OBSTETRICS PROTOCOLS

Contents
xvi Obstetrics Protocols
3. Gestational Trophoblastic Disease 30
• Definitions 30
• Hydatidiform Mole 30
• Gestational Trophoblastic Neoplasia (GTN) 35
4. Hyperemesis Gravidarum 40
• Risk Factors/Associated Factors 40
• Symptoms 40
• Features of Dehydration and Ketoacidosis 41
• Investigations 41
• Treatment 41
• Management 42
• Discharge Criteria 43
• Complications 44
5. Recurrent Pregnancy Loss 45
• Definition 45
• Incidence 45
• Etiology 46
• Etiological Factors in Recurrent Pregnancy Loss 47
• History 47
• Genetic Abnormalities 48
• Anatomic Abnormalities 50
• Endocrine Abnormalities 52
• Infections 53
• Immune Factors 53
• Immunology of Pregnancy 54
• Thrombophilias 54
• Hyperhomocysteinemia 57
• Antiphospholipid Syndrome 58
6. Multiple Pregnancy 65
• Diagnosis 65
• Complications 66
• Management during Labor 68
• Discordant Twins 71
• Twin to Twin Transfusion Syndrome 72
• Monozygous Twins 74
• Conjoint Twins 74
7. Intrauterine Growth Restriction 76
• Definition 76
• Classification 76
• Etiology 77
• Identification of Patients at Risk 78
• Management 79
• Practice Points 81
8. Rh-negative Pregnancy 83
• Non-immunized Mother 83
Contents xvii
9. Oligoamnios 92
• Definition 92
• Conditions Associated with Oligoamnios 92
• Types 93
• Diagnosis 93
• Management 95
• Amnioinfusion 96
10. Polyhydramnios 98
• Definition 98
• Causes 98
• Complications 98
• Management 99
11. Antepartum Hemorrhage 101
• Definition 101
• General Management 101
• Diagnosis 102
• Placenta Previa 103
• Morbidly Adherent Placenta (Total Placenta Accreta) 106
• Abruptio Placentae 107
• Complications 108
• Vasa Previa 113
12. Intrauterine Fetal Death 114
• Definition 114
• Diagnosis 114
• Management 117
• Evaluation Prior to Next Pregnancy 118
13. Preterm Labor 119
• Screening of Preterm Labor 120
• Prevention of Preterm Labor 122
• Tocolytics 128
• Steroids 133
• Antibiotics 135
• Adjunctive Prophylactic Antibiotic Therapy 136
• Management of Labor 136
• Neonatal Complications 137
14. Premature Rupture of Membranes 138
• Definition 138
• Management 138
• Clinical Examination 138
• PROM after 35 Completed Weeks 140
15. Preterm Premature Rupture of Membranes 142
• Diagnosis and Management of Preterm PROM (PPROM) 142
• Expectant Line of Management 143
xviii Obstetrics Protocols
16. Prolonged Pregnancy 144
• Definition 144
• Diagnosis 144
• Prevention of Prolonged Pregnancy 144
• Management 144
17. Previous LSCS (Vaginal Birth after Cesarean Delivery) 148
• Definition of Terms 148
• Planned VBAC in Special Circumstances 150
• Planned VBAC Adverse Maternal Outcomes 150
• Planned ERCS and Adverse Perinatal Outcome 151
• Antenatal Counseling 154
• Induction and Augmentation of Labor 155
• Management of Labor 156
18. Resuscitation in Pregnancy and Puerperium 159
• Resuscitation in Pregnancy and Puerperium 159
• Basic Life Support 162
• Advanced Life Support 163
Section 2: Labor
19. Normal Labor 169
• Definition 169
• Diagnosis 169
• Stages of Labor 170
• Management of Labor 170
• Investigations 171
• Gradually Developing Hypoxia 179
• Key Principle 186
• Meconium Aspiration Syndrome 187
20. Malpresentation and Malposition 188
• Occipito-posterior Position 188
– Definition 188
– Incidence 188
– Etiology 188
– Diagnosis 188
– Management of Labor 190
• Breech Presentation 191
– Types of Breech Presentation 191
– Etiological Factors 192
– Diagnosis 192
– Complications 193
– Investigations 193
– Induction/Augmentation of Labor 193
– Methods of Vaginal Delivery 193
– Indications for Cesarean Section 193
– Prerequisites for Vaginal Delivery 194
Contents xix
– Intrapartum Management 194
– Role of External Cephalic Version (ECV) during Labor 198
• Face Presentation 198
– Definition 198
– Etiology 198
– Diagnosis 199
– Management of Labor 200
– Mechanism of Labor in Left Mentoanterior Position 200
• Brow Presentation 201
– Definition 201
– Incidence 201
– Etiology 201
– Diagnosis 202
– Mechanism of Labor 202
– Management of Labor 202
• Transverse Lie 203
– Definition 203
– Positions 203
– Etiology 203
– During Antenatal Period 203
– During Labor 205
• Cord Prolapse 206
– Incidence 206
– Management 207
• Shoulder Dystocia 208
– Definition 208
– Factors Associated with Shoulder Dystocia 208
– Alarmer 211
• Version 212
– External Cephalic Version 212
– Internal Podalic Version 214
21. Episiotomy 216
• Definition 216
• Indications 216
• Procedure 216
• Care of Episiotomy 217
22. Active Management of Third Stage of Labor 218
• Signs of Placental Separation 218
• Steps of Active Management of Third Stage of Labor 218
23. Nutrition in Labor 221
• Composition of the Diet 221
• Effect of Nutritional Problems on Pregnancy 225
• Nutrition during Labor 225
• Recommendations 227
• Special Situations 227
• Exercise in Pregnancy 228
xx Obstetrics Protocols
24. Induction of Labor 232
• Definition 232
• Factors to be Considered before Induction 233
• Complications of Induction of Labor 234
• Classification of Methods of Induction of Labor 234
• Induction of Labor in Special Cases 238
25. Labor Analgesia 242
• Definitions 242
26. Prolonged Labor 251
• Prolonged Labor 251
27. Obstructed Labor 255
• Definition 255
• Etiology 255
• Complications 255
• Clinical Features 256
• Treatment 257
28. Instrumental Delivery 258
• Forceps Delivery 258
• Indications for Assisted Vaginal Delivery 260
• Contraindication to an Instrumental Vaginal Delivery 260
• Prerequisites 261
• Summary 261
• Application 262
• Ventouse or Vacuum Extraction 267
• Vacuum Extraction as Compared to Forceps 271
29. Cesarean Delivery 273
• Indications 273
• Indications for Classical Cesarean Delivery 275
• Anesthesia for Cesarean Delivery 276
• Delivery of the Fetus 279
• Thromboprophylaxis Guidelines Following CS 284
Section 3: Postpartum
30. Postpartum Hemorrhage 289
• Definition 289
• Atonic PPH 290
• Secondary PPH 305
• Traumatic PPH 306
31. Shock in Obstetrics 320
• Classification 320
• Hypovolemic Shock 321
• Septic Shock 322
• Distributive Shock 328
Contents xxi
32. Blood Transfusion 329
• The Purpose and Scope of Blood Transfusion 329
• General Principles of Blood Transfusion 330
• Administering Blood Products 338
• Monitoring the Transfused Woman 339
• Transfusion Reactions 341
• Future Trends 346
33. Postpartum Collapse 347
• Amniotic Fluid Embolism 348
• Drug Overdose/Toxicity 351
34. Venous Thromboembolism 353
• Risk Factors 353
• Diagnosis 354
• Deep Vein Thrombosis 354
• Complications with Anticoagulant Treatment 359
• Pulmonary Thromboembolism 361
• Radiation Exposure in Pregnancy 364
35. Cortical Vein Thrombosis 366
• Etiology 366
• Diagnosis 367
• Laboratory Tests 368
• Prognosis 368
• Treatment 369
36. Postpartum Contraception 371
• Healthy Timing and Spacing of Pregnancies [HTSP] 371
• Lactational Amenorrhea Method (LAM) 371
• Barrier Methods 372
• Progesterone-only Contraception 373
• Permanent Methods 375
• Methods of Sterilization 375
• Male Sterilization 376
Section 4: Medical Disorders in Pregnancy
37. Anemia 379
• Definition 379
• CDC Criteria 379
• Protocol for Blood Transfusion 383
• Erythropoietin 388
• Folic Acid Deficiency Anemia 390
• Folic Acid Prophylaxis 391
• Vit. B12 Deficiency Anemia (Addisonian Pernicious Anemia) 391
• Dimorphic Anemia 392
• Hemolytic Anemias 392
• Hemoglobinopathies 392
xxii Obstetrics Protocols
• Thrombocytopenia in Pregnancy 401
• Gestational Thrombocytopenia 402
• Idiopathic (Immune) Thrombocytopenic Purpura (ITP) 405
• Neonatal Alloimmune Thrombocytopenia (NAIT) 407
• Hemolytic Uremic Syndrome 408
• Thrombotic Thrombocytopenic Purpura 408
• Thrombocytopenia and Infection 408
• Platelet Transfusion 409
38. Hypertensive Disorders Complicating Pregnancy 411
• Classification 411
• Labor and Delivery 428
• Eclampsia 431
• Medical Management 434
• Chronic Hypertension 441
• Long-term Consequences 442
• Non-cardiogenic Causes of Pulmonary Edema 442
• Renal Disease 443
• Acute Kidney Injury/Acute Renal Failure 444
• Management 451
• Recommendations for Management 454
39. Heart Disease 457
• Heart Disease 457
• Risk Predictors of Adverse Fetal and Maternal Outcome 459
• Management of Specific Lesions 464
40. Diabetes 475
• Definition 475
• NICE Criteria for Diagnosis of GDM 475
41. Epilepsy 486
• Definition 486
• Pre-conceptional Counseling 488
• Management during Pregnancy 488
• Management of Pregnancy in Women with Epilepsy 489
• Management of Patients with Status Epilepticus 491
42. Bronchial Asthma 492
• Effect of Pregnancy on Asthma 492
• Effect of Asthma on Pregnancy 492
• Life-threatening Complications 492
• Counseling 492
• Classification of Asthma Severity 493
43. Jaundice 495
• Liver Function Tests in Normal Pregnancy 495
• Liver Function Tests Following Delivery in Normal Pregnancy 496
• Viral Infections 504
Contents xxiii
• Gallbladder Disease (Gallstones and Cholecystitis) 506
• Pregnancy Following Liver Transplantation 507
44. Thyroid Disorders 508
• Changes in Thyroid Physiology in Pregnancy 508
• Hypothyroidism 509
• Hyperthyroidism in Pregnancy 510
Section 5: Infections in Pregnancy
45. HIV Infection 517
• Incidence 517
• National Guidelines on Testing Adults 517
• Symptomatic Patients 517
• WHO Clinical Staging of HIV/AIDS for
Adults and Adolescents 2010 519
• ARV DRUGS 523
• New Feeding Guidelines 531
• Benefits of Guidelines 532
46. Hepatitis B Infection 537
• Prevention 539
47. Malaria 540
• Definitions 540
• Effects of Pregnancy on Malaria 540
• Effects of Malaria on Pregnancy 541
• National Drug Policy on Malaria 545
48. Urinary Tract Infection 548
• Principal Presentations 548
• Cystitis/Urethritis 549
• Acute Pyelonephritis 549
49. Tuberculosis 551
• Mode of Spread 551
• Clinical Features 551
• Pulmonary Tuberculosis 552
• Extrapulmonary Tuberculosis 552
• The Effects of Pregnancy on TB 553
• The Effects of TB on Pregnancy 553
• Investigations for Diagnosing TB in Pregnancy 553
• Risk Factors for TB 555
• Congenital TB 555
• Dosage of Antitubercular Drugs 557
• INH Prophylaxis for Pregnant Woman 561
50. Syphilis 563
• Mode of Transmission 563
• Clinical Features 563
• Diagnosis 564
xxiv Obstetrics Protocols
51. TORCH Infections 567
• Toxoplasmosis 567
• Rubella (German Measles) 570
• Cytomegalovirus Infection 572
• Herpes Simplex Virus Infection 575
52. Bacterial Vaginosis 577
• Etiology 577
• Microbiology 577
• Clinical Features 578
• Treatment 578
53. Monilial Vaginitis 580
• Causative Agents 580
• Clinical Features 580
• Diagnosis 580
• Treatment 581
Section 6: Gynecological Disorders in Pregnancy
54. Fibroid 585
• Natural History of Fibroids in Pregnancy 585
• Complications 585
• Management 585
55. Genital Prolapse 587
• Incidence 587
• Effects of Pregnancy on Prolapse 587
• Effects of Prolapse 587
• Management 588
56. Carcinoma Cervix 589
• Incidence 589
• Effects of Pregnancy on Carcinoma Cervix 589
• Effects of Carcinoma on Pregnancy 589
• Diagnosis 589
• Treatment 589
57. Ovarian Tumor 591
• Incidence 591
• Diagnosis 591
Bibliography 593
Index 595