyroidism- elevated serum TSH concentration and

normal serum free T4 concentration
Presentation Thyrotoxicosis/hyperthyroidism- heat intolerance, palpitation, tremors
and presence of goitre
Hypothyroidism- may be suggested by cold sensitivity, fatigue, or dry

skin or it may go unnoticed. Because many women remain
asymptomatic, only thyroid function confirms the diagnosis
Differential Physiological changes of pregnancy may mimic thyroid symptoms,
Diagnosis hence biochemical diagnosis is compulsory, gestational hyperthytoidism,
graves disease
Investigations Confirm biochemically by thyroid function tests
Serum TSH, Free T4. Serum TSH and FT4 (Free T4) is a more reliable
indicator of thyroid function in pregnancy.
Antenatal Joint management by an Obstetrician and a

Management Physician/endocrinologist at the combined clinic
PTU is preferred for the treatment of hyperthyroidism
in the first trimester. Patients on carbimazole should
be switched to PTU if pregnancy is confirmed in the
first trimester. Following the first trimester,
consideration should be given to switching to
carbimazole.
Propranolol – temporary usage to control sympathetic
symptoms
Aim for upper limit of normal value of free T4 ,
112
Hypothyroidism must be strictly be avoided
For hypothyroidism and subclinical hypothyroid
Levothyroxine is the treatment of choice.
Monitoring Serial maternal FT4 / TSH (frequency depending on
symptoms or control status- 2 to 6 weeks)
Serial fetal growth – IUGR is a known complication
Treatment targets for hypothyroidism on treatment

(TSH) :
1st trimester – 0.1-2.5 mIu
2nd trimester – 0.2-3.0 mIu
3rd trimester – 0.3-3.0 mIu
Treatment target for hyperthyroidism on treatment is

free T4 level 2/3rd of the normal range (9.5-23
pmol/L).
Intrapartum Obstetric management of thyrotoxicosis patient is
generally similar to that in a normal patient.
Thyroid crisis should be watched for, especially in
those who have not been satisfactorily controlled.
(Clinical features are vomiting, diarrhoea,
hyperpyrexia, tachycardia, hypotension, delirium and
coma.)
Refer newborn to paediatric team for assessment.
Fetal cord blood is to be taken by staff / doctor for full
thyroid function test.
Post partum Anti-thyroid therapy is continued in doses similar to
those taken prior to delivery.
Breast feeding is not contraindicated unless the dose
of anti-thyroid used is high.
Upon discharge, ensure follow-up with Medical Out
Patient Clinic (MOPD)/Health clinic.
Advise mother on the need for long term F/U for baby.
Notes Gestational hyperthyroidism is defined as ‘‘transient hyperthyroidism,
limited to the first half of pregnancy characterized by elevated FT4 and
suppressed or undetectable serum TSH. Antithyroid drugs (ATDs) are
not indicated, since the serum T4 returns to normal by 14–18 weeks
gestation. . In situations in which it is difficult to arrive at a definite
diagnosis, a short course of ATDs is reasonable.
113
Bronchial asthma in pregnancy

Introduction Asthma is a common condition that affects around 10% of pregnant
women, making it the most common chronic condition in pregnancy.
The severity of asthma during pregnancy remains unchanged, worsens

or improves in equal proportions. For women with severe asthma,
control is more likely to deteriorate (around 60% of cases) compared to
women with mild asthma (around 10% of cases). However, the authors
conclude that all pregnant women with asthma need to be closely
reviewed throughout pregnancy, irrespective of disease severity.
National guidelines recommend the management and treatment for

asthma in pregnant women should be generally the same as for non-
pregnant women and men, with the intensity of antenatal maternal and
fetal surveillance to be based on the severity of their condition.
Good asthma management during pregnancy is vital during pregnancy as

poor asthma control can have adverse effects on maternal and fetal
outcomes,(TOG).
Definition A chronic inflammatory disease of the airways with hypersensitivity
leading to bronchospasm when expose to triggering factors
Presentation cough, shortness of breath, wheezing and chest tightness
Clinical findings Tachypnoiec
Rhonchi/Wheezing
Reduced PEFR
Unable to talk in full sentence
Cyanosis
Differential Cardiac failure, peri-partum cardiomyopathy
Diagnosis Fluid overload
Pulmonary embolism
Investigations
Blood:
FBC
ABG
ECG
PEFR
Radiology: CXR with abdominal shield, if indicated.
114
Adjust maintenance medication to optimize respiratory function
Antenatal
The management of Bronchial Asthma in pregnancy is similar
as in non-pregnant state.
Early referral for combine clinic/chest clinic in patients with
suboptimal control.
Adjust asthma medication as needed to control symptom.
Baseline and serial peak expiratory flow rate (PEFR) need to be
assessed
Inhaler therapy is preferred (acts locally with no systemic effect
to mother).
Consider to seek anaesthesiology consultation in preparation
for delivery, if symptoms not well-controlled.
Intrapartum
Maintain adequate maternal oxygenation in symptomatic
patient.
Prostaglandin F2-α and ergometrine can be used with CAUTION
Parenteral steroid intrapartum for patients on long term oral
steroid therapy
ie > 7.5mg/day more than 2 weeks (to avoid Addisonian’s Crisis).
[Parenteral steroid : IV Hydrocortisone 200mg stat and 100mg 6
hourly]
Postpartum
Continue maintenance drug therapy and resume follow up at
health clinic.
Breast feeding is not contraindicated.
Contraception : all methods can be used as in
normal pregnancy
115
Jaundice in pregnancy
Introduction Pregnancy is a special clinical state with several normal physiological

changes that influence body organs including the liver. Liver disease can
cause significant morbidity and mortality in both pregnant women and
their infants.
Liver disease that unique in pregnancy includes:

- Hyperemesis gravidarum ( 1 in 200 pregnancies)
- Intrahepatic cholestasis in pregnancy (0.5-1.5% prevalence)
- To more frequent condition of pre-eclampsia (10% prevalence)
- To severe form HELLP syndrome (12% of pregnancies with
pre-eclampsia)
- To rate entity of Acute Fatty Liver of Pregnancy (1 per 7270 to
13000 deliveries)
Definition -
Presentation Vomiting, generalized pruritus, fever, headache, epigastric pain,
Clinical findings Fever
Jaundice
Dehydration
Right hypochondrium tenderness
Hepatomegaly
Differential Intrahepatic cholestasis
Diagnosis HELLP syndrome
Acute Fatty Liver
Active hepatitis (Hepatitis B, Hepatitis C, Hepatitis A)
Cholelithiasis
Sepsis
FBC
Renal profile
LFT
Hep B (HBS Ag), Hep C, Hep A
Coag profile
RBS
US hepatobiliary system
Confirm diagnosis
116
Stabilise patient
If pregnancy cause for emergency delivery after patient stabilise
If infective cause, treat infection and optimize patient
Intrapartum
Emergency LSCS after patient stabilise and optimize if
pregnancy cause
Postpartum
Supportive management until cause resolved
Consider ICU observation and management
Notes:
Obstetric Cholestasis of pregnancy
Obstetric cholestasis is diagnosed when otherwise unexplained pruritus
occurs in pregnancy and abnormal liver function tests (LFTs) and/or
raised bile acids occur in the pregnant woman and both resolve after
delivery. Pruritus that involves the palms and soles of the feet is
particularly suggestive.
Jaundice is uncommon. However, when present, it arises 2-4 weeks after
the onset of pruritus. The main symptom is pruritus, especially of the
palms and soles, which is followed by generalised symptoms. This
usually occurs from week 25 of gestation.
Women with persistent pruritus and normal biochemistry should have
LFTs repeated every 1–2 weeks.
Increase perinatal risk of stillbirth in patient with obstetric cholestasis
Postnatal, resolution of pruritus and a normal LFTs should be confirmed
117
Thrombophillia in pregnancy
Introduction Postpartum psychosis is a severe mental illness with a dramatic onset
shortly after childbirth, affecting approximately 1–2 in 1000 deliveries.
Incidence may be higher. Specific relationship between postpartum
psychosis and bipolar disorder. Women with bipolar disorder have at
least a 1 in 4 risk of suffering postpartum psychosis. Genetics are also a
factor and women with bipolar disorder and a personal or family history
of postpartum psychosis are at particularly high risk with greater than 1
in 2 deliveries affected by postpartum psychosis.
However, half of women who develop postpartum psychosis have no

family history or previous risk factors that put them in a high risk group
of suffering from the condition. Women at high risk of postpartum
psychosis need very careful care before conception, throughout
pregnancy and during the postpartum period, including pre-conception
counselling and close monitoring and psychiatric assessment after
childbirth.
Postnatal depression affects 10 to 15 in every 100 women after

childbirth. The symptoms are similar to those in depression at other
times. These include low mood and other symptoms lasting at least two
weeks.
Postpartum psychosis is different from postnatal depression. It is a more

severe illness
Definition Group of condition where there is increase tendency for blood to clot
more than normal leading to thrombus formation, DVT and pulmonary
embolism. Inherited thrombophilia of genetic origin and acquired
thrombophilia from underlying medical/immune disorders.
Presentation Unilateral leg swelling and pain,severe abdominal pain

History of thrombosis in family
History of recurrent miscarriage
History of SLE/ connective tissue disease
Clinical findings Venous thrombosis
Pain and swelling in legs
Mesenteric artery thrombosis
Abdominal guarding, tenderness, rebound
Spiking temperature
118
FBC
Renal profile
LFT
Thrombophillia screen
D-Dimer
Connective tissue screen
Imaging
US Doppler lower limbs
MANAGEMENT PRE-PREGNANCY
ANTENATAL
JOINT MANAGEMENT WITH HEMATOLOGIST
2. Consider antenatal anti-coagulant prophylaxis in high risk case ( Score

with thromboprophylaxis scoring ) until delivery.
3. Patient to deliver in hospital with specialist
INTRAPARTUM
JOINT MANAGEMENT WITH PHYSICIAN AND ANAESTHETIST
To withhold anti-coagulant theraphy when patient in labour (preferably

12 hours to 24 hours before delivery).
PUERPERIUM
To continue anti-coagulant prophylaxis 6 weeks postpartum
FOLLOW-UP
- Notify Klinik Kesihatan upon discharge for postnatal follow-up
- MO / FMS review at Klinik Kesihatan
- Ensure follow-up with hematology clinic .
119
SECTION E
ASSESSMENT OF FETAL WELL BEING
120
ASSESSMENT OF FETAL WELL BEING
Antenatal Fetal Monitoring

Introduction(9) Antenatal evaluation is to identify fetuses at risk for intrauterine injury
and death so that intervention and timely delivery can prevent
progression to stillbirth. There is a higher incidence of fetal compromise
in pregnancy with hypertension, diabetes, heart disorders and other
medical disorders.
Clinical assessment Fetal monitoring during the antepartum period consists of tests for:
• Fetal growth
• Fetal well being
• Fetal growth
Symphysio-fundal height (SFH) tape measurement should be
performed routinely from 22 weeks onwards in all pregnancies where
the POA is expected to correspond to the centimeters of the SFH. These
measurements should be regularly charted in the antenatal card
(KIK/1(a) /96). If there is a discrepancy between the SFH and POA of +/-
3cm, the patient needs to be reevaluated with regards to the accuracy of
the LNMP and referred for an Ultrasound assessment. This can be an
early indicator of impaired fetal growth.
Ultrasound scanning for dating is reliable if the parameters are taken

before 24 weeks (if possible at booking). During antenatal period there
need to be at least 3 Ultrasound evaluation done, preferably at booking,
at mid trimester and near term. Serial scan should be done every 2 – 3
weeks for fetal growth assessment if there is suspicion of IUGR or other
disorders.
Fetal well being

Fetal kick chart is an indirect tool for monitoring of fetal wellbeing. All
mothers should be given the fetal movement chart (Cardiff ‘count-to-
ten’) for recording of fetal movements from 28 weeks gestation onwards
and should be told to report to any health facility if movements are less
than 10 in 12 hours. This observation should be done at regular intervals
every day
Fetal heart auscultation should be routinely practiced from 24 weeks

onward using a Pinards Fetoscope. If Daptone is available, fetal heart can
be detected as early as 14 weeks. Fetal heart rate should be taken for at
least 30 seconds to determine the rate, rhythm and/or variability
121
Cardiotocogram(CTG) should be performed in cases where there is an
abnormal FHR by daptone and high risk of fetal compromise such as
poorly controlled hypertension/diabetes, IUGR or postdates.
Healthcare Refer to flowchart (optional)

MANAGEMENT centre
Hospital
Specialists
122
INTRAPARTUM FETAL MONITORING
Intrapartum CTG Monitoring
Normal CTG Suspicious CTG Abnormal CTG

• Baseline rate 110 bpm –
160 bpm Absence of accelerations and Absence of accelerations
• Baseline variability 5 bpm one of the following: and any of the following:
– 25 bpm • Abnormal baseline rate • Abnormal baseline rate
• Two accelerations in 20 (<110 bpm or >160 bpm) and variability (< 5 bpm for
minutes • Reduced baseline variability more than 40 minutes)
• No deceleration < 10 bpm for more than 40 • Repetitive late
minutes decelerations
• Variable decelerations • Variable decelerations
without ominous features with ominous features:
-- Duration over 60 seconds
Continue monitoring with -- Beat loss over 60 bpm
intermittent auscultation • Late recovery
• Late deceleration
Close fetal component
surveillance with CTG • Poor baseline variability
Consider transfer to between and/or during
hospital with decelerations
specialists
Delivery if suspicious
CTG persists and
deteriorates
Transfer to hospital with
specialists for delivery
Delivery by Emergency LSCS
123
SECTION F
PRENATAL SCREENING
124
PRENATAL SCREENING
Prenatal Diagnosis
Definition Diagnosis of a fetal condition(structural and chromosomal) during the
antenatal period. Methods for prenatal diagnosis include;
Ultrasound of the developing fetus
Serum screening
Invasive prenatal diagnosis
Ultrasound of the developing fetus-The Nuchal Translucency(NT) scan is

done at 11–13 weeks, and it can be used to identify higher risks of
Downs syndrome. Later morphology scans from 18 to 22 weeks to
identify fetal structural abnormalities(Indication as in table ).
Serum screening-First trimester maternal serum screening can check

levels of free β-hCG, PAPP-A and α feto protein, with the combined
measurement of nuchal translucency (NT) for the risk of fetal aneploidy.
Invasive prenatal diagnosis-Amniocentesis is an invasive, well-

established, safe, reliable, and accurate procedure performed at 15
weeks onwards. The amniocytes are cultured to identify for fetal
chromosomal abnormality and it is 90% accurate.(Indication as in table)
Indication for Advanced maternal age

Amniocentesis Suspicion of fetal chromosomal abnormality based on
ultrasound evaluation
Maternal request due anxiety
Indication for Established Diabetes currently on insulin therapy
detailed Ultrasound HbA1c readings of more than 7, at period of gestation less than 14
Screening weeks
Previous pregnancy with fetal structural anomalies (needs
consultation with the MFM specialist)
Previous pregnancy with fetal chromosomal abnormalities
Suspected fetal anomalies during ultrasound examination in this
pregnancy (after confirmation by FMS or O&G specialist)
Exposure to drugs in this pregnancy (Index of drug safety in
pregnancy should be at least category D or X)
Monochorionic twin pregnancy(MCDA, MCMA) or higher order
pregnancy
Pregnancy as a result of assisted reproductive technique (IVF, ICSI,
etc)
125
History of infectious disease (Toxoplasmosis, Chickenpox, Rubella,
CMV, Herpes Simplex) early in pregnancy (less than 12 weeks)
Mother with congenital heart disease (VSD, ASD, Tetralogy of Fallot)
Mother with cleft lip and cleft palate
MANAGEMENT centre
Hospital
Specialists
126
PRENATAL SCREENING
Prenatal screening according to

indication in high
POG at 10-13 weeks

POG at 15 weeks onwards
Combined first trimester

screening (free β-hCG, PAPP-A Amniocentesis
and α feto protein, with the
combined measurement)
Results and counselling session
127
SECTION G
INDUCTION OF LABOUR
128
INDUCTION OF LABOUR
Induction of Labour
Introduction Artificial initiation of labour before its spontaneous onset to deliver the
feto placental unit.
Definition The initiation of contraction in a pregnant woman who is not in labour to
help her achieve a vaginal birth in 24 to 48 hours.
Succesful induction is defined as a vaginal delivery within 24 to 48 hours
of induction of labour.
Indications Maternal Indications
Postdatism (>41 weeks)
Hypertensive disoder in pregnancy
Diabetes Mellitus (on Insulin Treatment)
Chorioamnionitis
Premature Rupture of Membrane (at or near term)
Fetal Indications
Intrauterine Growth Restriction
Intrauterine Death
Suspected Fetal Compromise
Contraindications Placenta Previa

Vasa Previa
2 Previous Scar
Previous History Classical Caeserean Section
Abnormal Presentation
Active genital Herpes
Invasive Cervical Cancer
Previous Uterine Rupture
Clinical Asessment Confirmation of Gestation
Maternal History
Abdominal Palpation for presentation and Engagement
Vaginal Examination for Cervical Asessment using Bishop Score
Asessment of Fetal Well Being by Monitoring Cardiotocograph
Bishop Score Refer to table
Investigations Informed Consent to Couple
CTG: Pre and post induction
Healthcare To refer patient at date plus 7 days
MANAGEMENT centre Do not require daily CTG monitoring in postterm and
uncomplicated pregnancy (post-term : date plus 7
129
days)
District To refer patient at date plus 7 days
Hospital Do not require daily CTG monitoring in postterm and
uncomplicated pregnancy (postterm : date plus 7
days)
Specialists
Regime Prostaglandin E2 3mg OD for 5 days (1 cycle)
Subsequent cycle and change of dosage must be discussed with
specialists on case to case basis
Complications Hyperstimulation
Failed Induction
Uterine Rupture
Cord Prolapsed
130
Induction Of Labour
Induction Of Labour
Assessment of Patient Including Bishop

Score
Bishop Score <6
Pre Prostin CTG
Prostin Insertion (refer to regime)
Post Prostin CTG
Favourable Unfavourable
Transfer to Labour Room Follow Regime

131
Follow Intrapartum Protocol

Modified Bishop Score
Cervical feature 0 1 2 3
Dilatation ( cm) <1 1-2 2-4 >4
Length of Cervix >4 2-4 1-2 <1

(cm)
Station -3 -2 -1/0 +1/+2
Consistency Firm Average Soft -
Posterior Mid ; Anterior
Favourable >6
Not Favourable <6
132
SECTION H
INFECTIONS IN PREGNANCY
133
HIV INFECTION
Introduction Antenatal Highly Active Antiretroviral Therapy (HAART) is now

recommended method for prevention of maternal-to-child transmis sion
(PMTCT). HAART must be started in all pregnant mothers who are HIV+
regardless of CD4 count.
Ideally HAART should be started at 14 weeks of pregnancy. HAART is

still efficacious when started as late as 28 weeks of pregnancy. The
treatment of women who start HAART after week 28th must be discussed
with an ID physician. Strict adherence to HAART must be stress through
out the pregnancy.
A viral load must be done between weeks 32-36 to determine ongoing

risks of transmission to the fetus. The mode of delivery will also be
determined by the results
Definition Retroviral infection with pregnancy (can be diagnosed pre-pregnancy or
during pregnancy)
Presentation Majority is asymptomatic
Investigations Screen patient and partner for other STD e.g. HBV, VDRL
All routine antenatal investigations - as usual.
Disease progression monitoring: CD4, VL, FBC, LFT
CD4 count once in every trimester
Viral load at 32-36 weeks
Healthcare Screening with Rapid test
MANAGEMENT centre If positive, proceed with confirmatory test (ELISA).
1. Confirmed, POA < 14 weeks, delay treatment
till 14 week
2. Confirmed, POA 14-28 weeks, start
treatment immediately
3. Confirmed, POA > 28 weeks, refer ID
physician
Counselling for HIV positive mother should include:

- Nature of disease
- Effect of disease on pregnancy
- Effect of pregnancy on disease
- Risk of maternal to child transmission
- Treatment modalities
Treatment
134
- CD4 < 350: start HAART as soon as possible
- CD4 > 350: may delay until 14th week
Choice of Agents Used for PMTCT
Preferred Alternative
TDF + 3TC (or FTC) + AZT + 3TC + EFV
EFV AZT + 3TC + NVP
TDF + 3TC (or FTC) + NVP
TDF + 3TC (or FTC) +
LPV/RTV
Hospital with Obstetrician review at 36 weeks to decide timing and
Specialists mode of delivery
Viral load at 32-36

Mode of delivery
weeks
< 50 copies/m SVD
PLCS
50-399 copies/ml
recommended
> 400 copies/ml or
PLCS
unknown viral load
Delivery must be in hospital with specialists
Intrapartum (spontaneous labour)

- loading dose IV AZT 2mg/kg over 1 hour
- followed by infusion of 1mg/kg/hour until delivery
- avoid artificial rupture of membrane
- avoid invasive fetal procedure (fetal scalp electrode,
fetal scalp sampling)
- avoid episiotomy, operative vaginal delivery if
possible
Elective C-section
- AZT infusion start 4 hours before C-section
Postpartum
- avoid breastfeeding
- PAP smear after 6 weeks
- family planning counselling
- continue follow up at RV clinic / PLHIV
- baby referred to Paediatrician upon delivery
Notes 1. Consensus Guidelines on Antiretroviral Therapy 2014, page 28-30

2. Clinical Practice Guidelines on Management of HIV Infection in
Pregnant Woman, 2008
135
HIV SCREENING FOR PREGNANT MOTHER I
PREGNANT WOMAN IN LABOUR

WHOSE HIV STATUS IS UNKNOWN
RAPID TEST
Reactive Non-reactive
Start HAART END
DELIVERY
Refer Paediatrician.
Pretest counselling.
Confirmatory test
immediately post
delivery.
Notification.
Contact tracing.
136
HIV SCREENING FOR PREGNANT MOTHER II
PREGNANT WOMAN ATTENDING ANC
GROUP PRE-TEST
COUNSELLING
RAPID TEST
Reactive Non-reactive
Negative
PRE-TEST
COUNSELLING AND
CONFIRMATORY TEST
Reactive
HIGH RISK LOW RISK
GROUP GROUP
CONFIRMED POSITIVE
Non-reactive
REPEAT RAPID TEST /
POST-TEST EIA 12 weeks after
COUNSELLING. first test is negative or
CONTACT TRACING. before 36 weeks
NOTIFICATION. gestation END
REFER TO ID
PHYSICIAN OR
FAMILY MEDICINE
SPECIALIST
137
MEDICAL MANAGEMENT OF HIV POSITIVE MOTHER I
NEWLY DIAGNOSED HIV

POSITIVE MOTHER
POA < 14 WEEKS POA 14-28 WEEKS POA > 28 WEEKS
Counselling. Counselling. Counselling.

Delay HAART at 14 Initiate HAART Consult ID physician
weeks. regardless of POA. for initiation of
Do VL at 34-36 week. Do VL at 34-36 week. HAART.
If VL < 50 copies/m, If VL < 50 copies/m,
for SVD. for SVD.
If VL 50-399 If VL 50-399
copies/ml, PLCS copies/ml, PLCS
recommended. recommended.
If > 400 copies/ml or If > 400 copies/ml or
unknown viral load, unknown viral load,
for PLCS. for PLCS.
During delivery, IV During delivery, IV
ZDV for mother. ZDV for mother.
Discuss with ID Discuss with ID
Physician / physician Physician / physician
regarding continuing regarding continuing
cART post delivery. cART post delivery.
Baby refer immediately to Paediatrician

Mother refer to ID physician 138
MEDICAL MANAGEMENT OF HIV POSITIVE MOTHER II
HIV POSITIVE MOTHER ON HAART
Stable on HAART Failing on HAART
Counselling. Refer ID Physician.

Continue HAART. Resistance testing if
Refer ID Physician. available.
If VL < 50 copies/m, Elective C-section
for SVD. about 38 weeks.
If VL 50-399 During delivery, IV
copies/ml, PLCS ZDV for mother.
recommended.
If > 400 copies/ml or
unknown viral load,
for PLCS.
During delivery, IV
ZDV for mother.
Continue HAART post
delivery.

Mother refer to ID physician
139
MEDICAL MANAGEMENT OF HIV POSITIVE MOTHER III
HIV POSITIVE MOTHER DIAGNOSED IN

LABOUR NO PRIOR THERAPY
Start IV ZDV infusion (2mg/kg for 1 hour)
Followed by
IV ZDV 1mg/kg/hour.

Mother refer to ID physician
140
SEXUALLY TRANSMITTED DISEASE
Syphilis
Introduction Sexually transmitted infections (STI) are recognized worldwide as
important causes of morbidity in both maternal and child health. They
also pose a major threat to reproductive health.
All women should be screened serologically for syphilis early in

pregnancy. Antenatal screening for syphilis with non-treponemal tests
(VDRL / RPR) should be routinely performed on booking and at 28
weeks of gestation. Positive results must be confirmed with treponemal
tests (TPHA / TPPA / EIA / Rapid tests).
Rapid treponemal test can be used for screening antenatal mothers. RPR
/ VDRL have to be performed on all patients with positive rapid
treponemal tests to determine disease activity and to monitor response
to therapy.
Definition The aetiology of syphilis is Treponema pallidum.
Early syphilis is define as infection during the first 2 years and includes
primary, secondary and early latent syphilis
Late syphilis is defined as syphilis occurring 2 years after infection and

includes late latent syphilis, benign tertiary syphilis (gumma),
cardiovascular syphilis and neurosyphilis
Presentation Primary syphilis presents classically as a solitary, non-tender, indurated

and well- circumscribed ulcer (chancre) with regional lymphadenopathy.
The incubation period is 9-90 days.
Secondary syphilis commonest presentation is a generalised non

irritating skin lesion involving the palms and soles with or without
generalized lymphadenopathy. Condylomata lata, mucocutaneous lesions
and patchy alopecia are seen less commonly. The incubation period is 6
weeks – 6 months
Latent syphilis is noted to have infection diagnosed by positive serology

without any symptoms and signs.
141
Clinical Findings History:
Ask for any sexual exposure?
Any anogenital or extragenital (most frequently oral) ulcer or
lesion?
Any history of being treated for syphilis before?
Any history of vaginal discharge?
On examination:
Examine the anogenital and extragenital for chancre or
condylomata lata.
Examine to look for vaginal discharge (for associated sexually
transmitted diseases)
Differential Urinary Tract Infection

Diagnosis Cystitis
Urethritis
Candidiasis
Chancroid
Condyloma Acuminata
Genital Warts
Herpes Simplex / Zoster
Granuloma Inguinale (Donovanosis)
Lymphogranuloma Venereum
Yaws
TPHA, VDRL titre
Do TPHA and VDRL for spouse or sexual partners
Health To treat if VDRL is reactive and TPHA is positive

MANAGEMENT Clinic VDRL titre > 1.8 indicates active syphilis infection
and needs to treat.
If VDRL < 1:8 but never been treated or
incomplete treatment or was unsure of receiving
any treatment, then treatment should be given
once pregnant.
Treatment:
IM Benzathine Penicillin G 2.4 mega units
weekly for 3 weeks (test dose needed) OR
IM Procaine Penicillin 1.2 mega units daily
for 10-14 days (test dose needed).
Treatment with Benzathine Penicillin needed to
be completed at least 1 month before delivery of
the baby otherwise the baby needs to be treated
as ‘congenital syphilis’.
If allergic to Penicillin, then used Oral
Erythromycin ES 800mg BD for 21 days OR
142
Azithromycin 1gm single dose.
Treatment that does not used penicillin, the baby
should be treated as ‘congenital syphilis’
VDRL titre is expected to decrease by 4 fold after
3 months treatment.
Spouse whom are negative (TPHA and VDRL)
needed to have a prophylaxis of IM Benzathine
Penicillin G 2.4 mega units stat dose but for those
who are positive (TPHA and VDRL) needs to be
treated as above.
Follow-up:
Repeat VDRL monthly till delivery, then
6 month, 1 year and 2 years
Registered at MSA Clinic and open up
the STI Folder
If spouse is negative, need to follow up 6
monthly for 2 years
District All TPHA positive mother need to deliver in the

Hospital and hospital.
Hospital with
Specialists On delivery:
Send the baby umbilical cord blood for VDRL /
TPHA after the delivery
Baby is referred to the Paediatrician for
assessment (KIV for the congenital syphilis
treatment).
Baby need to be treated as ‘congenital syphilis’ if
delivered by the VDRL positive mother and:
Not treated
Treated less than a month and she
delivered
Treated with a non-penicillin regime
during pregnancy
No decrease in VDRL /RPR after
treatment as expected
Treated but defaulted her serologic
follow-up and unable to assess the
disease activity.
Notes Notification: All cases need to be notified via the notification form and
need to be send to the Pejabat Kesihatan Daerah.
143
Gonorrhoea
Introduction Gonorrhea is a sexually transmitted disease (STD) that can infect both
men and women. It can cause infections in the genitals, rectum, and
throat. It is a very common infection, especially among young people
ages 15-24 years.
You can get gonorrhea by having vaginal, anal, or oral sex with someone
who has gonorrhea. A pregnant woman with gonorrhea can give the
infection to her baby during childbirth.
The aetiology of gonorrhea is Neisseria gonorrhoeaae. The incubation

period is 2-5 days
Presentation Altered vaginal discharge, mucopurulent endocervical discharge or
contact bleeding, caused by cervicitis
Lower abdominal pain and tenderness, caused by pelvic
inflammatory disease (PID).
Fever, petechiae or pustular skin lesions, asymptomatic arthralgia,
septic arthritis, tenosynovitis and very rarely, meningitis or
endocarditis caused by disseminated gonococcal infection (DGI)
Asymptomatic infection is common: encervix>50%, rectum>85%,
pharynx>90%
Transluminal spread of N. gonorrhoeae may occur from the
endocervix to involve the endometrium and pelvic organs in women
Clinical Findings Altered vaginal discharge
Differential Chlamydia
Diagnosis Candidiasis
Trichomoniasis
Investigations Exudates: Gram stain of urethral, cervical or rectal discharge or exudates
Gram-negative intracellular diplococci in leucocytes
Culture on modified Thayar Martin culture medium on all samples
Offers a high sensitivity, confirmation of diagnosis and antibiotic
sensitivity testing.
Health Ceftriaxone 250mg IM as a single dose OR
MANAGEMENT Clinic Spectinomycin 2gm IM as a single dose
District If suspected co-infection with Chlamydia trachomatis;
Hospital Erythromycin ES 800mg QID orally for 7 days
Hospital with Pregnant women should not be treated with
Specialists quinolone or tetracycline antimicrobials
Spouse also need to be treated if positive for GC smear
144
Genital Herpes
Introduction The aetiology of genital herpes is Herpes simplex virus type I or type II
(HSV-1, the usual cause of oro-labial herpes).
The incubation period is 2-21days.
Presentation No symptoms – 20%

Minor symptoms (unrecognised) – 60%
Painful sores – 20%
Symptoms
Painful ulceration, dysuria, vaginal or urethral discharge
Systemic symptoms e.g. fever and myalgia
Asymptomatic
Clinical Findings Blistering and ulceration of external genitalia (+cervix / rectum)

Inguinal lymphadenopathy
Differential Chancre
Diagnosis Chancroid
Healthcare First episode:

MANAGEMENT centre Acyclovir 200mg 5 times / day or 400mg TDS orally
for 5 days
Extends beyond 10 days if healing incomplete
Recurrent episode:
Acyclovir 800mg BD for 5 days OR
Ancyclovir 800mg TDS for 2 days
Refer O&G if active infection occurred after 37 weeks

of gestation for deciding mode of delivery
District Same as above

Hospital
Hospital with To decide mode of delivery

Specialists
For LSCS if having active herpes infection
near or in labour
145
LSCS is recommended for all women in
labour with active genital lesions or
prodromal symptoms such as vulvar pain.
146
GROUP B STREPTOCOCCUS (GBS)
Introduction Group B streptococcus has high neonatal morbidity and mortality.

Diagnosis Positive culture screening
Indications for low Preterm pre-labour rupture of membrane
or high vaginal swab Pre-labour rupture of membrane
Premature labour
History of GBS positive in previous baby
GBS bacteriuria
1. Commence prophylactic antbiotics if results are positive and
MANAGEMENT intrapartum antibiotics prophylaxis.
2. Antibiotics of choice:
- antenatal: depending on sensitivity
- intrapartum: IV Ampicillin 2g stat and 1g 6 hourly till delivery
3. Postpartum
- mother: monitor for maternal pyrexia
- baby: refer to Paediatric team
147
SECTION I
OBSTETRICS EMERGENCIES
148
OBSTETRICS EMERGENCIES
Severe antepartum haemorrhage

Postpartum haemorrhage
Intrapartum collapse
Postpartum collapse
Eclampsia
Uterine inversion
Initiation of *Red Alert System
Maternal Resuscitation
Rapid Assessment overall for colour , breathing

, consciousness, response, blood loss, and other
vital sign
Assessment of airway and breathing initially

with administration of high flow oxygen is
recommended
Wide bore intravenous access should be

established with blood sent for FBC,
coagulation profile and cross- match GXM
Appropriate infusion with fluids
Safe O transfusion if indicated
Keep patient warm
Establish and manage according

to Diagnosis
(follow according to protocol)
Monitoring and review

investigation regularly
Refer other unit if necessary 149
Documentation
POSTPARTUM COLLAPSE
Postpartum Collapse
Introduction Maternal collapse is a rare but life-threatening event with a wide-ranging
aetiology. The outcome, primarily for the mother depends on prompt
and effective resuscitation.
Definition An acute event involving the cardiorespiratory systems and/or brain,
resulting in a reduced or absent conscious level (and potentially death),
up to six weeks after delivery.
Causes Amniotic Fluid Embolism
Pulmonary Embolism
Eclampsia
Intracranial Hemorrhage
Post Partum Hemorrhage
Anaphylaxis
Cardiac causes: arrhythmias, myocardial infarction
,cardiomyopathy, Aortic dissection
Hypoglycaemia
Investigations Blood: FBC, RBS, RP, Electrolyte, Ca, Mg , PO, Blood C &S, Coagulation
Profile, GXM
Urine: Ketone, Protein,
Imaging: CT Brain, CT Thorax, CTPA
Others: ECG,
MANAGEMENT centre
Hospital
Specialists
Notes Anaesthetist should be summoned at the time of
the cardiopulmonary arrest call
150
MANAGEMENT OF AMNIOTIC FLUID EMBOLISM
Amniotic Fluid Embolism
Administer oxygen to maintain

normal saturation. Intubate if
necessary.
Initiate cardiopulmonary
resuscitation (CPR) if the patient
arrests.
Treat hypotension with

crystalloid and blood products.
Use pressors as necessary.
Consider pulmonary artery

catheterization in patients who
are hemodynamically unstable.
Treat coagulopathy with FFP for a

prolonged aPTT, cryoprecipitate
for a fibrinogen level less than
100 mg/dL, and transfuse
platelets for platelet counts less
than 20,000/µL.
151
POST PARTUM HEMORRHAGE
Post Partum Haemorrhage

Introduction Primary postpartum haemorrhage (PPH) is the most common form of
major obstetric haemorrhage. Worldwide PPH remains a preventable but
major cause of maternal morbidity and mortality accounting for 20-25%
of death. Uterine atony is the most common and the leading cause of
maternal mortality (80-90%).
Secondary PPH is that which occurs after 24hrs within12 weeks
postpartum.
Definition Bleeding from the genital tract more than 500mls in vaginal delivery and
more than 1000mls in Caesarean section or enough blood loss to cause
hypotension or shock within 24 hours of the birth of a baby.
Presentation Minor PPH – blood loss 500mls-1000ls with no clinical signs of shock
Major PPH – blood loss >1000 mls
Massive PPH – blood loss >1500mls
SVD > 500 ml
LSCS > 1000ml
Caesarean Hysterectomy >3000ml
Causes PPH may result from

Uterine atony
Genital tract trauma(vaginal or cervical lacerations),
Uterine rupture
Retained placenta tissue
Maternal bleeding disorders
Investigations FBC
GXM
Coagulation Profile
Ultrasound
Assessment Initial estimates of estimated blood loss and assessment of ongoing
blood loss is important.
1. mild PPH: 500ml-1000ml with no clinical shock
2. severe PPH: estimated blood loss >1000ml and continuing bleeding
3. Evidence of clinical signs of shock or tachycardia should initiate a
thorough assessment of patient including appraisal of blood loss both
concealed and revealed.
Healthcare Refer to table
MANAGEMENT centre
District Refer to flow chart
Hospital
152
Specialists
Notes Carboprost is not given in Bronchial Asthma
Hartmanns 1000 ml stat and Check response
Degree of Perineal Tear
1. Laceration is limited to the fourchette and superficial perineal
skin or vaginal mucosa
2. Laceration extends beyond fourchette, perineal skin and
vaginal mucosa to perineal muscles and fascia, but not the anal
sphincter.
3. Fourchette, perineal skin, vaginal mucosa, muscles, and anal
sphincter are torn.
4. Fourchette, perineal skin, vaginal mucosa, muscles, anal
sphincter, and rectal mucosa are torn
153
MANAGEMENT OF POST PARTUM HAEMORRHAGES
TABLE ON MANAGEMENT OF POST PARTUM HAEMORRHAGES
CONDITION CAUSES INVESTIGATIONS MANAGEMENT

TRAUMA hematoma FBC, GXM Examination under
perineal tear/ coagulation studies, Anesthesia and
episiotomy PT,PTT, platelet, evacuation of
fibrinogen hematoma or repair
of perineal tear of
episiotomy. If
*perineal tear more
than 3rd degree , for
surgical/colorectal
referral
ruptured uterus For repair of tear or
hysterectomy
TISSUES retained tissue Ultrasound Evacuation under

invasive tissue anesthesia
(placenta accreta) Antibiotic
THROMBIN coagulopathy coagulation studies, Transfuse FFP, GXM,
PT,PTT, platelet, Cryoprecipitate
fibrinogen
TONE uterine atony coagulation studies, refer protocol for
PT,PTT, platelet, postpartum
fibrinogen hemorrhage
OTHERS uterine inversion coagulation studies, refer protocol for
PT,PTT, platelet, uterine inversion
fibrinogen
154
Obstetric Emergency
(refer protocol)
PPH due to Uterine

Atony
Optimization of
Haemodynamic
status
1st dose of oxytocin

drug
Uterus contracts, Repeat 2nd dose of

continue with IV oxytocin drug
Infusion of 40U
Syntocinon in 500
ml NS run at
125ml/hour Carboprost 0.25mg IM
Repeat at intervals of
15 mins
Most PPH will respond to Oxytocin

regimes, bladder catheterization
and Repair of genital tract Ballon Tamponade (if
lacerations physical and
Bimanual compression can be pharmacological methods
continued fail)
Surgical intervention B-
Lynch sutures
Uterine artery ligation /

Internal Iliac Ligation
155
Hysterectomy
RETAINED PLACENTA
Retained Placenta
Definition Placenta that has not undergone placental expulsion within 30 minutes
of the baby’s birth where the third stage of the labour has been managed
actively
Clinical Assessment Maternal Condition
Vital signs monitoring
Hemodynamic status
Placental separation (partial or in situ)
Risk of adherent
Investigations Blood: FBC , GXM, Coagulation Profile
Healthcare Transfer to Hospital with specialists
MANAGEMENT centre
District Transfer to Hospital with specialists
Hospital
Specialists
Complications Postpartum hemorrhage
Placenta Accreta
Endometritis
156
MANAGEMENT OF RETAINED PLACENTA
Diagnosis of Retained Placenta
Maternal Assessment
Informed Consent
Secure Intravenous Access
Resuscitation if Patient in Shock
Manual Removal of Placenta

Manual Removal of Placenta Under GA:
In Labour Suite (if partially Failed removal at first
separated) attempt
Previous history of
retained
Risk of adherent
placenta
Check for Placenta Completeness

after removal and ensure Uterine
Cavity Empty
Oxytocin Infusion 40 IU/500 ml at

100 ml/hour
Cover with Antibiotics
Observe for excessive PV bleeding
157
OBSTETRIC EMERGENCIES
Morbidly Adherent Placenta

Introduction A morbidly adherent placenta includes placenta accreta, increta and
percreta as it penetrates through the decidua basalis into and then
through the myometrium and is associated maternal and fetal morbidity
and mortality
Clinical Assessment Women who have had a previous caesarean section who also have either
placenta praevia or an anterior placenta underlying the old caesarean
section scar at 32 weeks of gestation are at increased risk of morbidly
adherent placenta. Counseling with couple and appropriate preparations
for surgery should be made. Antenatal sonographic imaging can be
complemented by magnetic resonance imaging(MRI) in equivocal cases
Ultrasound criteria for diagnosis were as follows:
● loss of the retroplacental sonolucent zone

● irregular retroplacental sonolucent zone
● thinning or disruption of the hyperechoic serosa–bladder interface
● presence of focal exophytic masses invading the urinary bladder
● abnormal placental lacunae
Colour Doppler:
● diffuse or focal lacunar flow
● vascular lakes with turbulent flow (peak systolic velocity over 15cm/s)
● hypervascularity of serosa–bladder interface
● markedly dilated vessels over peripheral subplacental zone
Any woman with suspected mordbidly adherent placenta
MANAGEMENT should be reviewed by a consultant obstetrician in the
antenatal period.
Need adequate blood reserve planning and anaesthetic
backup.
Surgeons delivering the baby by caesarean section in the
presence of a suspected morbidly adherent placenta should
consider opening the uterus at a site distant from the
placenta, and delivering the baby without disturbing the
placenta, in order to enable conservative management of the
placenta or elective hysterectomy to be performed if the
accreta is confirmed
158
Morbidly Adherent Placenta
Identify High Risk Patients

Previous LSCS with
anterior placenta previa
major
Previous ERPOC with
placenta previa major
(needs to be discussed
with specialists)
Ultrasound Evaluation at 30 – 34
weeks
No ultrasound Features Ultrasound features suggestive of

suggestive of Morbidly Adherent Morbidly Adherent Placenta
Placenta
For elective LSCS Counselling of the couple

- To be performed by regarding the findings
Medical officer or senior
Medical officer
Planned for elective LSCS in view

of hysterectomy
- To be done by
specialists/ consultant
- To be done with
adequate anesthetist
backup
159
UTERINE INVERSION
Uterine Inversion
Introduction Uterine inversion is a potentially fatal childbirth complication with a
maternal survival rate of about 85%.
Definition Defined when the placental fails to detach from the uterus as it exits,
pulls on the inside surface , and turns the organ inside out
Clinical Hemorrhage with or without shock
Presentation Bradycardia
Hypotension
Uterus not palpable
Mass protruding from vagina
Absence of uterine fundus on abdominal palpation
Polypoidal red mass in the vagina with placenta attached
Classification According to Severity of Inversion

First degree: The fundus reaches the internal os
Second degree : The body or corpus of the uterus is inverted to
the internal os
Third degree: The uterus, cervix and vagina are inverted and
are visible
Investigations Blood: FBC, GSH

MANAGEMENT centre
Hospital
Specialists
Notes Red Alert system might not applicable in Health centre or district as they
do not have multidisciplinary team
160
MANAGEMENT OF UTERINE INVERSION
Maternal Resuscitation
Uterine Inversion
Manual Replacement (JOHNSON

Hydrostatic Reduction
MANOUVRE)
(O’SULLIVAN’S TECHNIQUE)
Re-inverting it and keeping the

hand in the uterus until firm
contraction of the uterus is felt Method of reinverting the uterus
by infusing warm saline into the
Using the tip of the finger push vagina.
the fundus of the uterus from the
side first along the direction of Women may be placed in the
the vagina towards the fornix. reverse Tredelenburg position to
assist gravity and reduce traction
Lift the uterus towards the on the infundibulo-pelvic
umbilicus and return to its ligaments, round ligaments and
normal position the ovaries
Successful Unsuccessful
Inversion Attach a 2 x 1 litre bags of
warmed saline to a Y-Cystoscopy
giving set. Additional fluids may
be required.
oxytocic infusion
(30iu Syntocinon® Insert the hand into the vagina
in 500mL with the open end of the tubing
Hartmann’s solution near the posterior fornix.
commencing at Obtain a seal at the vaginal
240mL / hour) as entrance by enclosing the labia
per PPH therapeutic around the wrist/hand to prevent
infusion regimen Unsuccessful fluid leakage.
Infuse warmed fluid under

gravity. Several litres of fluid161
may
Surgical be required
Management
MANAGEMENT OF OBSTETRIC
THROMBOEMBOLISM
Obstetric Thromboembolism
Introduction Pregnancy and the puerperium are considered as one of the highest risks
for otherwise healthy women to develop venous thrombosis(DVT) and
pulmonary embolism(PE).
Definition The blockage of a blood vessel by a thrombus carried through the blood
stream from its site of formation.
Presentation DVT
The signs and symptoms of DVT:
severe pain and edema of the leg and thigh
lower abdominal pain
pale, cool extremity with diminished pulsation (phlegmasia
alba dolens or milk leg)
PE
dyspnoea,
chest pain,
haemoptysis
collapse.
Clinical Findings DVT

Leg is
warm,
tender
swollen
PE
Tachypnea,
rales
friction rubs,
tachycardia,
accentuated second heart sound,
S3 or S4 gallop,
162
fever,
diaphoresis,
cyanosis
Differential DVT
Diagnosis Cellulitis
Calf muscle tear/Archilles tendon tear
Calf muscle haematoma
Ruptured popliteal cyst (Baker’s cyst)
Pelvic/thigh mass/tumour compressing venous outflow from
the leg
PE
Acute Coronary Syndrome
Acute Pericarditis
ARDS
Angina Pectoris
Anxiety Disorders
Aortic Stenosis
Dilated Cardiomyopathy
Investigations Blood: FBC, Coagulation profile, Renal Profile, LFT

Urine: FEME
Imaging:
DVT
1. Compression Duplex ultrasound
PE
1. ECG and CXR
2. computerized tomography pulmonary angiogram(CTPA)
Others:
ECG ;
Sinus tachycardia,
S1Q3T3
right-axis deviation may or may not be evident.
Healthcare Stabilize the patient.
MANAGEMENT centre Refer patient immediately to nearest hospital or
hospital with specialist after consultation with O&G
Specialist or Physician Oncall.
Patient preferably need to be accompanied by Medical
Officer if PE is suspected or diagnosed.
District Refer CPG ;

Hospital 1. Clinical Pathways in the Prevention and
Treatment of Venous Thromboembolism
163
published by MOH, Malaysian Society of
Haematology, NHAM and Academy of
Medicine, Malaysia Year 2013 (page 16-23)
2. Stabilize patient with PE and refer
immediately to hospital with specialist after
consultation.
Refer to Flow Chart.
Hospital with Refer CPG ;
Specialists 1. If CTPA is normal but the clinical suspicion of
PE remains. Anticoagulant treatment should
be continued until PE is definitively
excluded.
2. Refer to Flow Chart.
164
MANAGEMENT OF OBSTETRIC THROMBOEMBOLISM
Algorithm for the investigation and initial management of suspected PE in pregnancy

and the puerperium
Suspected PE:
- clinical assessment
- perform CXR and ECG
- test FBC, BUSE, LFTs
- commence LMWH unless
treatment is contraindicated
Sign and symptom of DVT
YES NO
Perform compression duplex

ultrasound
Compression ultrasound
confirms DVT No Is the CXR normal?
YES YES NO
Perform V/Q scan Perform CTPA

Continue therapeutic if available
doses of LMWH
PE confirmed
Follow protocol on
thromboembolism
NO YES
If clinical suspicion of PE is low, Continue therapeutic

discontinue LMWH and consider doses of LMWH
alternative diagnoses
If the clinical suspicion high,
165
consider alternative or repeat Follow protocol on
testing and continue LMWH thromboembolism
CORD PROLAPSE
Cord prolapse
Definition Defined as descent of the umbilical cord through the cervix alongside
(occult) or past the presenting part (overt) in the presence of ruptured
membranes.
Presentation Cord present at the introitus or feeling it during the vaginal examination
Risk Factors Multiparity Artificial rupture of
Low birthweight (< 2.5 membranes with high
kg presenting part
Preterm labour (< 37 Vaginal manipulation of
weeks) the fetus with ruptured
Fetal congenital membranes
anomalies External cephalic version
Breech presentation (during procedure)
Transverse, oblique and Internal podalic version
unstable lie Stabilising induction of
Second twin labour
Polyhydramnios Insertion of intrauterine
Unengaged presenting pressure transducer
part Large balloon catheter
Unstable lie induction of labour
Clinical Findings Abnormal fetal heart rate pattern soon after membrane rupture, either
spontaneous or artificial.
Assessment 1. Speculum and/or digital vaginal examination should be performed

when cord prolapse is suspected.
2. Continuous assessment of the fetal heart trace is essential
Healthcare Initial management

MANAGEMENT centre 2 pillows under mother’s buttocks
Oxygen to mother
Replace cord into the vagina with warm
gauze /pad
Inflate bladder with normal saline
Arrange transfer to hospital with specialists
(refer to protocol of transfer)
District Initial management

Hospital 2 pillows under mother’s buttocks
Oxygen to mother
166
Replace cord into the vagina with warm
gauze /pad
Inflate bladder with normal saline
Arrange transfer to hospital with specialists
(refer to protocol of transfer)

Specialists
Notes
167
MANAGEMENT OF CORD PROLAPSE
Umbilical Cord Prolapse
In-hospital event Out-of-hospital event
Trendelenburg
Vaginal delivery Vaginal Delivery
or knee chest
imminent not Imminent
position
Bladder filling
FHR reassuring FHR not reassuring
Trendelenburg
or knee chest
position
Await Operative vaginal or
spontaneous caesarean delivery Consider tocolysis
vaginal delivery if fetal distress
Manual elevation
of the presenting Transport
part
FHR absent FHR present
Vaginal Birth Emergent caesarean

Delivery delivery
(EMLSCS)
168
SHOULDER DYSTOCIA
SHOULDER DYSTOCIA
Shoulder Dystocia
Introduction Shoulder dystocia occurs when either the anterior or, less commonly, the
posterior fetal shoulder impacts on the maternal symphysis or sacral
promontory.
Definition A vaginal cephalic delivery that requires additional obstetric maneuvers

to deliver the fetus after the head has delivered and gentle traction has
failed
Presentation Head coming out of the birth canal but delay in delivery of shoulder
Clinical Findings Difficulty with delivery of the face and chin:
- the head remaining tightly applied to the vulva or even retracting
(turtle-neck sign)
- failure of restitution of the fetal head
- failure of the shoulders to descend.
Assessment Birth attendants should routinely look for the signs of shoulder dystocia.
Risk Factors Macrosomic baby

Previous history of shoulder dystocia
Diabetes Mellitus/Gestational Diabetes Mellitus
Grand multipara
Maternal body mass index > 30 kg/m2
Induction of labour
Short stature
Prolonged first stage of labour
Oxytocin administration
Prolonged second stage of labour
Secondary arrest
Operative delivery
Complications Maternal Complications
3rd / 4th degree perineal tears
postpartum haemorrhage
Fetal Complications
brachial plexus injury
clavicular fracture
169
ribs fracture
perinatal asphyxia
cerebral palsy
Healthcare
MANAGEMENT centre • Call for the most senior staff available
at the centre.
• IV line
• Shoulder dystocia Drill
• The mother must be in lithotomy position, legs up in
stirrups with buttock at the edge of the bed.
• Empty the bladder
• Extend episiotomy.
• McRobert maneuver:
• Hyperflex hips and knees and abducts hips.
• Suprapubic pressure to dislodge anterior shoulder.
• Downward axial traction on fetus.
• Failing the above,deliver the posterior shoulder
followed by the anterior shoulder.
• Failing the above,activate referral/retrieval system
District Refer to flow chart (required)
Hospital
Specialists
Notes
170
171
172
MANAGEMENT OF SHOULDER DYSTOCIA
ALGORITHM FOR THE MANAGEMENT OF SHOULDER DYSTOCIA
CALL FOR HELP

Midwife coordinator, additional
Discourage pushing
midwifery help, experienced
Move buttock to edge of
obstetrician, neonatal team to
bed
standby
MCROBERTS’ MANOEVRE
(thigh to abdomen)
SUPRAPUBIC PRESSURE
(and continue traction)
Consider episiotomy if will make

internal manoeuvres easier
Try either maneuver first

depending on clinical
circumstances
DELIVER POSTERIOR ARM INTERNAL ROTATION

MANOEUVRES
Inform consultant obstetrician

and anesthetist
If above manoeuvre fail to

released impacted sholders,
consider ALL-FOURS POSITION
(if appropriate) or repeat all
above again
Consider cleidotomy, Zavaneli 173

manoeuvre or symphysiotomy
SECTION J
PUERPERIUM CONDITIONS
174
PUERPERIUM CONDITION
Puerperal sepsis
Introduction Despite significant advances in diagnosis, medical management and
antimicrobial therapy, sepsis in the puerperium remains an important
cause of maternal death, accounting for around 10 deaths per year in the
UK. Severe sepsis with acute organ dysfunction has a mortality rate of
20-40%, rising to 60% if septicaemic shock develops.
Definition Sepsis developing after birth until 6weeks postpartum
Sepsis is defined as infection plus systemic manifestation of infection
Severe sepsis is defined as sepsis plus sepsis induced organ dysfunction

or tissue hypoperfusion
Septic shock is defined as persistence of hypoperfusion despite adequate

fluid replacement therapy
Causes e. Pelvic infection [Endometritis, abscess]
f. Retained placental tissues.
g. Surgical wound infection [Caesarean, episiotomy].
h. DVT.
i. UTI.
j. URTI/sore throat.
k. Pneumonia.
l. Mastitis or breast abscess.
m. Pelvic hematoma.
Clinical findings 1) Fever
2) Pain
3) General symptoms - vomiting, headache, loss of appetite,
general malaise.
4) Abdomen - deep tenderness (in wide-spread pelvic infection)
5) Vaginal examination - Vulva / vagina - infected wounds, pus,
inflamed and induration around wound. Uterus sub-involuted,
pain on movement of uterus, adnexal tenderness
Differential
Diagnosis
FBC - WBCs (white blood cells counts) raised
Blood cultures
Urine: UFEME and C&S
HVS C&S
175
Ultrasound scan: For Retain POC, haematoma.
MANAGEMENT Management involve detail history for risk factors for infection, detail
physical examination and appropriate investigations. Treatment usually
involved broad spectrum antibiotics and surgical intervention may be
necessary.
a) IV drip: Correct dehydration / for stabilization of patient.

b) Antibiotics : depend on organism, analgesics for pain, vitamin
supplements.
c) Surgery :
Infected episiotomies, stitches removed to drain out
pus.
Abscess - drained.
Retained tissues in the uterus - ERPOC should be
performed after iv antibiotics coverage.
d) Good nourishing diet.
e) Optimum perineal care.
f) Thromboprophylaxis if indicated.
g) Depend on severity of infection - ICU care .
176
PUERPERIUM CONDITION
Secondary postpartum haemorrhage

Introduction(9) In developing countries, postpartum haemorrhage (PPH) remains one of
the major cause of maternal morbidity and mortality.
Definition Excessive bleeding from genital tract 24 hours post delivery up to 6
weeks postpartum
Presentation Vaginal bleeding may present as slight to heavy bleeding (and rarely
hypovolaemic shock)
Clinical Findings May include offensive lochia, abdominal cramping, uterine tenderness,
pyrexia, enlarged uterus and an open cervical os.
Differential Infection
Diagnosis Endometritis, myometritis, parametritis
Infection or dehiscence of caesarean scar
Trauma
Missed vaginal lacerations and haematomas e.g. ruptured
vulval haematoma (may be associated with operative delivery)
Abnormalities of placentation
Subinvolution of the placental site
Retained products of conception
Placenta accreta
Pre-existing uterine disease
Uterine fibroids (leiomyomata)
Cervical neoplasm (rare)
Cervical polyp
Uterine arteriovenous malformation (rare)
Coagulopathies
Congenital haemorrhagic disorders (von Willebrand’s disease,
carriers of haemophilia A or B, factor XI deficiency)
> Use of anticoagulants (e.g. warfarin)
Investigations Blood: FBC, Coagulation profile, GSH/GXM, blood culture if signs of
infection
Urine:
Imaging:US pelvis
Others: HVS C&S
Healthcare
MANAGEMENT centre Assess vital signs, stabilize the patient, IV access and
District refer to Hospital with specialists
177
Hospital
Hospital with The pragmatic approach is stabilisation, investigation
Specialists to establish a cause for the bleeding and appropriate
treatment
The initial treatment mainstays are administration of
uterotonic agents, antibiotics and consider need for
surgical intervention if bleeding is heavy and ongoing
e.g. urgent evacuation of the uterus
Refer to flow chart (required)
178
MANAGEMENT OF SECONDARY PPH IN HEALTHCARE CENTRE
Significant causes of Assessment Condition stable

2ndary PPH
- ABC - Conservative
- Retained POC - History management
- Infection - Vital signs - Monitor vital
(endometritis) - Clinical symptoms signs
- Subinvolution and signs - IV access
- Assess uterine size - Investigations
- Estimate blood loss (see box below)
- Antibiotics
- Consider :
-Uterotonics
-Ultrasound
Stabilisation of massive bleeding
Call for senior obstetric and anaesthetic assistance
Resuscitation Investigations
- Lie flat - FBC, coagulation profile,

- Administer O2 GSH/GXM
- Monitor vital signs - blood cultures if temp > 38 oC
- 2 IV cannula - Speculum examination
- Consider uterine massage - Ultrasound
- IV Oxytocics, ergometrine,
Carboprost
- Resuscitate with rapid
infusion of cystalloids
- Avoid hypothermia
Treatment
- Commence antibiotic
- Consider balloon catheter,
179
surgical measures if bleeding
continues
PUERPERIUM CONDITIONS
Puerperal psychosis
Introduction Postpartum psychosis is a severe mental illness with a dramatic onset
shortly after childbirth, affecting approximately 1–2 in 1000 deliveries. It
is a severe episode of mental illness which begins suddenly in the days or
weeks after having a baby Women with bipolar disorder have at least a 1
in 4 risk of suffering postpartum psychosis. Genetics are also a factor and
women with bipolar disorder and a personal or family history of
postpartum psychosis are at particularly high risk with greater than 1 in
2 deliveries affected by postpartum psychosis.
Women at high risk of postpartum psychosis need very careful care

before conception, throughout pregnancy and during the postpartum
period, including pre-conception counselling and close monitoring and
psychiatric assessment after childbirth.
Postpartum psychosis is different from postnatal depression because it is

a more severe illness
Postnatal depression affects 10 to 15 in every 100 women after
childbirth lasting at least two weeks.
Postpartum blues usually starts 3 to 4 days after birth and usually stops
by the time the baby is about 10 days
Definition It is a severe episode of mental illness which begins suddenly in the days
or weeks after having a baby. Symptoms vary and can change rapidly
Presentation High mood (mania), depression, confusion, hallucinations and delusions
Clinical findings High mood (Mania)

feeling ‘high’, ‘manic’ or ‘on top of the world’
rapid changes in mood
severe confusion
being restless and agitated
racing thoughts
behaviour that is out of character
being more talkative, active and sociable than usual
feeling paranoid, suspicious, fearful
losing inhibitions
Depression
low mood and tearfulness
anxiety or irritability
180
being very withdrawn and not talking to people
finding it hard to sleep, or not wanting to sleep
Confusion
rapid changes in mood severe confusion
feeling as if in a dream world
Hallucination
Delusion
Differential Septicemia
Diagnosis Space occupying lesion (SOL)
FBC
Renal profile
LFT
UFEME
RBS
Septic workout if indicated
Imaging
CT brain if SOL suspected
MANAGEMENT Puerperium
-Referral to psychiatrist
-Investigate for organic cause and treat if present
-If sepsis, start broad spectrum IV antibiotics
-If SOL for neurosurgical intervention
-For anti-psychotic treatment(commenced by psychiatrist) after organic
causes excluded
-Ensure follow-up with psychiatric clinic
-MO / FMS review at Klinik Kesihatan
181
SECTION K
INTRAPARTUM CONDITIONS AND
PROBLEMS
182
INTRAPARTUM CONDITIONS AND PROBLEMS
Normal Labour Progress

Definition Physiological process during which the product of conception are
expelled outside the uterus.
Labour is a clinical diagnosis and the onset of labour is defined as
regular, painful intermittent uterine contractions resulting in the
progressive cervical effacement, dilatation and descend of presenting
part.
First Stage of Latent first stage of labour – a period of time, not necessarily continuous,
Labour when:
painful contractions
cervical change, including cervical effacement and dilatation up
to 4 cm.
Established first stage of labour :

regular painful contractions
progressive cervical dilatation from 4 cm
Second Stage of Complete Cervical dilatation ends with the delivery of fetus
Labour Monitoring of second stage of Labour with Partogram (see Partogram)
Monitoring of fetal well-being with intermittent Cardiotocograph
Pain relief and hydration
Companionship
Third Stage of Period between delivery of fetus and the delivery of placenta
Labour
Investigations Blood: FBC, GSH
Urine: UFEME, Dipstick Ketone and Protein
Maternal Well Being
First Stage Of 4 hourly temperature and blood pressure
Labour Hourly pulse
Management Half hourly documentation of contractions ( frequency per 10
min, duration of contractions <20, 20-40, >40)
Frequency of emptying the bladder
Abdominal and vaginal examination 4 hourly
Fetal Well Being

183
Fetal heart rate by daptone or CTG every 15 min
Second Stage of Monitor fetal heart for duration of 1 minute every 5 minutes after
Labour contractions.
Management Consider oxytocin for nulliparous if contractions inadequate.
Third Stage of Routine administration of uterotonic drugs
Labour Commonly used agent are IM Oxytocin (Syntocinon ) 10 IU or IM
Management Syntometrine (oxytocin 5 IU + Ergometrine 0.5 mg )
Early clamping and cutting of the cord
Placental delivery and controlled cord traction
Partogram A partograph is a diagrammatic representation of the progress of labour.
It is where all observations of the mother and her fetus are charted in a
manner which facilitates monitoring of the progress of labour by the
health care worker.
Modified WHO partograph commences at 4 cm cervical dilatation

and dispenses with the recording of the latent phase of labour.
The main components that need to be monitored and plotted on the

partograph are:
Fetal condition
The progress of labour
Maternal condition
184
Normal Labour
Admission
Assessment of patient
In labour
Os ≥4cm <4cm
Assessment of Discharge Admit and

Risks with Advice review 6
hours
Sent to labour suite

Manage Labour
Progress
Chart on Partogram
185
186
Abnormal Labour Progress
First Stage of If delay in the established first stage is suspected, take the following into
Labour account:
parity
cervical dilatation and rate of change
uterine contractions ( start Oxytocin )
station and position of presenting part
the woman's emotional state.
Primary dysfunctional labour

The rate of cervical dilatation is less than 1 cm/hour in the
active phase of labour due to ineffective uterine contractions of
less than 3 in 10 minutes, each lasting less than 40 seconds.
.
Cephalopelvic Disproportion (CPD)
Secondary arrest of cervical dilatation and descent of the
presenting part occurs despite good uterine contractions. This
can be either:
o Absolute – due to big fetus or small pelvis
o Relative – due to fetal malposition
Refer to Diagram
Management Healthcare Centre Refer to hospital with Specialists

District Hospital Refer to hospital with Specialists
without Specialists
Hospital with Follow protocol for Caeserean Section
Specialists
Second Stage of Prolonged Second Stage Of Labour
Labour Offer instrumental birth if there is concern about the baby's
wellbeing
Third Stage of Refer Third Stage Complication Protoccol

Labour
187
188
OPERATIVE DELIVERY
Instrumental Delivery
Definition Delivery in which the operator uses forceps or a vacuum device to
extract the fetus from the vagina, with or without the assistance of
maternal pushing
Indications Protracted second stage of labour,
Suspicion of immediate or potential fetal compromise
Shortening the second stage for maternal benefit
Assessment Mother is fully prepared
Clear explanation and informed consent
Appropriate analgesia
Maternal bladder is emptied
Aseptic technique
Maternal and Fetal Assessment

Fetal head at least station 1+
Fetal heartbeat present
Vertex presentation
Cervix fully dilated
Membranes are ruptured
Position of presenting part is known
No significant caput or moulding
Pelvic is adequate
Performed by trained and experienced operator or supervised operator
Investigations Blood: GSH ,

Others: Continous CTG
Forceps ( refer flowchart)
PROCEDURES Vaccuum ( refer flowchart)
COMPLICATIONS Maternal Complications

Third degree tear
Postpartum Hemorrhage
Uterine Atony
Shock
Prolonged Labour
Sepsis
189
Genital Prolapse
Urinary and Bowel Incontinence
Fetal Complications
Facial Nerve Injury
Injury to Soft Tissue and Face
Skull Fracture
Intracranial Hemorrhage
Asphyxia
Notes Alert the pediatric doctor to standby during the procedure
190
FORCEPS DELIVERY
Forceps Delivery
Strict Aseptic Technique
Reassessment Vaginal
Examination
Perform Perineal Block / Local

Infiltration
Check Blade before Application
Apply blade.
DO NOT FORCIBLY LOCK THE
BLADE
Apply Traction Only during

Contractions
Encourage Mother to bear down

Abandon the procedure if:
during contractions
Failure to insert
Failure to lock
No progress in descent
on traction
Remove Blade once The Head is

Delivered
191
Examine the Baby for Evidence of
Injury
Ventouse Assisted Delivery
Introduction Ventouse also known as vaccum assisted vaginal delivery, is a method to
assists delivery of a baby using a vacuum device.
It is used in second stage of labour if it has not progressed adequately.
It may be alternative to forceps delivery and caesarean section
Type of Ventouse
The rigid cup (i.e Malmstrom Cup)
The soft cup ( i.e Kiwi Omnicup, Silicone )
Indications Protracted second stage of labour,
Suspicion of immediate or potential fetal compromise
Shortening the second stage for maternal benefit
Asessment Mother is fully prepared
Clear explanation and informed consent
Appropriate analgesia
Maternal bladder is emptied
Aseptic technique
Maternal and Fetal Assessment

Fetal head at least station 1+
Fetal heartbeat present
Vertex presentation
Cervix fully dilated
Membranes are ruptured
Position of presenting part is known
No significant caput or moulding
Pelvic is adequate
Performed by trained and experienced operator or supervised operator
Investigations Blood: GSH

Others: Continous CTG
Maternal Complications
COMPLICATIONS Third degree tear
Postpartum Hemorrhage
Uterine Atony
Shock
Prolonged Labour
Sepsis
Genital Prolapse
Urinary and Bowel Incontinence
Fetal Complications
192
Injury to Soft Tissue
Cephalohematoma
Subgaleal Hematoma
Subaponeurotic Hemorrhage
Notes Should not be applied on the fetal scalp more than 20 minutes
Alert the pediatric doctor to standby during the procedure
193
VENTOUSE ASSISSTED DELIVERY
Vacuum Delivery
Strict Aseptic Technique
Reassessment of Vaginal
Examination
Perform Perineal Block/ Local

Infiltration
Connect Pump to check any

leakage prior to delivery
Insertion of Cup
Soft cup: collapsed the
cup by operator hand
and introduce to the
labia
Rigid cup : Separate the
labia and gently slipped
into the vagina, then
position against the fetal
head
Apply cup to the flexion point

(see diagram)
Apply vacuum pressure

7-8 kPA ( 450 -600 mmHg)
Apply Traction Only During

Contraction
Encourage Mother to Bear down

during Contractions Abandon the procedure when:
Hissing sound and the vaccum 194
did not build up
Cup slips off more than once
Released Cup Once Baby
Delivered
195
CAESAREAN SECTION
Definition Surgical Procedure used to deliver a baby through incision in the

mother’s abdomen and uterus
Indications Maternal Indications
2 or more previous scar or failed trial of scar
Cephalopelvic disproportion
Placenta previa / Vasa Previa
Severe Preeclampsia and eclampsia with unfavourable cervix
Maternal condition in which the stress of normal labour
significantly increase the risk of cardiac failure and and
cardiopulmonary collapse (i.e primary pulmonary
hypertension)
Maternal contraindication of Vasalva Manouver (i.e heart
disease)
Obstruction to the birth canal (i.e ovarian or uterine tumour)
Lesions at the lower genital tract
Maternal requests despite extensive counseling
Fetal Indications
Fetal Distress
Malpresentation ( i.e transverse and oblique lie)
Breech presentation (refuse or failed external cephalic version)
Brow presentation in labour
Macrosomic baby with previous history shoulder dystocia
Twin / multiple pregnancy with leading twin non vertex
presentation
Mother with active herpes infection
Mother with HIV infection, viral count more than 1000
copies/ml
Classification of Level 1 – Immediate threat to life of woman and fetus
Urgency of Level 2 – Maternal or Fetal compromise that is not immediately life
Caesarean Section threatening
Level 3- No maternal or fetal compromise but needs early delivery
Level 4- Delivery time to suit woman or staff
Investigations Blood: GSH or GXM , FBC
Others: Continuous CTG,
Written Informed Consent and Tubal Ligation when indicated
PREOPERATIVE Anesthetist review
Preoperative prophylactic antibiotic
Premedication with H2 blockers ( Ranitidine, Sodium citrate )
Foley’s catheter insertion
196
COMPLICATIONS Anesthetic Complications
Aspiration syndrome
Hypertension
Spinal headache
Atelectasis
Pneumonia
Surgical Complications
Bleeding (i.e Post partum hemorrhage)
Bladder injury
Paralytic ileus
Ureteric injury
Thromboembolism
Amniotic fluid embolism
Long term Complication ( placenta previa, placenta accrete, and
uterine rupture in future pregnancy)
Post Operative Care Vital signs monitoring

Input and output monitoring
Continue oral or parenteral analgesia
IV Oxytocin infusion (20-40 IU) in 500 ml over 4 hours
Thromboprophylaxis for at least 7 days to follow as protocol
Wound care and inspection on day 2
Contraception and breastfeeding advice
Notes Next vaginal birth delivery (VBAC) depends on the indication and
complication during the procedure
197
SECTION L
VAGINAL BIRTH AFTER CAESAREAN
SECTION (VBAC)
198
VAGINAL BIRTH AFTER CAESAREAN SECTION
Introduction Planned VBAC is appropriate for and may be offered to the majority of
women with a singleton pregnancy of cephalic presentation at 37+0
weeks or beyond who have had a single previous lower segment
caesarean delivery, with or without a history of previous vaginal birth.
Planned VBAC is contraindicated in women with previous uterine

rupture or classical caesarean scar and in women who have other
absolute contraindications to vaginal birth that apply irrespective of the
presence or absence of a scar (e.g. major placenta praevia).
Healthcare 1. Dating scan (preferably first trimester) to be certain
MANAGEMENT centre / O&G of gestational age.
clinic 2. Refer for Obstetrician review at 36-37 weeks.
3. Determine as accurate as possible:
- indication
- any complication of previous C-section
- contraindication for trial of scar
4. Review previous notes if available
5. Assessment of any contraindication for trial of scar.
6. Counselling with couples regarding trial of scar
versus repeat C-section
District If patient presented in labor, refer to hospital with
Hospital specialist
Hospital with Intrapartum managements:
Specialists 1. Allow clear fluid
2. Intravenous drip
3. Prepare GSH
4. Monitor signs and symptoms of impending rupture
- maternal/fetal tachycardia
- scar tenderness
- fresh PV bleeding
- hematuria
- abnormal CTG
5. Continous CTG monitoring
6. Adequate analgesia
7. Use of syntocinon if indicated
199
SECTION M
DRUGS IN PREGNANCY AND LACTATION
200
DRUGS IN PREGNANCY AND LACTATION
Introduction Pregnant women conceive taking a wide variety of both prescription and
over the counter medications in which required for specific pregnancy
and non-pregnancy related conditions. Large majority of drugs across
the placenta and secreted in the breastmilk with some drugs have
significant fetal/neonatal side effect.
Definition Any medications consume during pregnancy and lactation
Presentation 1. Allergic reaction towards the drugs
2. Effectiveness of the drugs due to increase in plasma volume,
reduce level of albumin and increase in the renal clearance
during pregnancy
3. Drugs that across the placenta and express in the breastmilk
4. Placental drug metabolism
5. Teratogenicity
Clinical Findings 1. Allergic reaction
2. Ineffectiveness of the drugs
3. Impairment in fetal growth and congenital abnormality
4. Miscarriages
5. Nephrotoxic effects in pregnancy- acute/chronic renal failure
Differential -
Diagnosis
Investigations Blood: FBC, specific drugs level in blood, blood C&S, coagulation profile,
RP,LFT
Urine: UPT, UFEME, urine for opioids
Imaging: ultrasound, MRI
Others: -
Healthcare Refer to table
MANAGEMENT centre
District Refer to table
Hospital
Hospital with Refer to table
Specialists
Notes Drugs in pregnancy and breastfeeding should be used at the lowest
effective dose, using the lowest number of drugs (monotherapy when
possible)
Mothers who are taking radioactive isotopes therapy and
antimetabolites therapy for cancer are contraindicated for breastfeeding
201
Examples of drug prescribing considerations during pregnancy
CARDIOVASCULAR SYSTEM
DRUGS PRECONCEPTION EFFECTS OF FETAL LACTATION
PREGNANCY CONSIDERATIONS
Ace inhibitors, Should be Avoid-only use if Teratogenic in Considered
ARBs changed to no alternative first trimester. compatible
alternative if with fetal Renal and cardiac
possible monitoring of problem in late
growth and gestation
liquor volume.
Stop if
oligohydramnios
Anti- Optimize blood Nifedipine may Beta-blocker Present in
hypertensives pressure control demonstrate associated with breast milk
increased fetal growth (except
clearance in 3rd restriction (less so nifedipine,
trimester with labetolol). which is >90%
Intravenous doses protein bound).
should be given Infant reported
with fetal normotensive,
monitoring so considered
safe
Statins - - Usually stop as Considered
may adversely compatible
affect placental
development.
Studies ongoing
ANTIBIOTICS
Penicillins/ - Increased renal Cross placenta, Small amount in
cephalosporins excretion, lower considered safe breastmilk, safe
plasma level
Tetracyclines - - Increased risk Found in
NTD, cleft palate breastmilk.
and Concern about
cardiovascular effect on teeth
effects (not
doxycline). Tooth
discoloration
Ciprofloxacin - - Only small Concentrated in
amount cross breastmilk.
placenta, but has Neonatal
been associated Clostridium
with difficile has
202
bone/cartilage been reported
problems.
However, few
data
ANALGESICS
Paracetamol - - Safe Safe
NSAIDS - - Premature closure Considered safe
of ductus and
kidney
dysfunction
>32weeks
Opiates - - No major effects May improve
known, fetal fetal withdrawal
dependence and symptoms
withdrawal
IMMUNOSUPPRESSANTS
Steroids - Usual maternal Weak association Unknown level
side effects. with cleft lip. in breastmilk
Risk-benefit Placenta but usually
analysis to metabolizes 90% considered
continuing of prednisolone. safe
treatment Association with
reduced fetal
weight
Azathioprine Counsel safe Considered Fetal liver lacks Low
safe enzyme to convert concentration
to active of metabolites
metabolite (6- in breastmilk.
marcaptopurine) However,
theoretical of
immunosuppre
ssion, thus
usually not
recommended
for
breastfeeding
Cyclosporine Counsel safe Counsel safe Increased risk of As above
fetal growth
restriction
203
PSYCHIATRIC DRUGS
SSRIs Consider May require Paroxetine and Present in
changing to ones increased dose sertraline breastmilk.
with lowest associated with Avoid feeding
association with teratogenicity at times of peak
abnormalities such as cardiac plasma
(i.e. change from defects,
paroxetine). omphalocoele
Discuss risks and (risk low
benefits approximately
2/1000).
Fluoxetine crosses
placenta but not
considered
teratogen
Lithium Risk-benefit Risk-benefit Cardiovascular Found in
analysis analysis involving malformation, breastmilk.
involving psychiatrist. Some floppy infant, Breastfeeding
psychiatrist suggest neonatal generally
reducing/stopping arrhythmias, avoided as
just prior to hypoglycemia, neonatal
delivery thyroid clearance
dysfunction slower than
adult
ANTI-EPILEPTICS
Sodium Optimize Total Teratogen that is Enter
valproate treatment on concentrations rapidly breastmilk.
lowest dose, fall, but more so transported to Neonatal serum
avoid if possible than the fetus. Associated level <10% of
unbound with ‘Valproate maternal levels
concentrations. syndrome’,
As developmental
teratogenicity is delay
dose dependent,
need to measure
unbound level
Carbamezepine Obtain control on - Associated with Probably safe in
lowest dose facial breastfeeding
possible dysmorphism,
developmental
delay, NTD,
204
phalanx and nail
hypoplasia
Phenytoin Obtain control on Total Associated with Low transfer in
lowest dose concentrations congenital heart breastmilk.
possible fall, but more so defects and cleft Considered safe
than the palate
unbound
concentrations.
As
teratogenicity is
dose dependent,
need to measure
unbound levels
Lamotrigine Obtain control on Increased Crosses placenta, Low transfer in
lowest dose clearance due to limited data as breastmilk.
possible increased UGT newer drug Considered safe
activity
ANTI-COAGULANTS
DRUGS PRECONCEPTIO EFFECTS OF FETAL LACTATION
N PREGNANCY CONSIDERATIONS
Warfarin Discuss risk, and Depends on Teratogen. Does not enter
make plan for reason for use. In Exposure between breastmilk as
pregnancy. general, avoid 6 and 10 weeks highly protein
Depends on use at period of associated with bound
indication for greatest embryopathy.
anti-coagulation teratogenicity Higher dose (>5
and after 36 mg/day)
weeks. Maybe associated with
safe to use higher fetal risk
heparin as
alternative
throughout
pregnancy, but
for women with
metal valves this
may not provide
sufficient anti
coagulation
Heparin Reassure safe in Safe in Does not across Safe in
pregnancy pregnancy. placenta due to breastfeeding
Increased renal molecular size
clearance, may
require increased
dose. Monitoring
of Xa levels if
therapeutic
205
(rather than
prophylaxis is
required)
206
SECTION N
CONTRACEPTION
207
CONTRACEPTION
Introduction Birth control also known as contraception and fertility control, is a

method or device used to prevent pregnancy. Planning, making available,
and use of birth control is called family planning.
Definition The deliberate use of artificial methods or other techniques to prevent

pregnancy as a consequence of sexual intercourse.
Methods Hormonal Non Hormonal Natural

COC Cu-IUD LAM
POP Barrier Method Withdrawal
Injectable Spermicide Calendar Method
Implant Tubal Ligation
LNG-IUD Vasectomy
Patch and Ring
Relevant Blood pressure

Examinations Weight (BMI)
Breast Examination
Bimanual examination and cervical inspection (if indicated)
i. Blood Sugar
ii. Lipid Profile
iii. Renal Profile
iv. Liver Profile
v. Full Blood Count
Urine: Urinalysis
Others:
PAP Smear
Healthcare Refer to WHO MEC WHEEL 2015 UPDATE
MANAGEMENT Centre
District Refer to WHO MEC WHEEL 2015 UPDATE
Hospital
Hospital with Refer to WHO MEC WHEEL 2015 UPDATE
Specialists
208
SECTION O
THROMBOPROPHYLAXIS IN OBSTETRICS AND
GYNAECOLOGY
209
THROMBO-PROPHYLAXIS
Introduction Venous thrombo-embolism (VTE) complicates between 1 in 500 and 1 in

2000 pregnancies and is more common postpartum than antepartum.
Furthermore, obstetric VTE is now recognized as a leading cause of
maternal death in Malaysia. It is a potentially preventable cause of death.
Those patient who at risk should be assessed before giving thrombo-
prophylactic therapy. VTE includes deep venous thrombosis (DVT) and
pulmonary embolism (PE).
Postoperative VTE is a recognized complication following major pelvic

surgery including gynaecological surgery. It is difficult to estimate true
incidence of VTE as many of them are asymptomatic. However, the risk
of symptomatic VTE is highest within 2 weeks of surgery and the risk of
fatal PE is highest within 1 week of surgery. (CPG: Prevention and
Treatment of Venous Thrombo-embolism; MOH 2013)
All patient undergoing major obstetrics and gynaecological surgery

should have their risk of VTE and bleeding risk assessed as
recommended in CPG; MOH 2013. The recommendation for thrombo-
prophylaxis for Kedah state is as listed in the table below.
Presentation Unilateral leg swelling
Calf pain
Unexplained tachycardia
Shortness of breath
Differential Cellulitis
Diagnosis Lymphoedema
Pneumonia
Heart failure
Pericardial effusion
Investigations Blood: FBC, PT/aPTT
Imaging: Compression ultrasound of lower limb,
CXR, ECG, CTPA scan if PE suspected
Notes 1. Recommendation for thrombo-prophylaxis in this protocol is
adapted from CPG: Prevention and Treatment of Venous
Thrombo-embolism; MOH 2013 with consideration of local
setting and cost implication.
2. Treatment of proven VTE to follow recommendation by CPG:

Prevention and Treatment of Venous Thrombo-embolism; MOH
2013.
210
VTE RISK ASSESSMENT
VTE risk assessment All patients undergoing gynaecology surgery need to have VTE
risk assessment as they are at risk for developing VTE. Risk
factors for VTE:
1. Active cancer
2. Obesity [ BMI > 30kg/m2 ]
3. Current use of estrogen containing OCP
4. Current use of HRT
5. Previous VTE
6. F/H of VTE
7. One or more medical co-morbidities
. Heart Disease
. Metabolic, endocrine or respiratory pathologies
. Acute infectious disease
. Inflammatory condition
. Sickle cell disease
. Thalassemia
. Varicose vein with phlebitis
BLEEDING RISK ASSESSMENT
THE IMPROVE BLEEDING RISK SCORE
Bleeding Risk Factor Score

1. Active gastro-duodenal ulcer 4.5
2. Bleeding episodes < 3 months prior to 4
admission
3. Platelet count < 50x 109 /L / concomitant 4
Anti-platelet therapy
4. Age > 85 yrs old 3.5
5. PT > 1.5x Normal 2.5
6. Renal failure with GFR < 30 ml/min 2.5
7. CCU / ICU Admission 2.5
8. Central Line catheter in place 2
9. Rheumatic/auto-immune disease 2
10. Current cancer 2
11. Age 40-84 yrs 1
12. Male 1
13. GFR 30 – 59 ml/min 1
High Risk Risk Score ≥ 7
Low Risk Risk Score < 7
211
THROMBO-PROPHYLAXIS
Gynaecology
VTE PROPHYLAXIS IN PATIENTS UNDERGOING GYNAECOLOGICAL SURGERY
Risk Category Recommended prophylaxis

Low risk 1. Ambulatory patient
Age < 40yrs old
without risk factor Early Aggressive Ambulation
( Grade A )
2. Minor surgery
(< 30 min)
Moderate risk 1. Patient with extra risk

1. LMWH for 7 Days or Discharge
2. Patient 40 – 60 years ( Whichever longer )
old without risk factor [grade A]
3. Major surgery (> 30

min) for benign
disease
High Risk 1. Surgery in patient

. > 60yrs 1. LMWH for 7 Days or Discharge
. 40-60yrs with an extra ( Whichever longer ) + TED stocking
risk [grade A]
. multiple risk factors
2. Major surgery for

Cancer
212
THROMBO-PROPHYLAXIS
Ovarian Hyperstimulation Syndrome (OHSS)

Introduction OHSS is a potential complication following ovarian stimulation during
assisted reproductive technique (ART)
Definition
Presentation
Clinical Findings Classification of severity of OHSS:
Grade Symptoms
Mild OHSS Abdominal bloating
Mild abdominal pain
Ovarian size < 8cm
Moderate OHSS Moderate abdominal pain
Nausea +/- vomiting
Ultrasound evidence of ascites
Ovarian size 8-12cm
Severe OHSS Clinical ascites ( +/- hydrothorax)
Oliguria
Hematocrit > 45%
Hypoproteinemia
Ovarian size >12cm
Critical OHSS Tense ascites or large hydrothorax
Hematocrit > 55%
WCC >25 x109
Oliguria/anuria
Thrombo-embolism
ARDS
Healthcare Refer hospital
MANAGEMENT District Refer table
Hospital
Hospital with In moderate and severe OHSS:
Specialists Start S/C Tinzaparin 3500unit daily till 4 weeks
beyond resolution of symptomatic OHSS in
unsuccessful cycles or till 12 weeks in successful
cycles
213
THROMBO-PROPHYLAXIS
Obstetrics
VTE PROPHYLAXIS IN OBSTETRICS: ANTENATAL
Risk Category Recommendation

Low Risk Ambulatory patient with any 2 or less Mobilisation
of the following risk factors Avoid dehydration
. Age > 35 yrs old
. Obesity BMI >30
. Parity ≥ 3
. Smoker
. Gross varicose vein
. Current systemic infection
. Immobility
. Pre- Eclampsia
. Dehydration / Hyperemesis /
OHSS
. Multiple pregnancy
. ART
Intermediate risk 1. ambulatory patient with ≥ 3
risk factors above or Start LMWH
admitted with ≥ 2 risk factors. In patient with obesity BMI > 40 +
another 2 risk factors.*
2. Patient admitted to hospital
With: Otherwise, follow as in Low risk
- Single previous VTE with category.
no Family History.
- Medical Co-morbidities
. Heart/Lung disease * Patient needed LMWH under
. SLE this categories need to be
. Cancer given postnatal prophylaxis
. Inflammatory conditions until 6 weeks postpartum
. Nephrotic Syndrome
. Sickle cell disease
. Thalassemia
. IVDU
3. Undergoind surgical
Procedure:
- Appendicectomy
214
- etc.
High risk Patients with : Start antenatal thromboprophylaxis

1. Single previous VTE with: with LMWH
. Family History or
. Unprovoked or estrogen
related VTE.
2. Previous recurrent VTE > 1
VTE PROPHYLAXIS IN OBSTETRICS: POSTNATAL
Risk Category Recommendation

Low risk Patient with any 1nof the Mobilization
following risk factors Avoid dehydration
. Age > 35 yrs old
. Obesity BMI >30
. Parity ≥ 3
. Elective CS
. Smoker
. Any surgical procedure in
the
Puerperium
. Gross varicose vein
. Current systemic infection
. Immobility
. Pre- Eclampsia
. Mid Cavity instrumental
delivery
. Prolonged labour > 24hrs
. PPH > 1L or required blood
transfusion
. ART
Intermediate risk Post natal patient with : 1.In patient with in-labour C-
section to give s/c heparin
1. ≥ 2 risk factors above 5000unit BD x 1 weeks.
2.Give at least 7 days post-
2. Any of this risk Factors: natal thrombo-prophylaxis
- Caesarean section in with LMWH in:
labour
- BMI > 40 i. patient with obesity
215
- Prolonged hospital BMI >40 x 7 days. and
Admission
- Medical Co-morbidities ii. patient with > 3 risk
. Heart/Lung disease factors . *
. SLE * Patient in category ii with
. Cancer one of the risk factor is BMI
. Inflammatory conditions >40, consider extension of
. Nephrotic Syndrome their duration of
. Sickle cell disease thromboprophylaxis and the
. Thalassemia duration need to be
. IVDU individualised according to
the discretion of the managing
Obstetricians.
High risk Postpartum patient with: Give LMWH until 6 weeks

post-partum
1. Any previous VTE
2. Those requiring antenatal

prophylaxis
# Not Included those require anticoagulant when not pregnant or on long term
anticoagulant such as previous VTE on warfarin, APLS with previous VTE, etc.
Recommended dose for LMWH thrombo-prophylaxis in pregnancy and postpartum are:

1) s/c tinzaparin 4500 iu daily
in patient with BW >90kg to dose s/c Tinzaparin at 75 unit/kg to a maximum of
10000unit daily
2) s/c clexane 1mg/kg body weight
216
SECTION P
REFERRALS
217
IN UTERO TRANSFER
Introduction In Utero Transfer is an important part of neonatal care and

recommended for maternal and fetal care.
Definition Safe transfer or retrieval of a woman from one clinical care setting to
another to provide care in specialist area or centre for neonatal reasons.
Management District Same

Hospital
Hospital with 1. Steroid if no contraindications and POG less
Specialists than 36 weeks.
2. Communication between all teams involved
in patient’s care.
Notes Indications for transfer

1. Requirement for enhanced care for mother, fetus and neonate.
2. Neonatal unit closed.
3. Ventilator not available.
Contraindications for transfer

1. Obstetric or Paediatric Team unable to accept patient transfer.
2. Risks of delivery during transfer (advanced labour).
3. Fetal distress requiring immediate delivery.
4. Mother refuses transfer.
218
INTERDEPARTMENTAL REFERRAL
Introduction Pregnant mother not free from medical or surgical diseases during their
pregnancy. Development of medical or surgical problems during
pregnancy require combine care management with respective speciality.

MANAGEMENT centre

Hospital
219
MANAGEMENT OF INTERDEPARTMENTAL REFERRAL IN HEALTHCARE
CENTRE/DISTRICT HOSPITAL
Acute medical/surgical-related problem with pregnancy
In labour Not in labour
Haemodynamically Haemodynamically Haemodynamically

stable not stable stable
Resuscitation
Consult on-call
specialist respective
Inform covering specialist department for further
on-call (O&G and management
respective department) Inform covering specialist
on-call (respective
department and O&G)
Admit to labour room
Casualty
220
APPENDIX
221
REFERENCES
1. Bacterial sepsis following pregnancy, Royal College of Obstetrics and Gynecologist,

Green-top guideline No.64b, April 2012
2. Centres for Disease Control and Prevention (CDC) Weekly Report, Sexually Transmitted
Disease Treatment Guidelines, MMWR 2010.
3. Clinical Practice Guidelines on Management of HIV Infection in Pregnant Woman, 2008
4. Consensus Guidelines on Antiretroviral Therapy 2014
5. Division Of Family Health Development Ministry Of Health Malaysia. Perinatal Care
Manual 2013 .3rd Edition
6. Epilepsy in pregnancy, Australia family physician 2014
7. Garis Panduan, Pengendalian Masalah Perubatan Di Kalangan Ibu Hamil di Kesihatan
Primer, 2011
8. Guideline of the American thyroid association
9. GUIDELINE ON TERMINATION OF PREGNANCY (TOP) FOR HOSPITALS IN THE
MINISTRY OF HEALTH 2012
10. M H Goldie, C E Brightling. Asthma in pregnancy. The Obstetrician & Gynaecologist2013
11. Malaysian Guidelines in the Treatment of Sexually Transmitted Infections, Fourth
Edition, 2015
12. Management of Chronic Kidney Disease in Adults, Clinical Practice Guideline, 2011
13. Management of hypertension (4th edition), Clinical Practice Guideline, 2013
14. Management of Type 2 Diabeted Mellitus (5th edition), Clinical Practice Guideline, 2015
15. National Institute of Health and Care excellence guideline
16. National Obstetrics Registry, 3rd Report 2011-2012
17. Obstetrics and gynaecology protocol state of kedah 3rd edition (2010)
18. Perinatal care manual KKM 2013, 3rd edition
19. Prevention and Treatment of Venous Thrombosis, Clinical Practice Guideline, 2013
20. Prof Dato’Dr. Sivalingam Nalliah, Prof Dato’Dr. Sachchithanantham. Clinical Protocols in
Obstetric and Gynaecology For Malaysian Hospitals. Aug. 2015
21. Report on Confidential Enquiries into Maternal Death 2006-2008
22. Royal College of Obstetricians and Gynaecologists (RCOQ), www.rcog.org.uk
23. Royal college of psychiatry 2011
24. Rushdan Noor, Bavanandan Naidu. Normal Pregnancy, Labour And Operative Delivery
For Students And Practitioners. First edition 2015
25. South Australia perinatal practice guideline
26. The management of 2’ PostPartum hemorrhage, Global library of woman medicine
27. The National Institute for Health and Care Excellence (NICE), www.nice.org.uk
28. The Royal College of Obstetricians and Gynaecologists .Green-top Guideline.
222
GYNAECOLOGY
PROTOCOL
223
CHAPTER 1
ABNORMAL VAGINAL BLEEDING
224
PER VAGINAL BLEEDING
Introduction Per vaginal bleeding can relate to an issue with reproductive system or
to other medical problems or certain medications. Many women have
abnormal bleeding between their period at some point of their life
Definition Abnormal vaginal bleeding unrelated to normal menstruation
Presentation Abnormal Vaginal bleeding
1.Menorrhagia-Heavy flow with regular menstrual cycle
2.Intermenstrual Bleeding
3.Postcoital Bleeding
4.Post-menopausal bleeding
5.Menstrual cycle longer than 35 days or shorter than 21 days
6.Bleeding before age 9
Clinical Findings 1. Signs of anemia e.g. SOB, chest pain, lethargy
2. Bleeding tendency
3. Pelvic mass
4. Constitutional symptoms of malignancy
5. Climateric symptoms
Differential PALM –COEIN (FIGO classification)
Diagnosis 1. P- Polyp
2. A-Adenomyosis
3. L-Leiomyoma
4. M-Malignancy and Hyperplasia
5. C-Coagulopathy
6. O-Ovulatory Dysfunction
7. E-Endometrial
8. I-Iatrogenic
9. N-Not yet classified
Investigations Blood: FBC, RP,LFT, Coagulation Profile, Hormonal Study (FSH,LH,
Prolactin, TFT, Day 21 Serum Progesterone)
Urine: UPT, UFEME
Imaging: Ultrasound of Pelvis, MRI, CT Scan
Others:
Biopsy of Suspicious lesion
1. Endometrial Sampling (Pipelle sampling, DD&C, Hysteroscopy
Guided DD&C)
2. Cervical biopsy/Pap Smear
3. Polyp for HPE
225
MANAGEMENT 1.Acute Resuscitation-ABC
2.Anaemia correction (Blood Transfusion and Haematinics)
3.Medication
A) Non Hormonal-Tranexamic acid iv or oral 500mg tds
-NSAID
B) Hormonal-After exclusion of malignancy
-Tab Provera 5mg daily for 21 days for 3 cycles
-Tab Duphaston 10mg bd for 21 days for 3 cycles
-COCP
4.Surgery if fail medical treatment- conservative surgery endometrial
ablation or Hysterectomy kiv BSO
Notes Refer Flow Chart
226
FLOWCHART PERVAGINAL BLEEDING MANAGEMENT
PV BLEEDING
Single/not sexually active Married/ sexually active
USG
UPT
Pelvic mass positive negative
YES NO Refer chapter

YES bleeding in - VE
pregnancy - pap smear
- pipelle/endometrial
sampling/ hysteroscopy &
CT scan / - ovulatory problem DD&C
MRI - coagulation disorder - biopsy of suspicious lesion
- DUB - polypectomy
Identified lesion Benign

Malignant
Refer
Lower genital Uterus/ adnexa Medical Rx
tract (vagina -Non hormonal chapter on
Conservative genital
cervix) -Hormonal surgery-
tract
removal of
lesion malignancy
(polypectomy,
myomectomy,
VE Laparoscopic cone biopsy
Hysteroscopy removal of
Biopsy lesion
Surgical -
Hysterectomy 227
+/- BSO
CHAPTER 2
ABNORMAL VAGINAL DISCHARGE
228
PERVAGINAL DISCHARGE
(INFECTIVE CAUSE)
Bacterial Vaginosis (NSTI)

Introduction Bacterial vaginosis (BV) is the most prevalent cause of infective vaginal
discharge. It results from a reduction in normal hydrogen-peroxide
producing Lactobacillus species that allows overgrowth of anaerobic and
other fastidious bacteria. Organisms: Gardenerella vaginalis (40%) or
other species of Prevotella, Mycoplasma, Mobilincus and
Peptostreptococcus
Presentation i. Abnormal vaginal discharge with strong fish-like odour

ii. Dysuria and / itching around the outside of the vagina
iii. 50% asymptomatic
Clinical Findings i. Discharge, if present, is usually homogeneous thin, white or

grey, uniformly adherent – coating the walls of the vagina and
vestibules
ii. Inflammation of the vaginal wall is absent
Differential i. Vaginal candidiasis

Diagnosis ii. Trichomoniasis
iii. Gonorrhea
iv. Chlamydia trachomatis
Investigations Blood: STD screening (Hep B, Hep C, HIV, VDRL, TPHA)
Urine: UFEME
Imaging: -
Others: Cervical smear for microscopy to look for clue cells or gram stain
* The Amsel Criteria can be used for diagnosis (3 of 4 criteria is
diagnostic) :
1. grey, white or yellow homogenous discharge
2. vaginal pH > 4.5
3. fishy odour (after application of 10% KOH)
4. presence of clue cells (bacteria coated vaginal epithelial cells)
Healthcare Recommended :
MANAGEMENT centre i. T. Metronidazole 400mg BD x 5-7 days or
ii. T. Metronidazole 2g in single dose
229
Alternative :
i. T. Clindamycin 300mg BD x 7 days or
ii. Intravaginal Metronidazole gel (0.75%) OD
for 5 days or
iii. Intravaginal Clindamycin cream 2% OD for 7
days
District As above
Hospital
Hospital with As above
Specialists
Notes
230
Candida (NSTI)
Introduction Candida is the second most common cause of infective vaginal discharge
and is caused by overgrowth of vaginal yeasts. The organisms involved
are: Candida albicans (80%), C. glabrata, C. tropicalis and C. krusei.
Presentation i. non-offensive thick and white discharge (‘curdy’)

ii. pruritus
iii. superficial dyspareunia
iv. dysuria
Clinical Findings Vulval erythema, oedema, fissuring or satellite lesions (small white
plaques)
Differential i. Bacterial vaginosis

Diagnosis ii. Trichomoniasis
iii. Gonorrhea
- STD screening (Hep B, Hep C, HIV, VDRL, TPHA)
- FBS TRO DM in recurrent candidiasis
Urine: UFEME and urine C+S if evidence of dysuria
Imaging: -
Others: HVS for microscopy to look for spores and pseudohyphae
Healthcare i. Vaginal Imidazole (for example, Clotrimazole

MANAGEMENT centre vaginal pessary 500mg ON)
ii. Nystatin 100 000 units/5g vaginal cream
iii. Oral Fluconazole 150mg STAT
District As above
Hospital
Specialists
Notes
231
Trichomonas Vaginalis (STI)

Introduction Trichomonas vaginalis (TV) is a pathogenic flagellate, and is the most
common STI worldwide.
Presentation i. Profuse, yellowish-green and frothy PV discharge

ii. Strong-smelling fishy odour
iii. Pruritus
iv. Dyspareunia
v. Dysuria
vi. Occasional lower abdominal discomfort
Clinical Findings i. Vagina pH of >4.5, (often > 6.0)

ii. ‘Strawberry’ cervix: punctate haemorrhagic lesions
Differential i. Bacterial vaginosis

Diagnosis ii. Candida
iii. Gonorrhea
Urine: UFEME
Imaging: -
Others:
i. Saline wet smear from posterior fornix
- Microscopy should be performed as soon as possible
after the sample is taken motility diminishes with
time
- Motile flagellates, oval or pear shaped organism with
jerky movement
- Positive in 40-80% of cases
ii. Cervical pap smear
- Sensitivity 60%, but high rate of false positives
- Not recommended
iii. PCR
- Sensitivity and specificity almost 100%
MANAGEMENT centre i. T Metronidazole 400mg BD 5-7 days or
ii. T Metronidazole 2g orally single dose or
iii. Tinidazole 2g single dose orally
232
District As above
Hospital
Specialists
Notes
233
Chlamydia Trachomatis (STI)

Introduction Chlamydia trachomatis is the commonest bacterial STI and the
prevalence is highest in persons aged < 25 years. Asymptomatic infection
is common among both men and women.
Presentation i. Asymptomatic (60-70%)
ii. Mucopurulent vaginal discharge (30-40%)
iii. Postcoital/intermenstrual bleeding
iv. Lower abdominal pain
v. Dysparaeunia
vi. Dysuria
Differential i. Candidiasis
Diagnosis ii. Bacterial vaginosis
iii. Gonorrhea
Urine: UFEME
Imaging: -
Others:
- Endocervical swab and low vagina swab for culture or
- Enzyme-linked immunosorbant assay (ELISA)
MANAGEMENT centre i. T Doxycycline 100mg BD for 1 week or
ii. Azithromycin 1g orally single dose
District As above
Hospital
Specialists
Notes
234
Neisseria Gonorrhoeae (STI)

Introduction The key sign of Neisseria gonorrhoeae is vaginal discharge in up to 50%
of cases (owing to cervicitis, rather than vaginitis). However, up to 80%
of cases are asymptomatic
Presentation i. dysuria
ii. intermenstrual or postcoital bleeding
iii. lower abdominal pain
iv. pruritus or burning sensation
Differential i. Candidiasis
Diagnosis ii. Bacterial vaginosis
Investigations Blood: STD screening (Hep B, Hep C, HIV, VDRL, TPHA) both partners
Urine: UFEME, Midstream urine for NAAT if indicated
Imaging: -
Others:
- Gram stain of urethral and cervical exudates to look for Gram
negative intracellular dipplococci
- Endocervical swab for culture using chocolate agar (gold
standard)
- Cervical swab and ELISA of fluid sample from affected area
MANAGEMENT centre i. Ceftriaxone 500mg M as a single dose and
ii. Azithromycin 1 orally as a single dose
iii.
Alternative :
i. Cefixime 400mg single dose orally or
ii. Cefotaxime 500mg IM as a single dose or
iii. Spectinomycin 2g IM as a single dose
District As above
Hospital
Specialists
Notes
235
(NON INFECTIVE CAUSE)
Introduction Pervaginal discharge can be psyhiological and pathological. Pathological

can be infective and non-infective. Non infective cause of vaginal
discharge can be due to foreign body, fistulae, cervical polyp, allergic
reaction or genital tract malignancy.
Presentation - Foreign body : Persistent, foul smelling vaginal discharge,

bleeding and/or pelvic pressure
- Fistulae : chronic foul or faeculent vaginal discharge following

history of trauma or previous surgery
- Cervical polyp : increased vaginal discharged, post coital or

intermenstrual bleeding or heavy menstrual bleeding
- Genital tract malignancy : blood stained discharge or frank

bloody, purulent and foul smelling discharge due to secondary
infection in advanced malignancies
- Allergic reaction : vaginal discharge, pruritus and burning

sensation of vagina
Clinical Findings Present of foreign body (ie tampon, condom), vaginal/cervical

growth/polyp
Urine: UFEME
Imaging: -
Others:
- Cytologic smear
- Colposcopy
- HVS C+S
- All screening TRO infective causes
** All PV discharge need to be screened for STD
Healthcare Removal of foreign body if feasible otherwise, refer to

MANAGEMENT centre tertiary center
236
District Removal of foreign body if feasible otherwise, refer to
Hospital tertiary center
Hospital with Examination under anaesthesia (EUA), removal of

Specialists foreign body, polypectomy, excision biopsy of growth
Notes
237
CHAPTER 3
LOWER ABDOMINAL PAIN
238
LOWER ABDOMINAL PAIN
Introduction Abdominal pain is an extremely common complaint in women. The vast

majority is benign and self-limiting. However, identification of serious
pathology is necessary to allow successful treatment to be implemented
Definition Pain confined to the area below the umbilicus
Presentation 1. Pain in the lower abdomen
2. Nausea, vomiting
3. PV bleeding/ discharge
4. Diarrhea or altered bowel habit
5. Urinary tract infection symptoms
6. Fever
7. Syncopal attack
Clinical Findings 1. Tender abdomen +/- signs of peritonism
2. Hemodynamic collapse
3. Cervical excitation
4. Renal punch positive
5. Signs of sepsis-fever
6. Abdominal distension with absence of bowel sound
7. Leg swelling
8. Groin tenderness
Differential Non Obstetric/ Gynecological causes of abdominal pain
Diagnosis
Investigations Blood: FBC, C-Reactive Protein, RP, serum amylase, HCG, serum
progesterone, blood culture
Urine: UFEME, UPT, Urine C&S
Imaging: Ultrasound, Abdominal x-ray, CT scan, MRI, Doppler ultrasound
Others: Laparoscopy, Colonoscopy
MANAGEMENT centre
Hospital
Specialists
Notes Involvement of other specialties is indicated
239
FLOWCHART LOWER ABDOMINAL PAIN MANAGEMENT
Lower abdominal pain
History and examination
Investigations
Bloods
Urine
Imaging
Others
Obstetric Gynaecological Medical/Surgical

-Abruptio -Miscarriage -Appendicitis
-Polyhydramnios -Ectopic pregnancy -Bowel obstruction
-Uterine rupture -Ruptured corpus -Pancreatitis
-Chorioamnitis luteal cyst -Renal calculi
-Symphysis pubis (Haemorrhagic cyst) -Pelvic vein
dysfunction -Torsion of cyst thrombosis
-Fibroid degeneration -Leiomyoma -DKA/sickle cell crisis
-Rectus abdominal
rupture
*management depends on the diagnosis and refer to the respective chapters in the
protocol
240
CHAPTER 4
FUSED LABIAL IN CHILDREN
241
FUSED LABIA IN CHILDREN
Introduction Labial fusion is a medical condition of the female genital anatomy where
the labia minora become fused together. It is generally a common
condition of the prepubertal girl and it constitutes one of the most
common complaints presenting to paediatrician/ gynaecologists.
Definition The partial or complete adherence of the labia minora.
Presentation i. Most girls are asymptomatic

ii. Presents in infants at least 3 months old.
iii. May present with associated symptoms of dysuria, urinary
frequency, refusal to urinate, or post-void dribbling.
iv. May present with vaginal discharge (vulvavaginitis)
Clinical Findings i. Flat vulva

ii. Edges of the labia minora are sealed along the midline
beginning at the posterior fourchette and extending anteriorly
towards the clitoris
iii. A thin translucent membrane obscures the vaginal introitus
and hymen
Differential i. Mullerian agenesis

Diagnosis ii. 2. Imperforate hymen
iii. 3. Congenital adrenogenital syndrome (rare)
Investigations Blood: -
Urine: Urinalysis and Urine C&S
Imaging: Voiding Cystourethrogram (if indicated)
Others:
MANAGEMENT Centre
Hospital
Specialists
Notes
242
FLOWCHART
Labia Adhesion
Symptomatic Asymptomatic
No treatment required
Local Estrogen(Premarin Cream) treatment

-no longer than 6 weeks
Labial separation No separation/Symptoms

persisting
Application of blend emolient

(Vaseline) Surgery
243
CHAPTER 5
LABIAL/VULVAL SWELLING
244
LABIAL/VULVA SWELLING
Introduction Swelling in the labia maybe generalized, that is throughout the vulva, or
localized confined to particular structures only.
It maybe unilateral or bilateral. There may be other symptoms
associated with it like burning pain and itching
Definition Swelling in the labial or vulva
Causes/ Differential Vulva swelling maybe caused by diseases, disorders or conditions that
Diagnosis affect the vagina and other reproductive organs
1. Local swelling
-Allergy or irritation caused by soaps, feminine hygiene
products, perfumes, lubricants, douches, creams or latex
-Cyst or abscess of Bartholin’s glands
-Gartners duct cysts
-Epidermal Inclusion cyst
-Endometriotic cyst
-Skene duct cyst
-Genital Herpes
-Vaginal trauma
-Vaginal Tumors (benign e.g. lipoma, meningioma,
hidraadenoma or malignant)
-Hamartomas
-Hernia
-Infections (Candidiasis, bacterial, trichomonas)
-Insect bite
2. Generalized swelling
-Allergy
-Infection/ Cellulitis
-Generalized edema
-Pregnancy
-Lymphedema
-Injuries
-Renal Failure
-Heart Failure
-Venous Insufficiency
3. Other causes
-Fournier’s gangrene
-Drugs
Clinical Findings Swelling, Pain, Discharged, Bleeding, fever

Complications 1.Pain
2.Difficulty with sexual activities
245
3.Sexual Transmission to partner
4.Spread of cancer
5.Spread of infection to other part of bodies
Investigations Blood: STI screening, Hormonal FSH/LH,LFT, RP
Urine: Urinalysis, Urine culture
Imaging: Ultrasound Pelvis and Abdomen, CT Scan
Others: Swabs direct smear, HVS
-Vulva biopsy
MANAGEMENT Management according to condition
1. Allergic-avoidance of offending chemicals, oral antihistamine,
topical corticosteroids.
2. Inflammatory-Topical /Oral Corticosteroid, estrogen cream
3. Infection/ Cellulitis- antibiotics therapy
4. Herpes- Antiviral
5. Cyst- If recurrent or persistent –perform marsupialization,
excision of the cyst required in postmenopausal women.
6. Endometriosis- (refer to chapter on endometriosis)
7. Abscess- I&D and antibiotic therapy
8. Hernia- Herniorraphy
9. Benign Tumors and Hamartomas- Excision
10. Malignancy - refer to chapter Genital Malignancy.
Notes Refer to Flow Chart
246
FLOWCHART LABIAL SWELLING
LABIAL SWELLING
History & Examination
Investigations
Blood
Urine
Imaging
Others
Localised Generalised swelling

Cyst Allergy
Hernia Infection/ Cellulitis
Abscess /General oedema
Insect Bite During pregnancy
Vulval injury Blockage of lymphatic
Malignancy channel
Vulval injury
Renal failure / Heart
failure
247
CHAPTER 6
DYSMENORRHOEA
248
DYSMENORRHOEA
Introduction Pain related to or exarcebated during menstruation maybe a

consequence of underlying pelvic pathology although not all women with
pelvic pain have gynecological disorder. 15% reported limitation in daily
activity and lack of relief from analgesic with 8% reported repeated
absence from work and school.
Definition Pain that occur during menstruation
1. Primary dysmenorrhea is defined as menstrual pain in the
absence of pelvic pathology, resulting from excessive
prostaglandin production with the onset in young women. Pain
is crampy and spasmodic in the lower abdomen or back and
begins within a day of onset of flow, lasts 24 to 72 hours.
Primary dysmenorrhea usually improves after childbirth.
2. Secondary dysmenorrhea is defined as menstrual pain

associated with pelvic pathology. Secondary dysmenorrhea
usually has an onset in the reproductive age group, progresses
with age, and is less characteristically timed with menses. Pain
begins several days before the menses and gradually increases
in severity as menses approach.
Presentation 1. Pain during menses (may even started prior to menses)

2. Cramping lower pain that may radiated to lower back and
thigh
3. Headache, fatigue, nausea, vomiting, diarrhea and
dizziness
Clinical Findings 1. Pelvic mass
2. Tender abdomen
3. Thickened uterosacral ligament-presence of uterosacral nodule
4. PV discharge
5. Abnormal uterine bleeding/amenorrhea
Differential 1. Chronic pelvic pain
Diagnosis 2. Pelvic venous congestion
3. Premenstrual syndrome
4. Adhesions from previous surgery/infections
5. Irritable bowel syndrome
6. Interstitial cystitis
Investigations Blood: FBC, tumor markers for ovarian cysts
Urine: UFEME
Imaging: USG (TAS/TVS), MRI, HSG
249
Others: Pap smear, HVS C&S, endometrial biopsy, laparoscopy,
hysteroscopy,
MANAGEMENT centre
Hospital
Specialists
Notes
250
FLOWCHART DYSMENORRHEA MANAGEMENT
DYSMENORRHOEA
History and Examination
Investigations
Blood
Urine
Imaging
Others
PRIMARY SECONDARY
Reassurance Treat underlying causes
NSAIDs -Endometriosis
-Mefenemic -Leiomyoma
acid/Ibuprofen -IUCD user
-Naprosyn sodium -Polyps
-Celecoxib -PID
-Buscopan 10mg TDS -Cervical stenosis
Hormonal -Ovarian cysts
-COCP -Imperforated
-Depo Provera hymen/obstructed
GnRH analogue malformation of genital
tract
-Uterine synechiae
251
CHAPTER 7
PRIMARY AND SECONDARY AMENORRHOEA
252
AMENORRHEA
Primary Amenorrhea
Introduction Amenorrhea is the absence or abnormal cessation of the menses.
Primary or secondary describe the occurrence of amenorrhea before and
after menarche respectively. Menstruation requires an intact orchestra
of the hypothalamic-pituitary-ovarian and genital tract axis.
Definition Primary amenorrhea is defined as;

When there has been a failure to menstruate by age 15 in the
presence of normal secondary sexual development
When there has been a failure to menstruate and failure to
initiate breast development by the age of 13
Presentation Patients will present or referred with

i. No menses
ii. Absent of secondary sexual characteristic development such as
no breast development, no pubic and axillary hair
Clinical Findings 1. Height (normal height or short stature)

2. Secondary sexual characteristic (breast development/thelarche,
pubic hair/pubarche, height/adrenarche)
3. Examination of external genitalia to look for the presence of
vaginal or any other abnormality
4. Specific features of syndromes ie Turner Syndrome
Differential (refer table for list of differential diagnosis)

Diagnosis
Investigations Hormonal profiles (FSH, LH, TFT, PROLACTIN, OTHERS IF INDICATED)
Karyotyping (if indicated)
Urine: Urine Pregnancy Test (if indicated)
Imaging: Ultrasound abdomen to look for present of uterus or any other

abnormality
Others:
Healthcare Refer flowchart of diagnosis or management
MANAGEMENT centre
District Refer flowchart of diagnosis or management
253
Hospital
Hospital with 1. In patients diagnosed with
Specialists hypergonadotrophic hypogonadism (POF) it
is important to restore the estrogen
deficiency state
i. In patients who has no secondary sexual
characteristic, incremental dose of
estrogen can be commenced to initiate
breast and uterus development.
ii. Once satisfactory breast development
achieved, patient will require cyclical
estrogen/progesterone hormone
therapy
iii. Calcium and vitamin D supplementation
to prevent osteoporosis
iv. Patients with Turners syndrome may
require referral to other specialities.
v. Counseled on the fertility outcome.
2. In patients diagnosed with

hypogonadotrophic hypogonadism, MRI may
be indicated to rule out brain pathology.
Otherwise hormonal therapy as above.
3. Once fertility is desired, ovulation induction
can be achieved by giving FSH/LH hormonal
stimulation
Notes
254
EVALUATION OF PRIMARY AMENORRHEA
Secondary sexual characteristic present
No Yes
Measure FSH/LH Ultrasound of uterus
FSH/LH FSH > 20 miu/ml Absent Uterus

LH > 40 miu/ml present/
normal
Hypogonadotrophic
hypogonadism Hypergonadotrophic Karyotype analysis
hypogonadism
Refer to Karyotype analysis 46 XX 46 XY

Reproductive MRKH/ Androgen
Medicine Specialist Mullerian Insensitivity
agenesis Syndrome
46 XX 45 XO Refer to
Chromosome Chromosome Reproductive Outflow
competent incompetent Medicine Specialist obstruction
ovarian failure ovarian failure
(Turner
syndrome)
No Yes
Refer to
Reproductive
Medicine Specialist Refer to
Reproductive Evaluation Imperforate
Medicine Specialist for 2nd hymen or
amenorrhea transverse
vaginal
septum
Refer gynae
gynaegynae
255
AMENORRHEA
Secondary Amenorrhea
Introduction Amenorrhea is the absence or abnormal cessation of the menses.
Primary or secondary describe the occurrence of amenorrhea before and
after menarche respectively. Menstruation requires an intact orchestra
of the hypothalamic-pituitary-ovarian and genital tract axis.
In secondary amenorrhea it is important to rule out pregnancy.
Definition Secondary amenorrhea is defined as cessation of menses for 6 months or

longer in a women who has been having normal menstrual cycle
previously.
Presentation Patients will present or referred with cessation of menses
Clinical Findings 1. Weight (extreme of weight either obese or thin can cause
cessation of menses)
2. Hirsutism
3. Galactorrhea
4. Other general medical illness such as chronic illness that
may interfere with menstruation eg CRF, Thyroid disorder
Differential (refer flowchart for list of differential diagnosis)

Diagnosis
Investigations Hormonal profiles (FSH, LH, TFT, PROLACTIN, OTHERS IF INDICATED)
Urine: Urine Pregnancy Test
Imaging: TVS to visualize ovaries and rule out PCOS

Abdominal ultrasound to see uterus and rule out any outflow obstruction
HSG or hysteroscopy if indicated
Others: Karyotyping (if secondary amenorrhea occur in a women who is

less than 30 years old and investigations show POF )
Healthcare Refer flowchart of diagnosis or management

MANAGEMENT centre
District Refer flowchart of diagnosis or management
Hospital
Hospital with 1. In patients diagnosed with
256
Specialists hypergonadotrophic hypogonadism (POF) it
is important to restore the estrogen
deficiency state
i. Patient will require cyclical
estrogen/progesterone hormone
therapy to replace the
ii. Calcium and vitamin D supplementation
to prevent osteoporosis
iii. Patients should be counseled on the
difficult aspect of fertility function.
Options of donor oocyte but subjected
to ethical and religious issues
2. In patients diagnosed with

hypogonadotrophic hypogonadism, MRI may
be indicated to rule out brain pathology.
Cyclical estrogen/progesterone treatment
will be started if necessary.
3. In patients with anovulation who bleed with

progestogen challenge test, more than 90%
of anovulatory cycles is due to PCOS
a. Obese PCOS are encouraged to reduce
weight. Weight reduction will restore
menstrual cycle
b. Cyclical progesterone or OCP. Patients
with PCOS must bleed at least once in
every 3/12 to reduce the risk of
endometrial hyperplasia
4. In patients suspected of having outflow

obstruction, hysteroscopy evaluation will be
done followed by hysteroscopic
adhesionlysis and IUCD insertion and cyclical
estrogen/progesterone treatment for 3 to 6
cycles
Notes
257
EVALUATION OF SECONDARY AMENORRHEA
Secondary amenorrhea
Negative pregnancy test
Hormonal analysis
Progestogen challenge test
Withdrawal bleeding No withdrawal bleeding
Anovulation
FSH, LH FSH, LH FSH normal

Estrogen
Hypogonadotrophic OCP challenge

Repeat, if hypogonadism (estrogen
similar /progesterone)
MRI if
POF needed No bleeding
Refer gynae
TRO
Asherman/
synechia
Will require
HSG/hystero-
scopy
258
CHAPTER 8
POLYCYSTIC OVARIAN SYNDROME
259
POLYCYSTIC OVARIAN
SYNDROME (PCOS)
PCOS and Infertility

Introduction PCOS is a syndrome that has wide heterogeneity of clinical presentation.
Diagnosis is based on Rotterdam 2003 consensus criteria. About 5% of
women of reproductive age has PCOS and 25%-30% of patient attending
infertility clinic has PCOS.
Definition Rotterdam criteria 2003, (requires the presence of 2 out of 3 criteria)

Oligoamenorrhea (cycle > 35 days) or amenorrhea (absence of
menstruation)
Hyperandrogenism (biochemical and chemical)
‘PCO” ovary on transvaginal untrasound ( defined as follicle >
10 with 1 ovary being sufficient)
Presentation Infertility due to anovulation
Clinical Findings i. Obese (more than 50% of PCOS patients are obese)
ii. Hirsutism
iii. PCO ovary on transvaginal ultrasound
Differential Must exclude other endocrine abnormalities such as other causes of

Diagnosis hyperandrogenism (CAH)
Investigations Blood: If suspected other endocrine abnormalities (TSH, prolactin, serum

testosterone, FSH, LH ) otherwise not required for diagnosis
Urine: -
Imaging: Transvaginal ultrasound to visualized the ovaries and also

endometrial thickness
Others: Specific investigation to rule out other morbidity (Please refer to

PCOS and long term morbidities)
Healthcare 1. General advice on healthy lifestyle which

MANAGEMENT centre includes weight reduction in obese PCOS
patients. This is achieved via lifestyle
modification through dietary and exercise.
10% of weight reduction will help to achieve
ovulation in 40% of obese patients.
260
2. Baseline investigations of infertility which
includes seminal fluid analysis.
3. Other general advice to improve fertility
such as avoidance of tobacco and alcohol,
healthy food and micronutrients.

Hospital
Specialists
Notes
261
DISTRICT HOSPITAL/SPECIALIST WITHOUT INFERTILITY SERVICE
PCOS with infertility
SFA normal SFA abnormal on 2 occasions (at

least 6 weeks apart)
BMI < 35 BMI > 35
Weight reduction + Weight loss programme

Refer Infertility
OI commence
Specialist
Clomiphene citrate (CC)

50mg D2-D6
TVS / day 21 progesterone
Ovulating Not ovulating
Continue up to Increase 100 mg D2-D6

6 cycles TVS /day 21 progesterone

No pregnancy =
CC failure
Increase 150 mg D2-D6

TVS /day 21 progesterone
Refer Infertility
Specialist
No pregnancy =
CC resistant
262
Refer Infertility
Specialist
HOSPITAL WITH SPECIALIST INFERTILITY
CC failure/CC resistant
Check tube via HSG/ diagnostic

laparoscopy (preferable HSG if
no suspicious pelvic pathology)
Tube patent (both or either

Tube block
one)
FSH stimulation/IUI x 3 IVF
No pregnancy
263
POLYCYSTIC OVARIAN
SYNDROME (PCOS)
PCOS and Long Term Health Consequences

Introduction PCOS is a syndrome that has wide heterogeneity of clinical presentation.
Diagnosis is based on Rotterdam 2003 consensus criteria. Women
diagnosed with PCOS should be informed of the possible long term risks
to health.
Definition Rotterdam criteria 2003, (requires the presence of 2 out of 3 criteria)

i. Oligoamenorrhea (cycle > 35 days) or amenorrhea (absence of
menstruation)
ii. Hyperandrogenism (biochemical and chemical)
iii. ‘PCO” ovary on transvaginal untrasound ( defined as follicle >
12 with 1 ovary being sufficient)
Presentation All associated long term health risk associated with PCOS which include :
1. Metabolic consequences
2. Cardiovascular risk
3. Cancer risk
4. Psychological, behavioral and reduced quality of life
5. Sleep apnae
Differential Must exclude other endocrine abnormalities such as other causes of :

Diagnosis - hyperandrogenism eg (CAH)
- testosterone secreting tumour
- Hyperprolactinemia
- thyroid disorder
Investigations Blood: MOGTT at 24 to 28 weeks in patients diagnosed as PCOS before

pregnant.
MOGTT in patients with BMI >25 or lean PCOS BMI <25 with other risk
such as advance age or family history of type 11 DM. If normal to repeat
annually.
Fasting Lipid Profile annually.
Urine: -
Imaging: Transvaginal ultrasound in patients with irregular bleed to rule

out endometrial pathology particularly endometrial hyperplasia and
264
carcinoma. Patients with PCOS has 2.89 fold risk of endometrial cancer.
Others: -
Healthcare 1. Lifestyle modification through dietary and
MANAGEMENT centre exercise.
2. Baseline investigations to identify metabolic
and cardiovascular risk.
3. Asessment to exclude other comorbidities :
a. OSA
b. Endometrial hyperplasia
c. Depressive or anxiety symptoms
District As healthcare centre and include :

Hospital 1. May consider commencing anti-insulin such
as metformin in obese PCOS patients.
2. In patients with hyperlipidemia, to
commence lipid lowering treatment.
3. In oligoamenorrhea women, regular
withdrawal bleed of at least once in 3
months can be achieved by OCP or
progesterone. Endometrium can also be
protected by exposure to progesterone via
IUS.
Hospital with As healthcare centre and district hospital and include

Specialists 1. Bariatric surgery in patients who are obese
and failed conservative treatment.
2. Referral to ENT specialist for suspected sleep
apnoea for further evaluation.
3. In patients with thick endometrium, referral
TRO endometrial cancer by doing
endometrial sampling.
Notes
265
CHAPTER 9
ENDOMETRIOSIS
266
ENDOMETRIOSIS
Endometriosis and dysmenorrhea

Introduction Endometriosis is a common condition with many diverse manifestations
with highly variable and unpredictable clinical course. It may be
asymptomatic but most commonly present with pelvic pain.
Definition Presence of endometrial-like tissue outside the uterus, which induces a

chronic, inflammatory reaction. Affect about 2-10% of women of
reproductive age and up to 50% of infertile women
Presentation i. Dysmenorrhea
ii. Chronic pelvic pain
iii. Deep dyspareunia
iv. Infertility
v. Cyclical intestinal complaint
Clinical Findings i. Abdominal mass

ii. Adnexal mass, tenderness & palpable nodule in pod on
bimanual examination
Differential i. Primary dysmenorrhea

Diagnosis ii. Pelvic Inflammatory Disease
iii. Cervical stenosis
iv. Obstructed hemivagina with ipsilateral renal agenesis
(OHVIRA)
Investigations Blood: CA 125
Urine: -
Imaging: Pelvic ultrasound to look for endometrioma (negative

ultrasound does not exclude endometriosis)
Others: Laparoscopy
Healthcare i. Non Steroidal Anti Inflammatory

MANAGEMENT centre Drugs(NSAIDs)
ii. Continous Combined Oral Contraceptive
Pills (COCP)
iii. Progestogen - oral or depo
medroxyprogesterone acetate (MPA)
267
District As above
Hospital
Hospital with 1. Medical treatment as above PLUS :
Specialists i. Cyproterone acetate, oral Dienogest
ii. Levonogestrel intra uterine system
(LNG-IUS)
iii. Antiprogestogen- gestrinone
iv. GnRH agonist – leuproline,
buserelin
v. Aromatase inhibitor – letrozole
vi. Androgenic steroid – danazol
2. Surgical treatment :
i. Laparoscopic
cystectomy/eviseration of
endometrioma
ii. Laparoscopic presacral neurectomy
– as an additional procedure to
conservative surgery
Notes
268
ENDOMETRIOSIS
Endometriosis and Infertility

Introduction Endometriosis is a chronic disease that affects 5% of women in
reproductive age. About 20-25% of women with infertility has
endometriosis.
Definition Ectopic implantation of the endometrium outside the endometrium

cavity. Implantation within the myometrium is called adenomyosis.
Endometriosis may affect fertility in several ways including dyspareunia

and coital dysfunction, reduced ovarian reserve due to multiple
surgeries, reduced oocyte quality, tubal blockage and dysfunction,
release of inflammatory mediators to the sperm and oocyte, impaired
fertilization and implantation.
Presentation i. Infertility
ii. Dysmenorrhea and chronic pelvic pain
iii. Pelvic Mass
iv. Dyspareunia
v. Menorrhagia
vi. Other rare presentation depending on location such as cyclical
hemoptysis, dyschezia and hematuria
Clinical Findings i. Mass per abdomen

ii. Per vaginal nodule
iii. Distorted uterine position and axis
Differential Ovarian tumour

Diagnosis
Investigations Blood: FBC , CA125
Urine: -
Imaging: Transvaginal ultrasound to visualize position of uterus, pelvic

mass and echogenicity (speckled appearance in endometriosis),
bilaterality, presence of adenomyosis and size.
Others: Diagnostic laparoscopy and staging of endometriosis. Staging is

important to plan for subsequent fertility management
Healthcare Refer flow chart

MANAGEMENT centre
269
District Refer flowchart
Hospital
Hospital with Refer flowchart
Specialists
270
MANAGEMENT OF ENDOMETRIOSIS
INFERTILITY
- History
- Physical examination
- TVS
- Semen analysis
- Tubal patency
assessment
No suspicious of Suspicious History of surgery

endometriosis or endometriosis for advanced
previous surgery for (ovarian endometriosis
stage I-II endometriosis,
endometriosis retrovaginal nodules)
Other infertility test Surgery

unremarkable
IUI x 2-3
With FSH IVF
271
CHAPTER 10
INFERTILITY
272
INFERTILITY
Introduction Infertility affects up to 15% of couples worldwide.

The most common causes of infertility includes: anovulation (30%),
endometriosis (10-15%), tubal factor (10%), male factor (30-40%) and
unexplained (10%).
Definition Inability to conceive after one year of regular unprotected sexual

intercourse or 6 month for those age >35 or underlying gynaecological
disorder
Primary – without any previous pregnancy.
Secondary - had previous pregnancy irrespective of outcome.
History Detail menstrual, obstetric, contraceptive, sexual, medical and surgical

history must be obtained in both partners.
Clinical Female Partner

Examination General Examination: BMI, hyperandrogenism, thyroid examination
Breast Examination : TRO any galactorrhea
Abdominal Examination: for any abdominal mass, organomegaly, ascites,
abdominal striae, and surgical scars
Genital Examination
Male Partner
General Examination: BMI, sign of hypogonadism
Breast Examination: for gyanecomastia
Abdominal Examination: for any abdominal mass, undescended testis,
inguinal hernia, organomegaly, or ascites
Genital Examination if indicated
Differential Premature ovarian failure

Diagnosis
Investigations Female Partner
Basic Investigations
General: Pap smear, Hepatitis B and C, HIV serology, and VDRL (infective
screening if indicated for IVF)
Hormonal assay:
1. FSH/LH only indicated if suspected poor ovarian reserve or
premature ovarian failure.
273
2. Mid-luteal serum progesterone level (5-10 days before the
expected menstrual cycle).
3. Prolactin (if cycles are irregular with/without galactorrhoea or
pituitary adenomas).
4. Thyroid function tests (for women with symptoms of thyroid
disease).
Transvaginal ultrasonography: to monitor natural ovulation, to detect

any pelvic pathology as uterine or ovarian masses, abnormally-shaped or
mal-directed uterus.
Hysterosalpingography or Hysterosalpingo-Contrast-Sonography
(HyCoSy): to evaluate shape of uterine cavity and patency of both
fallopian tubes in low-risk women, after review SFA and if planned for
IUI.
Advanced Investigations
Laparoscopy: for possible associated pelvic pathology or adhesions in
cases with abnormal HSG findings, previous history of pelvic
inflammatory disease or endometriosis.
Hysteroscopy: for intrauterine space-occupying lesions detected on HSG

as adhesions or polyp (no evidence linking it with enhanced fertility).
Chromosomal karyotyping: for suspected genetic disorders as Turner's

syndrome.
Male Partner
Basic Investigations
General: Full blood count, Hepatitis B and C, HIV serology, and
Chlamydia trachomatis serology if indicated.
Semen analysis (after 72 hours of sexual abstinence): interpreted for its

volume, sperm count, motility, and morphology according to the WHO
reference values (Two analyses with 6 weeks apart at the same lab).
Advanced Investigations
Hormonal assay: FSH, LH, Testosterone, TSH and Prolactin (for male
with abnormal seminal analysis and suspected endocrine disorder).
Testicular biopsy: A fine-needle aspiration biopsy may required to

differentiate between obstructive and non-obstructive azoospermia.
Chromosomal karyotyping: for suspected genetic disorders as sex

chromosomal aneuploidy, cystic fibrosis, and deletion of Y-chromosome
274
MANAGEMENT Healthcare Counselling :
centre 1. Regular intercourse 2-3 times/week.
2. Healthy life style which include cessation of
smoking and alcohol, exercise and weight
reduction for obese patients.
3. Folic acid for female.
District Semen analysis if service available

Hospital
Hospital with Refer to chart
Specialists
Female Partner
Induction of Ovulation: for women with ovulatory
dysfunctions. Provide a controlled ovarian stimulation
for assisted reproduction techniques
Intra-uterine Insemination (IUI): Could be used for

unexplained infertility and female cases with minimal
endometriosis
Hysteroscopic surgery: as resection of IU adhesions

or polyp
In-vitro Fertilisation (IVF) and Embryo transfer

(ET): Used procedure for female tubal factor,
moderate male factor, and for unexplained infertility
Male Partner
Intra-uterine Insemination (IUI): Used for mild
male factor infertility problems
Intra-cytoplasmic Sperm Injection (ICSI):

Commonly used procedure for severe male factor or
for recurrent unexplained failed IVF cycles. Surgical
sperm retrieval (SSR) usually done by percutaneous
epididymal sperm aspiration (PESA), testicular sperm
aspiration (TESA), testicular sperm extraction (TESE)
Notes
275
Referral to Infertility Unit
History
Examination
TVS
Menses irregular Menses regular
Refer infertility SFA for husband

management in
PCOS
SFA normal/near Persistent OATS

normal
HSG Blocked tubes
Patent tube(s)
IVF/ICSI
IUI
IUI x 3 failed
276
CHAPTER 11
CLIMATERIC SYMPTOMS AND MENOPAUSE
277
MENOPAUSE
Introduction Menopause is a state of natural ovarian senescence with accompanying

estrogen deficiency. It also refer to states of ovarian failure and ovarian
destruction/removal with accompanying estrogen deficiency
Definition Premature menopause

This refers to menopause in a woman aged below 40 years
Early menopause
This refers to menopause in a woman aged 50 years to 59 years
Late menopause
This refers to menopause in a woman aged 60 years and over
Surgical menopause
This refers to menopause occurring as a result of surgical removal of
both ovaries in a woman
Medical menopause
This refers to menopause occurring as a result of permanent damage to
both ovaries in a woman following either chemotherapy or radiotherapy
Presentation i. Vasomotor symptoms (ie hot flushes, night sweats)

ii. Musculoskeletal symptoms (ie joint, muscle pain)
iii. Mood symptom (low mood)
iv. Urogenital symptoms (ie vaginal dryness, dyspareunia, urinary
incontinence, recurrent uti)
v. Sexual difficulties (ie low sexual desire)
Relevant - BMI
Examination - Blood pressure
- Breast examination
- Bimanual vaginal examination & cervical cytology (if indicated)
Diagnosis 1. Clinical criteria :

- age around menopause (around 50 years)
- no menses for 12 months
- menopausal symptoms
(* all 3 clinical criteria need not be present for a diagnosis)
278
2. Laboratory criteria :
- FSH level > 35 miu/ml
(*estradiol levels can be tested for, but this is not required for the
establishment of diagnosis)
- FSH
- lipid profile
- blood sugar
- FBC
- LFT
Urine: -
Imaging:
- pelvic ultrasound to rule out pelvic pathology
- mammogram
Others:
- Assessment of bone mineral density (BMD) if indicated
- Pap smear
Healthcare Management of menopause is based on the symptoms

MANAGEMENT centre and the need for prevention of osteoporosis.
Refer flow chart.
1. General advice to women and their family

members on :
- the stage of menopause
- lifestyle modification
- benefits and risks of treatment for
menopausal symptoms
- long term health implication of
menopause
2. Treatment of menopausal symptoms :

- Hormonal : ie hormonal therapy (HT)
either estrogen therapy (ET) or
estrogen-progestin therapy (EPT).
Treatment should be at the lowest
effective dose for up to 5 years. If
symptoms persist after 5 years, may
consider continuation up to 10 years.
** Contra-indications of hormonal therapy

- History of breast cancer
- History of venous thromboembolism
(VTE) or stroke
- Undiagnosed uterine bleeding
279
- Significant cardiovascular disease
- Hypersensitivity to estrogen
Alternative hormonal approaches :

transdermal routes, intravaginal
estrogen (premarin cream)
Non-hormonal (alternative): ie
Selective Serotonin Receptor Inhibitors
(SSRIs) or Serotonin-Norepinephrine
Reuptake Inhibitors (SNRIs)
- Non-pharmaceutical (alternative): ie
cognitive behavioural therapy(CBT),
herbal remedies
3. Follow up assessment and frequency :

- Annual risk-benefit assessment should
be carried out such as in pre-treatment
evaluation
- Mammogram - 2 to 3 yearly if the initial
mammogram is normal
District As above
Hospital
Specialists
Notes Risk of osteoporosis. Refer CPG osteoporosis
280
INITIATION OF HRT BASED ON SYMPTOMS
For initiation of HT in postmenopusal women

For initiation of HT in postmenopausal women
(based on symptoms)
(based on risk for osteopoosis
Symptoms of menopause
no yes
No hypertension Contraindications to
Healthy lifestyle HT
Reassess yearly
yes no
Alternative Uterus
approaches
Reassess yearly
yes no
Menopause Menopause
status status
Early Late Early Late

< 10 years >10 years < 10 years >10 years
EPT Do not ET Do not

start EPT start EPT
Alternative Alternative
approaches approaches
Reassess Reassess
yearly yearly
281
INITIATION OF HRT BASED ON RISK OF OSTEOPOROSIS
For initiation of HT in postmenopausal women
For initiation of HT in postmenopusal women
(based on risk for osteoporosis)
(based on risk for osteopoosis

Increased risk of osteoporosis
no yes
No hypertension Contraindications to
Reassess yearly HT
no yes
Menopause Consider
status biphosphonates,
raloxifene or
alternative
Early Late approaches
< 10 years >10 years (calcium,
calcitriol)
Reassess yearly
Hysterectomy
no yes
EPT ET
282
CHAPTER 12
ABNORMAL PAP SMEAR
283
ABNORMAL PAP SMEAR
AND MANAGEMENT OF CIN
Introduction The cervical cancer screening programme was established in 1969,

following the integration of family planning services. Malaysia has been
using opportunistic screening program since 1960s. The various
screening method available are:
1) Pap smear
2) Liquid based cytology
3) HPV DNA +- E6 biomarker
4) VIA or VILI
In Kedah conventional Pap smear is the most common method of
screening and liquid based cytology is also used in Hospital Sultanah
Bahiyah.
Definition Pap smear reporting can be divided into:
1) Negative for intraepithelial lesion or malignancy (NILM)
2) Squamous epithelial abnormality ranging from ASC-US, ASC-H,
LSIL, HSIL, SCC
3) Glandular abnormality ranging from AGC-favour neoplasia,
atypical endocervical cell favour neoplasia and
adenocarcinoma.
4) Other malignant neoplasm
Cervical Intraepithelial Neoplasm (CIN) is a histological diagnosis based

on assessment of tissue from cervical biopsy. It is premalignant condition
of cervix which can be divided into CIN 1, CIN 2 and CIN 3 based on
histological characteristic of biopsy specimen. The probability of
progression from CIN 3 to invasive cancer was approximately 12%. In
CIN 1 and CIN 2, the probability of the lesion persist or progress to
higher grade CIN were 43% and 57% respectively (Ostor et al., 1993)
Presentation Abnormal smear report
Clinical Findings 1) Asymptomatic
2) Abnormal vaginal bleeding
3) Vaginal discharge
Investigations Blood: -
Imaging: -
MANAGEMENT District Refer to flow chart
Hospital
Specialists
284
FLOWCHART MANAGEMENT OF NILM
PAP SMEAR
NILM
Atrophic No Specific Inflammatory Endometrial

changes endocervical microorganis changes cells seen in
( without /TZ cells m identified women > 40
inflammatory) seen years and
suspicious
Repeat Treat Treat any

Changes
smear in 1 appropriately infection or Correlate
resolve
year as clinically atrophy. with clinical
indicated Repeat findings,
smear in 4 – clients’s age,
6 weeks hormonal
after and
treatment menstrual
status
Repeat in 2nd smear

4 – 6 weeks with
after similar
treatment
changes
Routine Refer Refer

Routine Gynaecologi
screening Gynaecologist
screening st/ FMS
schedule / FMS
schedule
285
FLOWCHART MANAGEMENT OF SQUAMOUS CELL ABNORMALITIES
PAP SMEAR
* NOTE
ATYPICAL SQUAMOUS CELLS HPV DNA testing should be considered

if available
If positive for high risk HPV, to refer for
colposcopy
Cannot exclude
Undetermined HPV status
high grade
lesion (ASC-H) significance (ASC-US)
Unknown Known
Refer for colposcopy

Repeat smear in 6
months
HPV -VE HPV +VE
ASC-US NILM
ASC-H
Low-grade
squamous
intraepithelial lesion
High-grade
squamous
intraepithelial lesion
Resume routine
screening
Refer for
Refer for colposcopy
colposcopy
286
FLOWCHART MANAGEMENT OF LOW GRADE SQUAMOUS INTRAEPITHELIAL
LESION
PAP SMEAR
LOW-GRADE SQUAMOUS
INTRAEPITHELIAL LESION (LSIL)
Yes Assessment of No
women for risk
Presence of at least one factor
criteria:
Age > 30 years

Poor compliance
Immunocompromised HPV status
Symptomatic
History of pre invasive
lesion Repeat smear in 6
Known Unknown
Positive for high risk months
n n
HPV
HPV +VE HPV -VE
Immediate NILM Low-grade

colposcopy squamous
intraepithelial
lesion (LSIL)
Refer for
colposcopy
Resume routine
screening schedule 287
FLOWCHART MANAGEMENT OF HIGH GRADE SQUAMOUS INTRAEPITHELIAL
LESION AND SQUAMOUS CELL CARCINOMA
PAP SMEAR
HIGH-GRADE SQUAMOUS SQUAMOUS CELL

INTRAEPITHELIAL LESION CARCINOMA
(HSIL)/ SUSPICIOUS FOR
INVASION
Refer for colposcopy Refer to Gynaecological

Oncologist
288
FLOWCHART MANAGEMENT OF GLANDULAR ABNORMALITIES AND
ADENOCARCINOMA
PAP SMEAR
ATYPICAL
ALL ATYPICAL GLANDULAR
ENDOMETRIAL CELLS ADENOCARCINOMAIN SITU
CELLS (EXCEPT ATYPICAL (AIS)
ENDOMETRIAL CELLS) & ADENOCARCINOMA
Refer to Gynaecologist for: Refer to Gynaecologist Refer to Gynaecological

Oncologist
colposcopy (with
endocervical sampling)
endometrial sampling (if >
35 years or abnormal
bleeding)
289
CHAPTER 13
MANAGEMENT OF CIN
290
FLOWCHART MANAGEMENT OF CIN 1 (HISTOLOGIC PROVEN)
CIN 1
Low risk group *High risk group for treatment
Observation Treatment
Repeat Pap smear and colposcopy in Ablation or excision method

6/12 decided by colposcopists
Normal results Abnormal results Pap smear and follow-up in 6/12
Persistant CIN 1 CIN progression Normal
Treatment indicated Return to 3 yearly screening if

2 consecutive annual smears
are normal
*High Risk : HRHPV positive, multiple sexual partners, sex workers, smokers,
immunosuppressed patients, patient with other gynae cancer
291
FLOWCHART MANAGEMENT OF CIN 2/CIN 3 (HISTOLOGIC PROVEN)
CIN 2/3
Age < 25 years Age > 25 years OR/AND

HIGH RISK
CIN 2 CIN 3
Treatment
Treatment
Observation :
Colposcopy &
repeat Pap smear in
6/12
Ablation - Cryotherapy
Excision 1. The upper limit of the lesion is completely

visualized
1. LEEP / LEETZ 2. The whole transformation zone is seen on
2. Cold Knife Conisation colposcopy
3. Laser Cone 3. There is no discrepancy of more than one
grade between cytology, colposcopy or
biopsy
4. There is no suspicion of microinvasive /
invasive disease on cytology, colposcopy
or biopsy
5. There is no suspicion of any glandular
lesion on cytology, colposcopy or biopsy
Pap smear in 6/12
Pap smear and colposcopy at 12/12
Pap smear in 6/12 for second year

292
Yearly PAP smear

CHAPTER 14
CERVICAL CANCER
293
CERVICAL CARCINOMA
Cervical carcinoma
Introduction Cervical cancer is the most common gynaecological cancer in Malaysia.
Cervical carcinoma is due to persistent infection of high risk HPV
Definition Cancer arising from the cervix. Cervical cancer can be divided into
1. Microinvasion (stage 1A1)
2. Early operable disease (stage 1A-2A)
3. Locally advanced disease (stage 2B-4A)
4. Metastatic cervical cancer (stage 4B)
Presentation Asymptomatic, postcoital bleeding, intermenstrual bleeding, blood stained
vaginal discharge, loss of weight, loss of appetite (in advanced stage)
Clinical Findings No visible lesion in microinvasive stage or microscopic early stage (1A2,
some 1B1 disease). The abnormalities were observed during colposcopic
examination. For macroscopic disease, visible cervical lesions seen as
exophytic or endophytic growth arising from the ectocervix or endocervix,
contact bleeding and presence of atypical vessels.
Differential Condylomata acuminata
Diagnosis Cervicitis
Preinvasive cervical lesion (Cervical intraepithelial neoplasm)
Cervical polyps
Cervical leiomyoma
Investigations Blood: Full blood count, Renal profile, Liver function test
Urine: None
Imaging: Chest x-ray , CT scan abdomen and pelvis or MRI
Others: Cervical punch biopsy for confirmation, if the lesion is not visible,
biopsy must be done under colposcopic guidance.
Staging : Once cervical cancer is confirmed by histology, staging of cervical
cancer is done clinically. Clinical staging involved examination under
anaesthesia, cystoscopy ± proctosigmoidoscopy
Healthcare Refer to medical officer in charge, Medical officer in
MANAGEMENT charge healthcare facility must re-examine patient and
if cervical lesion was noted, refer to Hospital with O&G
specialist for re-evaluation.
District Hospital As above.
Specialists
Notes Please DO NOT do pap smear when cervical lesion is obvious. Biopsy is
better done by experienced doctor to ensure specimen is obtained from
the most representable area. It is strongly advised to refer this patient
straight to centre with Gynae Oncologist
294
FLOWCHART MANAGEMENT OF CERVICAL CARCINOMA (Stage 1A-2A)
Cervical growth or suspicious cervix
Refer to Gynaecologist or Gynae Oncologist
Cervical biopsy or cone biopsy with or without colposcopic guidance
Histology confirm the diagnosis of cervical carcinoma
Investigations including radiological staging

Examination under anaesthesia, cystoscopy and staging
(To be done in centre with Gynae Oncologist)
Early cervical carcinoma
Fit for surgery Not fit for surgical treatment or

patient refuse surgery
Type of surgery depends on stage

1. Stage 1A1: Extrafascial hysterectomy
2. Stage 1A2: Modified radical hysterectomy Refer for Radiotherapy or
and pelvic lymphadenectomy Chemoradiation
3. Stage 1B1 (less than 2cm): Modified radical
hysterectomy and pelvic lymphadenectomy
4. Stage 1B-2A1: Radical hysterectomy and
pelvic lymphadenectomy
5. Stage 1B2 and 2A2 and patient refuse or High risk for recurrent
unsuitable for primary radiotherapy*: cervical cancer (based on
Option 1: Radical hysterectomy, pelvic and histological reports and GOG 295
para-aortic lymphadenectomy score)
Option 2: Neoadjuvant chemotherapy To be decided by Gynae
followed by radical hysterectomy and pelvic Oncologist
lymphadenectomy
*to be decided by Gynae Oncologist
FLOWCHART MANAGEMENT OF CERVICAL CARCINOMA (Stage 2B-4)
Cervical growth or suspicious cervix
Refer to Gynaecologist or Gynae Oncologist
Cervical punch biopsy
Histology confirm cervical carcinoma
Investigations including radiological staging

Examination under anaesthesia, cystoscopy and staging
(To be done in centre with Gynae Oncologist)
Stage 2B-4A Selected stage 4A Stage 4B
Primary Pelvic Palliative care

Radiotherapy or Exenteration Symptomatic
Chemoradiation treatment
Or
Palliative
Chemotherapy
(First line:
Paclitaxel/Platinum
combination)
296
CERVICAL CARCINOMA STAGING FIGO 2009
STAGE DESCRIPTIONS
STAGE 1 The carcinoma is strictly confined to the cervix ( extension to the corpus
should be disregarded)
Stage 1A Invasive cancer diagnosed only by microscopy. All visible lesion is stage
1B. Stroma invasion with a maximum depth of 5mm measured from the
base of the epithelium and horizontal spread of 7mm or less.
Stage 1A1 Stroma invasion 3mm and 7mm horizontal spread
Stage 1A2 Stroma invasion > 3mm and 5mm and 7mm horizontal spread
Stage 1B Clearly visible lesion confined to cervix or microscopic lesion (preclinical
cancer) greater than in stage 1Aa
Stage 1B1 Clinically visible lesions 4cm in greatest diameter
Stage 1B2 Clinically visible lesion > 4 cm in greatest diameter
Stage 2 Cervical carcinoma involving the upper 2/3 of vagina or parametrium
but not to the pelvic side wall
Stage 2A Involvement of upper 2/3 of vagina with no obvious parametrial
involvement
Stage 2A1 Clinically visible lesions 4cm in greatest diameter
Stage 2A2 Clinically visible lesion > 4 cm in greatest diameter
Stage 2B Parametrium invasion bilateral or unilateral without extension to the
pelvic sidewall
Stage 3 Carcinoma extends to the pelvic wall and/or involves lower third of
vagina or causes hydronephrosis/non-functioning kidneyb
Stage 3A Tumour involves lower third of vagina, no extension to pelvic wall
Stage 3B Tumour extend to pelvic wall or causes hydronephrosis or non-
Functioning kidney
Stage 4A Tumour invade bladder mucosa or rectum and/or extends beyond
true pelvis.
Stage 4B Distant metastases
a All macroscopically visible lesions–even with superficial invasion–are allotted to Stage IB.
Invasion is limited to a measured stromal invasion with a maximal depth of invasion 5.0 mm
and a horizontal extension of 7 mm. Depth of invasion should be taken from the base of the
epithelium of the original tissue—superficial or glandular. The involvement of vascular
spaces–venous or lymphatic–does not change the stage. These rules now apply to adenoma
carcinomas.
b On rectal exam there is no cancer-free space between the tumor and the pelvic side wall. All
cases with hydronephrosis or a non-functioning kidney should be included, unless they are
known to be due to other causes
297
OVARIAN / ADNEXAL
MASS
INTRODUCTION(9) Ovarian / adnexal mass are frequently observed in women of all ages
who seek gynecological care, and are still a leading indication to perform
surgical treatment. Up to 10% of women will have some form of surgery
during their lifetime for the presence of an ovarian mass. The overall
incidence of a symptomatic ovarian cyst in a premenopausal female
being malignant is approximately 1:1000 increasing to 3:1000 at the age
of 50. The underlying management rationale is to minimize patient
morbidity by:
conservative management where possible
use of laparoscopic techniques where appropriate, thus avoiding
laparotomy where possible
referral to a gynaecological oncologist where appropriate
DEFINITION Mass arising from ovary or fallopian tube
PRESENTATION Explore the chief complaint and associated symptoms
Explore history suggestive of possible malignancy, e.g. persistent
abdominal distension, appetite change including increased satiety
and unexplained weight loss.
Detail menstrual history
Family history of malignancy which may contribute to hereditary
malignancy.
Previous significant gynaecological / medical / surgical condition
which may relate to the ovarian / adnexal mass
Assessment of co-morbidities (IHD, CVA, CKD, etc) which may affect
the management of ovarian/adnexal mass.
CLINICAL FINDINGS General Examination:
Vital signs
Body Mass Index (BMI)
General well being & nutritional status
Specific Examination:
Full abdominal examination
Pelvic examination – speculum and bimanual vaginal examination
Breast examination
Examine for any lymphadenopathy
DIFFERENTIAL Benign ovarian
298
DIAGNOSIS Functional cysts
Endometriomas
Serous cystadenoma
Mucinous cystadenoma
Mature teratoma
Benign non-ovarian
Paratubal cyst
Hydrosalpinges
Tubo-ovarian abscess
Peritoneal pseudocysts
Appendiceal abscess
Diverticular abscess
Pelvic kidney
Primary malignant ovarian
Germ cell tumour
Epithelial carcinoma
Sex-cord tumour
Primary malignant fallopian tube
Serous adenocarcinoma
Secondary malignant ovarian
Predominantly primary peritoneal, breast and gastrointestinal
carcinoma
INVESTIGATIONS Trans-vaginal (TVS) / trans-abdominal (TAS) ultrasound
Baseline blood investigations
Tumour markers if suspicious of malignant ovarian/adnexal mass
Further radiological surveillance if required
Healthcare Refer flowchart
MANAGEMENT District Refer flowchart
Hospital
Hospital with
Specialists
NOTES
299
FLOWCHART MANAGEMENT OF OVARIAN / ADNEXAL MASS
Women presenting with
ovarian / adnexal mass
Detail history and Physical examination
TVS / TAS
Functional / simple ovarian cyst < 5cm can be followed in 3 months.
Otherwise see below.
TVS / TAS applying on International Ovarian Tumour Analysis

(IOTA) Group – Simple Rules
* An adnexal mass is classified as malignant if at least one M-feature and no B-features are present
and vice versa. When no B-features or M-features are present or if both B-features and M-features
are present, then simple rules are considered inconclusive.
Benign (B-) Rules: Malignant (M-) Rules:

Unilocular cyst Irregular solid tumour
Smooth multilocular cyst with Irregular multilocular solid / cystic
largest diameter <10cm tumour with largest diameter ≥
Presence of solid components 10cm.
where the largest solid component Ascites
<7mm At least 4 papillary structures
Presence of acoustic shadowing Very strong blood flow on doppler
No blood flow on doppler
Early referral gynae-

Refer gynaecologist for surgery
oncologist for further
*Minimally invasive surgery is
assessment and surgery
preferred where possible
Inconclusive of Benign /
Malignant Features
Referral to Gynaecology
clinic for further
assessment with tumour
marker / RMI/ radiological 300
surveillance (CT / MRI)
CHAPTER 16
OVARIAN CARCINOMA
301
OVARIAN CARCINOMA
Ovarian Carcinoma
Introduction Ovarian tumour can be classified histologically as:
1) Benign Tumour
2) borderline Tumour
3) Ovarian Carcinoma
Ovarian Carcinoma can be subgrouped into 3 different categories:

1) Epithelial Ovarian cancer such as serous and mucinous ovarian cancer
2) Germ cell tumour such as dysgerminoma, endodermal sinus tumour,
etc.
3) Sex cord stromal tumour
Definition Diagnosis of ovarian carcinoma should be suspected based on clinical,

biochemical parameter and ultrasound characteristics. Risk Malignancy
Index (RMI) (see appendix) can further be used to predict the possibility
of malignancy in order to planned further course of investigation and
management including referral.
Presentation Abdomino-pelvic mass, abdominal pain, abdominal distention or

sometimes accidental finding on routine medical examination
Clinical Findings Distended abdomen, complex adnexal mass, may have ascites or may
have evidence of metastatic lesion such as at virchow’s nodes.
Differential Benign ovarian tumour, Uterine tumour, Mesenteric tumour, GIT tumour,
Diagnosis retroperitoneal masses etc.
Investigations Blood: FBC, BUSE, LFT, RFT, CA125, CEA, CA19.9, α-FP, β-HCG
Imaging: CT scan Thorax, abdomen and pelvis
Healthcare Refer to hospital with specialist
MANAGEMENT District Correct anaemia. Transfused if hb <10gm% And refer
Hospital to Gynaecology oncologist
Hospital with Refer to the management flow chart.

Specialists
Notes
302
FLOWCHART MANAGEMENT OF SUSPECTED OVARIAN MALIGNANCY
WITHOUT ATYPIA
Suspected ovarian tumour
Clinical assessment including

complete clinical examination,
pelvic examination,
pelvic ultrasound
and tumour markers
Risk of Malignancy Index (RMI)
< 200 ≥200
Low Risk for malignancy High risk for malignancy
Refer/managed in Hospital with Further evaluation with CT scan

O&G specialist Thorax, abdomen and pelvis
Refer to Gynae oncologist for

further evaluation and
management 303
FLOWCHART MANAGEMENT OF OVARIAN MALIGNANCY
WITHOUT ATYPIA
1. Medically fit for surgery

2. Able to achieve optimal debulking
(extend of disease ) *
* To be decided by gynae oncologist
Yes No
Primary surgery +/- Adjuvant Ultrasound guided biopsy

chemotherapy of the tumour / cytology
Neoadjuvant chemotherapy
(NACT) followed by interval
debulking surgery and adjuvant
chemotherapy
* Diagnosis of cancer must be confirmed by HPE or cytology

prior to NACT.
* Chemotherapy regimens used are as recommended by national
chemotherapy protocol 2015
304
FIGO 2014 STAGING FOR OVARIAN CARCINOMA
WITHOUT ATYPIA
Stage Descriptions
Stage 1 Tumour confined to ovaries or fallopian tube(s)
1A Tumour limited to one ovary (capsule intact) or fallopian tube, no
tumour on ovarian or fallopian tube surface; no malignant cells in the
ascites or peritoneal washing
1B Tumour limited to both ovaries (capsule intact) or fallopian tubes; no
tumour on ovarian or fallopian tube surface; no malignant cells in the
ascites or peritoneal washing
1C Tumour limited to one or both ovaries or fallopian tubes, with any of
the following:
1C1:Surgical spill
1C2:Capsule ruptured before surgery or tumour on ovarian or
fallopian tube surface
1C3:Malignant cells in the ascites or peritoneal washings
Stage 2 Tumour involves one or both ovaries or fallopian tubes with pelvic
extension (below pelvic brim) or primary peritoneal cancer
2A Extension and/or implants on uterus and/or fallopian tubes and/or
ovaries
2B Extension to other pelvic intraperitoneal tissues
Stage 3 Tumour involves one or both ovaries or fallopian tubes, or primary
peritoneal cancer, with cytologically or histologically confirmed
spread to the peritoneum outside the pelvis and/or metastasis to
the retroperitoneal lymph nodes
3A1 Positive retroperitoneal lymph nodes only (cytologically or
histologically proven)
3A1 (i): Metastasis up to 10 mm in greatest dimension
3A1(ii): Metastasis more than 10 mm in greatest dimension
3A2 Microscopic extrapelvic (above the pelvic brim) peritoneal involvement
with or without positive retroperitoneal lymph nodes.
3B Macroscopic peritoneal metastasis (above the pelvis up to 2cm in
greatest dimension, with or without metastasis to the retroperitoneal
lymph nodes
3C Macroscopic peritoneal metastasis beyond the pelvis more than 2 cm in
greatest dimension, with or without metastasis to the retroperitoneal
lymph nodes (includes extension of tumour to capsule of liver and
spleen without parenchymal involvement of either organ)
Stage 4 Distant metastasis excluding peritoneal metastases
4A Pleural effusion with positive cytology
4B Parenchymal metastases and metastases to extra-abdominal organs
(including inguinal lymph nodes and lymph nodes outside of the
abdominal cavity)
305
RISK MALIGNANCY INDEX (RMI)
WITHOUT ATYPIA
Criteria Score awarded Score
Menopausal status
Premenopausal 1 A ( 1 or 3)
Postmenopausal 3
Ultrasound features None of these features, score 0
Multiloculated One feature , score 1 B (0,1 or 3)
Solid areas More than one features, score 3
Bilaterality
Ascites
Metastasis
Serum CA125 Absolute concentration of CA125 C

concentration (IU/ml)
Risk of malignancy index (RMI) = A X B X C
306
CHAPTER 17
ENDOMETRIAL HYPERPLASIA/ EIN
307
ENDOMETRIAL
HYPERPLASIA AND EIN
Endometrial Hyperplasia
Introduction The revised 2014 World Health Organization (WHO) classification
separates endometrial hyperplasia into two groups based upon the
presence of cytological atypia: i.e.
(i)hyperplasia without atypia and
(ii) atypical hyperplasia.
In clinical practice, atypical hyperplasia is treated in similar manner with
Endometrial Intraepithelial Neoplasia ( EIN).
It is often associated with multiple risk factor such as Obesity, PCOS with
or without metabolic syndrome , diabetic and exogenous hormone
intake. This should be identified and monitored.
Definition Diagnosis of endometrial hyperplasia should be made via histological

assessment of endometrial tissue obtained via office endometrial biopsy
or DD&C. Diagnostic hysteroscopy should be done if fail office
endometrial biopsy.
Presentation Abnormal vaginal bleeding, Metabolic syndrome
Clinical Findings Thick Endometrial lining on TVS, normal or enlarge uterus
Differential Endometrial Carcinoma, dysfunctional uterine bleeding
Diagnosis
Urine:
Imaging:
Others:
Healthcare FBC, refer to hospital with pakar
MANAGEMENT District Correct anaemia. Transfused if hb < 8gm% or above
Hospital that in symptomatic patient.
Specialists
Notes
308
FLOWCHART MANAGEMENT OF ENDOMETRIAL HYPERPLASIA
WITHOUT ATYPIA
Simple / complex
endometrial hyperplasia
without atypia
Presence of Concomittent
benign gynae disorder e.g:
fibroid and fertility not an Issue
Yes No
Hysterectomy +/- BSO Medical Treatment:

1. Low Dose Progestogen
i) Tab MPA 10 – 30mg/day
continuous or cyclical
Consider fail medical treatment if failed ii) Tab Norethisterone 10-15mg/day
histological regression after >12months 2. LNG-IUS ( Mirena)
treatment
Re-assess including endometrial biopsy Re-assess including endometrial biopsy

within 3-4 months within 3-4 months
Medical Treatment:
1. High Dose Progestogen
Tab MPA 100 mg/day continuous Histologic regression of endometrial
2. LNG-IUS ( Mirena) hyperplasia
No Yes
Continue medical treatment till at least 6

months or untill complete histological
resolution
* Identified and modify the patient risk
factor : eg: weight reduction, exogenous
hormone intake.
309
MANAGEMENT OF ENDOMETRIAL HYPERPLASIA WITH ATYPIA
Simple / complex
endometrial hyperplasia with
atypia / EIN
Fertility preservation required
Yes No
Medical Treatment:
1. High Dose Progestogen Hysterectomy +/-
i) Tab MPA 100 – 600mg/day continuous BSO
Re-assess including endometrial biopsy

within 3-4 months Consider fail medical
treatment if failed
histological regression
after >12months
treatment
Histologic regression of endometrial
hyperplasia
Re-assess including
endometrial biopsy within
3-4 months
Yes No
Continue medical Medical Treatment:

treatment till at least 6 1. Increase MPA dose
months or untill complete 2. LNG-IUS (Mirena)
histological resolution
* Identified and modify the patient risk 310

factor: eg: weight reduction, exogenous
hormone intake.
CHAPTER 18
ENDOMETRIAL CARCINOMA
311
ENDOMETRIAL CARCINOMA
Endometrial Carcinoma
Introduction Carcinoma of Endometrium is the malignancy derived from the
endometrial lining of uterus. It’s divided into 2 distinct types:
1) Type 1 : Endometriod Adenocarcinoma
2) Type 2 : Non endometriod histological type such as serous, clear cell ,
adenosquamous etc.
It is often associated with multiple risk factor such as
Obesity,Anovulation, PCOS with or without metabolic syndrome ,
diabetic and exogenous hormone intake. This should be identified and
monitored.
Definition Diagnosis of endometrial carcinoma should be made via histological

assessment of endometrial tissue obtained via office endometrial biopsy
or DD&C. Diagnostic hysteroscopy should be done if fail office
endometrial biopsy.
Presentation Abnormal vaginal bleeding,Postmenopausal bleeding
Clinical Findings Thick Endometrial lining on TVS, normal or enlarge uterus
Differential Endometrial Carcinoma, dysfunctional uterine bleeding, endometritis
Diagnosis
Urine:
Imaging: CT scan Thorax/ abdomen and pelvis in confirmed cases of Ca
endometrium
Others:
Healthcare FBC, refer to hospital with pakar
MANAGEMENT District Correct anaemia. Transfused if hb < 8gm% or above
Hospital that in symptomatic patient. And refer to Gynaecology
oncologist
Hospital with Refer to the management flow chart.

Specialists
Notes
312
FLOWCHART MANAGEMENT OF ENDOMETRIAL CARCINOMA
Endometrial carcinoma
WITHOUT
by endometrial ATYPIA
biopsy
Clinical Assessment including

complete clinical examination,
Pelvic examination and
CT Scan Thorax/abdomen and
pelvis
Refer to Gynae Oncologist within 2 weeks of

Histological diagnosis
No Distant Metastatic Metastatic Disease

Disease
Extrafascial hysterectomy +
BSO +PLND +/- Lower Para-
Exploratory Laparotomy, THBSO+
aortic nodes sampling +/-
Tumour Debulking
omentectomy
Consider Adjuvant treatment in Adjuvant treatment

patient with high recurrent risk: 1. Adjuvant chemotherapy
1. Adjuvant Pelvic RT 2. Adjuvant Hormonal therapy
2. upfront chemotherapy and pelvic
RT
Post treatment follow up

3 monthly for 1 year
4 monthly for 2nd year
6 monthly year 5 – yr 10
Discharge from f/up if 10 years disease
free
* Fertility preserving medical

treatment may be an option in
selected patient requiring fertility
preservation and fulfil all the pre- 313
requisite.
FIGO STAGING 2009 FOR ENDOMETRIAL CARCINOMA
WITHOUT ATYPIA
Corpus Cancer Staging, FIGO 2009

Staging Desriptions
Stage 1 Tumour confined to corpus uteri
Stage 1A G123 No or less than half myometrial invasion
Stage 1B G123 Invasion ≥ 50% of myometrium
Stage 2 Tumour invades cervical stroma but not
outside uterus a
Stage 3 Local and/or regional spread of tumour
Stage 3A G123 Tumour invades serosa and/or adnexaeb
Stage 3B G123 Vaginal and/or parametrial involvementb
Stage 3C G123 Metastasis to pelvic and/or para-aortic nodesb
Stage 3C1 G123 Positive pelvic nodes
Stage 3C2 G123 Positive para-aortic lymph nodes with or without
positive pelvic lymph nodes
Stage 4 Tumour invades bladder and/or bowel mucosa,
and/or distant metastases
Stage 4A G123 Tumour invade bladder mucosa and/or bowel
mucosa.
Stage 4B Distant metastasis including intra-abdominal
metastases and/or inguinal lymph nodes
a Endocervical glandular involvement only should be considered as Stage 1
and no longer as Stage 2

b Positive cytology has to be reported separately without changing the stage
G123 : Grade 1, Grade 2 or Grade 3
314
CHAPTER 19
VULVAR CARCINOMA
315
VULVAR CARCINOMA
Introduction Vulvar carcinoma account 3-5% of all female genital cancer and 1% of all
malignancies in women. Approximately 75% are older than 60 years old.
The incidence is increasing due to increase in life expectancy and
increase in prevalence of HPV infection.
About 40% of women with vulva carcinoma diagnosed at advanced stage
Definition
Vulvar carcinoma is defined as cancer involving the vulva which includes
mon pubis, labia majora and minora, clitoris, vestibule and perineal
body. It can be classified into:
Squamous cell lesions (90%)
-Squamous cell carcinoma
-Basaloid carcinoma
-Verrucous carcinoma
-Condylomatous carcinoma
-Basal cell carcinoma
Glandular cell lesions (5%)
-Bartholin’s Gland carcinoma
-Sweat Gland carcinoma
Others (5%)
-Melanoma
Presentation Common presentation:

pruritus vulva
vulva swelling or mass
vulva ulceration
dysuria
pain
Clinical Findings Vulva inspection reveals an ulcer or vulvar mass. Surrounding tissue may
edematous and indurated.
Inguinal lymphadenopathy may present.
Examination of pelvic organs including cervix, vagina, urethra and
rectum is essential for co-existent other primary cancer.
Differential Condylomata accuminata

Diagnosis Syphilitic ulcer
Tubercular ulcer
Lymphogranuloma venereum
Investigations Blood:- FBC, RFT,LFT

Urine:-
Imaging:
316
Others: Tissue Biopsy
Healthcare Unresolved pruritus vulva or obvious lesion warrant
MANAGEMENT further assessment by Gynaecologist
Hospital
Specialists
317
FLOWCHART MANAGEMENT OF VULVAR LESION IN HEALTH CENTRE
Women presented with vulva lesions Women presented with pruritus vulva
Treat as indicated with topical

medication. If unresolved after 3
months
Refer to Gynaecologist
318
FLOWCHART MANAGEMENT OF VULVAR LESION IN HOSPITAL WITH
SPECIALIST
Obvious vulvar lesion
Yes No
Biopsy For HPE Vulvar Colposcopy

and Directed
biopsy
Biopsy confirmed
Vulvar Carcinoma
Refer to Gynae-
oncologist
Treat accordingly
319
FIGO STAGING OF VULVAR CANCER (2009)
STAGE DESCRIPTIONS
Stage 1 Tumor confined to the vulva. No nodal metastasis
Stage 1A Lesions ≤2 cm in size, confined to the vulva or perineum and with stromal
invasion ≤1.0 mm*. No nodal metastasis
Stage 1B Lesions >2 cm in size or with stromal invasion >1.0 mm, confined to the vulva
or perineum, with negative nodes
Stage 2 Tumor of any size with extension to adjacent perineal structures (1/3
lower urethra, 1/3 lower vagina, anus) with negative nodes
Stage 3 Tumor of any size with or without extension to adjacent perineal

structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive
inguino-femoral lymph nodes
Stage 3A a. With 1 lymph node metastasis (≥5 mm), or

b. 1–2 lymph node metastasis(es) (<5 mm)
Stage 3B a. With 2 or more lymph node metastases (≥5 mm), or

b. 3 or more lymph node metastases (<5 mm)
Stage 3C With positive nodes with extracapsular spread
Stage 4 Tumor invades other regional (2/3 upper urethra, 2/3 upper vagina), or
distant structures
Stage 4A Tumor invades any of the following:

a. Upper urethral and/or vaginal mucosa, bladder mucosa rectal mucosa, or
fixed to pelvic bone, or
b. Fixed or ulcerated inguino-femoral lymph nodes
Stage 4B Any distant metastasis including pelvic lymph nodes
*The depth of invasion is defined as the measurement of the tumor from the
epithelialstromal junction of the adjacent most superficial dermal papilla to the deepest
point of invasion
320
CHAPTER 20
GESTATIONAL TROPHOBLASTIC NEOPLASIA
(GTN)
321
GESTATIONAL
TROPHOBLASTIC
NEOPLASM (GTN)
Introduction GTN is malignant spectrum of GTD which include invasive mole,

choriocarcinoma, placenta site trophoblastic tumour (PSTT) and
epitheliod trophoblastic tumour (ETT)
Definition PTD is biochemical diagnosis made during the follow up of patient with
hydatiform mole. It is characterized by:
1. Plateuing or raising of β-HCG level more than 2 occasions for at
least 2 weeks apart.
2. Persistent level of β-HCG level above normal 6 months after
evacuation eventhough still showing a decreasing trend.
The underlying cause of PTD are incomplete evacuation or GTN.

After ruling out incomplete evacuation, the diagnosis of GTN should be
made and GTN work up should be initiated.
The common underlying cause of PTD are invasive mole and

choriocarcinoma which can only be differentiated by histology.
Choriocarcinoma can be subdivided into:
1. Gestational Choriocarcinoma
2. Non Gestational Choriocarcinoma
Presentation Commonly diagnosed during the follow up of patient with hydatiform

mole but can complicate any type of pregnancy including term
pregnancy or miscarriage. It can be asymptomatic or complication
resulting from uterine or metastatic lesion such as vaginal bleeding,
acute abdomen from intraperitoneal bleeding, hemoptysis or shortness
of breath from lung metastasis. Occasionally presented with central
nervous system symptoms secondary to brain metastasis.
Clinical Findings Depending on site of metastasis.
Investigations Blood: β-HCG, FBC, RFT, LFT
Imaging: Pelvic ultrasound, CT Scan Thorax, abdomen and pelvis. CT
brain should be done if presence of CNS manifestation.
Healthcare Refer hospital with specialists
MANAGEMENT District Refer hospital with specialists
Hospital
Hospital with Refer to flow chart/ table
Specialists
322
FIGO anatomical staging of GTN
Stage I Disease confined to the uterus

Stage II GTN extends outside the uterus, but is limited to the genital
structures (adnexa, vagina, broad ligament)
Stage III GTN extends to the lung, with or without known genital tract
involvement
Stage IV All other metastatic sites
Modified WHO prognostic scoring system as adopted by FIGO
Score 0 1 2 4
Age < 40 ≥ 40 - -
Antecedent pregnancy mole abortion term -
Interval months from <4 4-6 7-12 >12
index pregnancy
Pretreatment serum <103 103 - 104 104 - 105 >105
hCG (IU/L)
Largest tumour size <3 cm 3 – 4 cm ≥5 cm -
(including uterus)
Site of metastases lung Spleen, kidney gastrointestinal Liver, brain
Number of metastases - 1-4 5-8 >8
Previous failed - - Single drug ≥2 drugs
chemotherapy
Total score for patient is obtained by adding the individual scores for each prognostic factor.
Total score: ≤ 6 = low risk, ≥ 7 = high risk
323
Flowchart management of patient with PTD
Diagnosis of PTD based on biochemical

criteria’s as above
Pelvic ultrasound
Show residual molar
inside uterus
Yes No
Presence of metastatic
lesion clinically Yes GTN
No
Incomplete evacuation CT scan thorax, abdomen,

pelvis
*include CT scan brain if
has CNS manifestation
WHO staging and risk

scoring
Score <7 Score >

7
Low risk regime Refer to Gynaeoncology

MTX/FA require high risk regime324
*EMA –CO
*CHAMOCA
CHAPTER 21
URINARY INCONTINENCE
325
URINARY INCONTINENCE
Introduction Known as urinary leakage, is an embarrassing problems that

affect millions of women. Although is more common in elderly,
it can affect younger women as well
Definition Any involuntary leakage of urine which is a social or hygienic
problem, and is objectively demonstrable
Types and 1.Stress incontinence
Presentation -leaking of urine during sneezing, coughing, laughing, lifting,
jumping, jogging, walking, going down stair.
2.Urgency Incontinence/overactive bladder

-sudden overwhelming urge to urinate
-frequency >8x per day and nocturia >1 at night
3.Mixed Incontinence
-Symptoms of both stress and urgency incontinence
4.Overflow Incontinence
-overflow when the bladder becomes overly full
Causes 1.Genuine Stress Incontinence (urethral sphincter

incompetence)
-Pregnancy and childbirth
-Menstruation
-Menopause
-Obese
-Hysterectomy
-Neurological condition
-Brain and Spinal Cord e.g. Multiple Sclerosis,
Parkinsonism
-Connective Tissue Disease
2. Urge Incontinence
-Alcohol or Caffeine
-Poor fluid intake-concentrated urine
-UTI
-Tumors
-Neurological
3.Detrusor Instability
4.Overflow Incontinence
-Bladder stone
-Constipation
5.Fistulae
6.Congenital Abnormalities e.g. Epispadias, Ectopic ureter,
326
spina bifida occulta
7.Medications e.g. ACEI, Diuretics, Antidepressants
Clinical 1.Symptoms: As above and

Assessment -Enuresis- bed wetting while asleep
-Need to wear pad
-Need to restrict social or physical activities
-Incontinence during sexual intercourse
-Faecal Incontinence
2.Assess coexisting medical problems e.g. Diabetes, Neurologic

disorders, Heart Failure, arthritis, pelvic irradiation, trauma
and medications.
-Neurologic causes maybe associated with weakness or
numbness of legs, faecal incontinence.
3.Assess previous surgery- genitourinary surgery anterior or

posterior colporraphy, vaginal hysterectomy, Burch
Colposuspension, Sling,
Radical Hysterectomy etc
Investigations 1. Urinalysis
2. Urine Culture and Sensitivity
3. Urodynamic Investigation
4. Ultrasound, IVU, Cystoscopy
5. Bladder Diary ( 3 comfortable days of charting the
type and amount of fluid intake vs amount of urine
pass out
1.Behaviour –Bladder Training- slowly delay urination after
MANAGEMENT feel the urge
2.Lifestyle changes and Pelvic Floor exercise (Kegel)
3.Medications
-Treat UTI
-Premarin cream or Gel
-Imipramine
-Various medication for Overactive Bladder (Antimuscarinic
Agents eg Tolterodine (Destrusitol), Solifenacin, Oxybutynin,
Trospium, Botox if other medication does not work.
4.Medical device- Ring Pessary, acupuncture, electrical
stimulation
5. Surgery- Failed conservative treatment
-TVT (Tension Free Vaginal Tape)
-Burch’s colposuspension (Retropubic Suspension)
-Fistula Repair
327
FLOWCHART URINARY INCONTINENCE MANAGEMENT
URINARY INCONTINENECE
CLINICAL ASSESMENT +
INVESTIGATION
Conservative Mx
Bladder Retraining
Pelvic Floor Exercise
Premarin Cream/gel biweekly
Rx UTI
Vaginal Ring Pessary
Supplements - Calcium/ Calcitriol
Weight reduction
Type of incontinence
OAB MIXED UI OVERFLOW

USI
Antimuscarinic Refer urology

(tro stone)
+/- suburethral
sling
Suburethral sling - Antimuscarinic

TVTO
Burch’s Detrusitol
colposuspension Oxybutynin
Imipramine
Solifenacin
328
CHAPTER 22
UTERO-VAGINAL PROLAPSE
329
UTERO-VAGINAL PROLAPSE
Introduction Pelvic floor defect maybe created as a result of childbirth and are caused
by stretching and tearing of the endopelvic fascia and elevator muscle
and perineal body
Definition Abnormal descend or herniation of the pelvic organ from their normal
attachment sites or their normal position in the pelvis
Presentation 1.Anterior Vaginal Wall Prolapse
-dragging discomfort
-Urinary symptoms-eg stress/overflow incontinence, voiding difficulty,
frequency and inadequate emptying
2.UV Prolapse
-Low backache
-Mass per vagina
-Decubitus ulcer of the cervix
-Vaginal bleeding and discharge
3.Posterior Vaginal Wall Prolapse
-Vaginal discomfort
-Acute abdominal pain-strangulated small bowel
-Backache
-Lump in the vagina
-Incomplete bowel emptying, difficult or unsatisfactory defecation
Aetiology 1.Congenital
-Bladder exstrophy
-Altered collagen metabolism
-Connective tissue abnormalities-joint hypermobility
-Congenital shortness of the vagina and deep uterovesical or uterorectal
peritoneal pouches
2.Acquired
-Childbirth
-Rise in intraabdominal pressure
-Adverse dietary influences-lack of vitamin C, Corticosteroid therapy
-Surgery-sacrospinous fixation or colposuspension
Stage of Pelvic S.0-No prolapse
Organ Prolapse (S) S. II--most distal portion>1cm above the level of hymen
(ICS-International S.III->1 cm below the plane of Hymen
Continence Society) S.IV-complete eversion, distal portion at least (total vaginal length -2 cm
(Procidentia)
Urine: UFEME & Urine C&S,
-PAP Smear (age <65 years old and those with Pap smear abnormality
before)
330
-Vaginal Swab C&S
-Urodynamic studies
-Bladder Diary
Imaging: Ultrasound Pelvis

-Ultrasound, CT Scan Abdomen for abdominal mass
-CXR for chronic cough
1.Prevention
MANAGEMENT -Pelvic Floor Exercise
-Delivery -Shortening the active second stage of delivery, decrease use of
instrumental delivery and selective use of caesarean section, particularly
in those who have already had prolapse prior to pregnancy
-Weight reduction
-Avoiding heavy lifting
-Avoid smoking
-Avoid straining at stool, constipation
-Improve management of chronic cough eg COPD
-Avoiding high impact exercise or heavy physical work
2. Conservative
-Premarin cream 0.625 mg biweekly
-Vaginal Ring Pessary-to change every 3-4 month
-Antibiotic for the decubitus ulcer
-Supplement- calcium /calcitriol
3. Surgery
i) Intact uterus-vaginal Hysterectomy and Pelvic Floor Repair
ii) Vault Prolapse- Sacrospinal fixation or Abdominal Sacrocolpopexy or
Colpocleisis
331
FLOWCHART PELVIC ORGAN PROLAPSE MANAGEMENT
POP
Surgical Mx
Conservative Mx
Premarine
cream/gel biweekly
Vaginal ring pessary
Pelvic floor exercise
UDS proven USI
Vault prolapse Intact uterus
TVT-O
VH+PFR
colpoclesis
SSF/
abdominal
sacrocolpopex
y
332
CHAPTER 23
MANAGING RAPE VICTIM
333
MANAGING SURVIVORS OF
SEXUAL ASSAULT
Introduction Rape is when a man has sexual intercourse with a women against her
will/consent.
It is considered as statutory rape when the sexual act is performed with
or without consent, to a girl under 16 years old.
Rape cases should be managed in OSCC.
Presentation May present in varies ways :

1. Presented with alleged rape
2. Brought by parents / guardian/ teacher/ child protector
3. Pregnant
4. Brought in semi-critical or critical condition
5. Referred from District hospitals or Health clinics
6. Emergency and Trauma Department Call Center
Clinical Findings 1. Acute external injury

2. General appearance (behaviour, clothing, emotional state)
3. Any marks (bites, strangulation, finger marks etc) on body
surface (face, neck, chest, thigh)
4. Pelvic examination
** Please note the accompanying person for medicolegal purposes

Differential 1. Trauma/injury
Diagnosis 2. Foul play/ false accusation
i. DNA,
ii. infectious screening
iii. toxicology (if indicated)
Urine:
i. pregnancy test (if indicated)
ii. toxicology (only if indicated)
Imaging: ultrasound for cases of pregnancy
Others: clothing, nails, pubic and scalp hair, cotton swab from the skin,
334
sites of bite mark and body orifices
Healthcare Refer to OSCC

MANAGEMENT centre
District Refer to OSCC
Hospital
Specialists
Notes ** refer to rape kit
All cases of sexual abuse or rape involving victim age below 16 year old
must be seen by O&G Specialist.
335
INITIAL MANAGEMENT
1.
Survivor comes to hospital
2.
Brought by parents/teacher/ public/ child protector/
FOR INITIATIONreferral
OF HT fromIN POSTMENOPUSAL
Health clinics to hospital WOMEN
3. Brought by police/NGO/GP/ medical officer from
hospital without O&G specialist referral to hospital
(BASED ON RISK FOR OSTEOPOOSIS
Triage at Emergency Department
Clinically stable?
Red or Yellow Zone OSCC

- Give acute medical/surgical
treatment
- Call relevant specialist
- Proper documentation & Police report
collections of evidence as
required
Consent Advice lodge

police report
Initial assessment by Emergency and Assessment by Emergency

Trauma Department Medical Officer Department Medical Officer
Referral to relevant
disciplines as necessary
Referral to relevant :
- Obstetric & Gynaecology
- Surgery
- Paediatric
- Forensic
- Psychiatry
- Medical Social Worker
Evidence collection
- Witnessed by police
- Handed over to police
Admit Discharge with Temporary 336

follow up shelter
MANAGEMENT
FOR INITIATION OF HT IN POSTMENOPUSAL WOMEN

Follow up
(BASED ON RISK FOR OSTEOPOOSIS
Obstetric & Paediatric Medial social Psychiatry

gynaecology worker
Follow up Follow up Age >18 years, Follow up as

(refer to (refer to referred with necessary
guideline) guideline) consent
Review all Referrals to:
investigations - JKM
& refer - Counselor
accordingly - NGO’s
- Law
Bureau
Medical/
Infectious
disease
Discharge
All cases of sexual abuse or rape involving victim age below 16 year old must be seen by O&G
Specialist.
337
REFERENCES
1. Lina Michala, Sarah M Creighton, Fused labia: a paediatric approach. The

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OBSTETRICS AND

I would like to congratulate and express my sincere thanks and

Dato’ Dr. Norhizan bin Ismail

The development of this protocol started off with a brainstorming workshop

In conclusion, I would like to express my heartfelt gratitude to each and every

Dato’ Dr. Mohd Rushdan bin Md Noor

PAKAR OBSTETRIKS & JAWATAN/HOSPITAL

PAKAR PERUBATAN KELUARGA JAWATAN/TEMPAT BERTUGAS

Dr. Abdul Jalil bin Ahmad Pakar Perunding Perubatan Keluarga KK

Dr Siti Sarah binti Ahmad Pegawai Perubatan UD48 HSB

Sharifah binti Yahaya Penyelia Jururawat HSB U36

HSB: Hospital Sultanah Bahiyah, Alor Setar, Kedah

Kata Pengantar Pengarah Kesihatan Negeri 2

OBSTETRICS PROTOCOL PAGE

SECTION B: PROBLEMS IN EARLY PREGNANCY 15

SECTION C: ANTENATAL CONDITIONS AND PROBLEMS 36

SECTION D: MEDICAL DISORDERS IN PREGNANCY 82

SECTION E: ASSESSMENT OF FETAL WELL BEING 120

SECTION F: PRENATAL SCREENING 124

SECTION G: INDUCTION OF LABOUR 128

SECTION H: INFECTIONS IN PREGNANCY 133

SECTION I: OBSTETRICS EMERGENCIES 148

SECTION J: PUERPERIUM CONDITION 174

SECTION K: INTRAPARTUM CONDITIONS AND PROBLEMS 182

SECTION L: VAGINAL BIRTH AFTER CAESEREAN SECTION 198

SECTION N: CONTRACEPTION 207

SECTION O: THROMBOPROPHYLAXIS IN O&G 209

SECTION P: REFERRALS 217

GYNAECOLOGY PROTOCOL PAGE

Introduction Making pregnancy safer is an important component of maternal and

Definition A set of intervention that aim to identify and modify biomedical,

Criteria for referral 1. General

SOP 1-Preexisting chronic medical illness

Notes Refer flow chart

Screening and history taking

Definition Accurately establishing the period of gestation by various modalities.

Presentation 1. Amenorrhea - > 4 weeks

Clinical Findings Breast tenderness

Investigations Blood: FBC, β-HCG

Imaging: USG (TAS/TVS)

Healthcare Refer to flow chart

Notes Ectopic pregnancy should be considered if IUGS not see

Management of late booker is as followed:

4. The decision for induction of labour should be made by O&G Specialist.

USG Gynae scan

Empty Fetal measure

Refer to ectopic Refer to

Fetal pole seen

*A repeat scan 2-4 weeks later is

Re-dating based on ultrasonography

Gestational age range Method of Discrepancy between

PV Fresh / Fresh/nil fresh +/- +

Abdominal nil nil + nil +

Passage of nil nil + nil +

Cervical os closed open open closed open

Uterine = date =date < date < date <

Fever nil nil nil nil +

Differential 1. Ectopic pregnancy

Imaging: USG (TAS/TVS)

Others: swab C&S