INDEX

TOPIC PAGE
INTRODUCTION 3
CONTRIBUTORS 4
ANTENATAL CARE 6
MANAGEMENT OF THE PATIENT IN LABOUR 8
FIRST STAGE OF LABOUR 8
OXYTOCIN IN LABOUR 10
THE MULTIGRAVID PATIENT 10
THE SECOND STAGE OF LABOUR 11
THE THIRD STAGE OF LABOUR 12
OXYTOCIN REGIMEN FOR LABOUR WARD 13
ANALGESIA IN LABOUR 14
ANAESTHETIC TO THE PERINEUM 14
POSTPARTUM ADMINISTRATION OF ANALGESIA 14
ADMINISTRATION OF VITAMIN A TO MOTHER POSTPARTUM 14
POSTPARTUM CONTRACEPTION 15
GUIDELINES FOR THE USE OF MISOPROSTOL (CYTOTEC) 16
USE OF MISOPROSTOL FOR THE INDUCTION OF LABOUR 16
GUIDELINES FOR THE USE OF OXYTOCINE IN LABOUR WARD 17
GUIDELINES FOR THE USE OF PROSTAGLANDINS 18
PROTOCOL ON MANAGEMENT OF PATIENTS WITH CONFIRMED INTRA-UTERINE FETAL 19
DEATH (IUD) AFTER 24 WEEKS
PROTOCOL ON INDUCTION OF LABOUR 21
ASPHYXIA 22
RESPONSE OF THE FETUS TO ASPHYXIA 23
FACTORS AFFECTING OXYGENATION 23
SEVERE ASPHYXIA 25
DEPARTMENTAL POLICY ON STILLBIRTHS 26
VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) 27
CLASSIFICATION OF URGENCY FOR CAESAREAN SECTION 29
POLICY REGARDING PREMEDICATION FOR ELECTIVE / EMERGENCY CAESAREAN 30
SECTION
POLICY REGARDING PROPHYLACTIC USE OF MEFOXIN – EMERGENCY CAESAREAN 30
SECTION
ANTEPARTUM HAEMORRHAGE 31
ALGORITHM FOR MANAGEMENT AND DIAGNOSIS OF ANTEPARTUM HAEMORRHAGE 32
DIFFERENCES BETWEEN ABRUPTIO PLACENTAE AND PLACENTA PRAEVIA 33
ESSENTIALS IN MANAGEMENT OF ABRUPTIO PLACENTAE 34
MANAGEMENT OF PLACENTA PRAEVIA 36
APH OF UNKNOWN ORIGIN 36
POST-PARTUM HAEMORRHAGE 37
ALGORITHM FOR MANAGEMENT OF POST PARTUM HAEMORRHAGE 39
BLEEDING AFTER CAESAREAN SECTION 40
PREVENTION OF POSTPARTUM HAEMORRHAGE (PPH) 41
OBSTETRIC EMERGENCIES : FOETAL COMPROMISE 42
MANAGEMENT OF FOETAL COMPROMISE 42
CORD PROLAPSE 43
SHOULDER DYSTOCIA 43
A GUIDE TO HIGH RISK PREGNANCY 44
SCREENING FOR DIABETES 45
SCREENING PROTOCOL FOR GESTATIONAL DIABETES 45
MANAGEMENT OF DIABETES IN PREGNANCY 46
PROTOCOL FOR OBSTETRIC DIABETIC PATIENTS – IN PATIENTS 48
CARDIOVASCULAR DISEASE IN PREGNANCY – ANTENATAL MANAGEMENT 50
1
MANAGEMENT OF LABOUR 50
MITRAL VALVE STENOSIS 51
MECHANICAL VALVE PROSTHESIS 51
EMERGENCY MANAGEMENT OF ACUTE PULMONARY OEDEMA DUE TO LEFT 52
VENTRICULAR FAILURE
HYPERTENSION IN PREGNANCY 53
MANAGEMENT OF ECLAMPSIA 54
PROTOCOL FOR ADMINISTRATION OF MgS04 57
PRETERM RUPTURE OF MEMBRANES 59
TOCOLYSIS 60
ANTENATAL CORTICOSTEROIDS TO PREVENT RESPIRATORY DISTRESS SYNDROME 61
ULTRASOUND PROTOCOL 62
PROTOCOL ON PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM 63
(VTE) PREGNANCY
PROTOCOL ON MANAGEMENT OF SUSPECTED OR CONFIRMED EBOLA IN 66
PREGNANCY
ADMISSION AND DISCHARGE CRITERIA – GYNAECOLOGY 70
BLOOD TRANSFUSIONS 71
MANAGEMENT OF PATIENTS WHO REFUSE TRANSFUSION OF BLOOD COMPONENTS 71
(E.G. JEHOVAH’S WITNESS PATIENTS)
GENERAL GYNAECOLOGY – MISCARRIAGES 72
PROTOCOL FOR EVACUATION OF THE UTERUS 75
PROTOCOL FOR USE AT THE TERMINATION OF PREGNANCY (TOP) CLINIC 78
RECURRENT MISCARRIAGE 82
PROTOCOL FOR MANAGEMENT OF RAPE VICTIMS 83
VAGINAL DISCHARGE 86
VULVODYNIA 88
ADNEXAL MASS 89
PELVIC INFLAMMATORY DISEASE 92
ETOPIC PREGNANCY 94
HYPEREMESIS GRAVIDARUM 97
ABNORMAL VAGINAL BLEEDING IN A PREPUBERTAL CHILD 98
ABNORMAL UTERINE BLEEDING IN AN ADOLESCENT 98
ABNORMAL UTERINE BLEEDING IN THE REPRODUCTIVE YEARS 100
PERIMENOPAUSAL BLEEDING 103
MENOPAUSE 104
PRIMARY OVARIAN INSUFFICIENCY 106
AMENORRHOEA 107
PRIMARY AMENORRHOEA 107
SECONDARY AMENORRHOEA 110
HIRSUTISM 113
POLYCYSTIC OVARIAN SYNDROME 118
INFERTILITY 121
FIBROIDS 123
ENDOMETRIOSIS 124
URINARY INCONTINENCE 125
URINARY FISTULA 128
PELVIC ORGAN PROLAPSE 129
GYNAE-ONCOLOGY PROTOCOLS – REFERRAL TO GREY’S HOSPITAL – GENERAL 132
SUGGESTED PROTOCOL FOR MANAGEMENT OF GYNAECOLOGICAL PRENEOPLASIA 133
AND MALIGNANCIES IN REGIONAL / TERTIARY CENTER

2
 INTRODUCTION

The first edition of this document was developed by the management of the Department of
Obstetrics and Gynaecology in the uMgungundlovu Functional District in 2006. It served as a
guide for staff with respect to the management of patients in the field of reproductive health in the
uMgungundlovu region and the surrounding areas.

This revised Protocol and Policies document attempts to address common problems that arise in
reproductive health. The Obstetric Protocols and Policies have been updated and rewritten, while
a much more extensive Gynaecology management guideline is provided.

While attempts have been made to ensure that the instructions and the guidance provided are
comprehensive, it is inevitable that they will not cover all probabilities. Neither will they cover all
schools of thought.

These protocols are not set in stone and can be adapted to suit local circumstances and
preferences. They will also require regular review and updating in line with advances in Women’s
Health.

We hope that this guide will contribute to improving Women’s Health in the District and to
maintaining a high standard of Obstetrics and Gynaecology practice at all levels of care.

______________________

DR TD NAIDOO

Head Clinical Unit Greys Hospital

______________________

DR MJ TITUS

Head: Clinical Department & Metropolitan Head

3
CONTRIBUTORS

Dr GTT Buthelezi

Dr P Israel

Dr RC Pillay

DR M Moodley

Dr TD Naidoo

Dr MJ Titus

Dr David Bishop

ACKNOWLEDGEMENTS

Mrs J Erasmus for formatting and final layout.

4
OBSTETRICS

5
ANTENATAL CARE

The aim of antenatal care is to achieve the best possible outcome for mother and baby. This may
be achieved through screening and management of pregnancy complications, risk assessment,
information provision and physical and psychological preparation for labour, delivery and
parenthood.

The antenatal file

All pregnant patients should receive a standard Department of Health file in which their antenatal
notes should be documented. Patients should be reminded to carry this file with them at each visit
to hospital, especially in the event of an emergency. It is important that the file is filled in
completely and accurately at each antenatal visit as poor documentation may negatively impact on
patient care.

The first antenatal visit

Antenatal care should begin as soon as pregnancy is diagnosed. After one visit a patient is
regarded as “booked”.

The following should be done at the first visit:

 Establish the gestational age by documenting the date of the last normal menstrual period.
Enquire about contraceptive history, regularity of the menstrual cycle and if she is sure of
her dates.
 Take a thorough history which should include:
 Previous pregnancies, complications, outcomes, mode of delivery, birth weights
 Medical and surgical history
 Family history
 Use of medication
 Social history including use of illicit substances
 Allergies
 Discuss future family planning
 Physical Examination
 General examination including weight and height
 Systematic examination
 Pregnancy examination
 Inspection for previous scars
 Palpation of the uterus
 Measurement of SFH
 Investigations
 HIV, Rh, RPR, Hb
 Urine dipstix
 Medication
 Iron, Folate and Calcium supplementation
 Ferrous sulphate 200mg daily
 Folate 5mg daily
 Calcium carbonate 1g daily
6
  Provide information on:
 Danger signs
 Vaginal bleeding, severe headache, reduced fetal movements, rupture of
membranes, severe abdominal pain
 Self- care
 Diet, exercise
 Avoiding alcohol, smoking and illicit drugs
 Breast care
 Infant feeding options

 Final assessment
 Clearly list the risk factors that have been identified for the pregnancy
 Outline further management of any risk factors
 Document the next appointment date
 Discuss delivery options with the patient, especially in patients who have previously
delivered by Caesarean section.

Subsequent visits

Enquire about

 General health
 Fetal movements
 Danger signs
 New problems

Plot the SFH and interpret the growth of the fetus compared to previous SFH and LNMP. If a
discrepancy is detected, follow up with ultrasound to exclude conditions such as IUGR, multiple
pregnancy, fetal anomalies, liquor volume abnormalities and uterine abnormalities.

Repeat HIV and RPR testing at 32 weeks.

7
MANAGEMENT OF THE PATIENT IN LABOUR

Primigravida and Multigravida behave differently when they are in labour.

PRIMIGRAVIDA

 First labours are prolonged due to inefficient uterine contractions and the genital tract not
having been stretched before.
 Cephalopelvic disproportion (CPD) is a distinctive feature of first labours because the
functional capacity of the pelvis is not known.
 Rupture of the uterus is an uncommon event.
 Obstructed labour in a primigravida is preceded by a delay in the rate of cervical dilatation.

MULTIGRAVIDA

 Inefficient uterine activity is rare.

 Slow progress in labour, in a parous woman, should never be assumed to be due to
inefficient uterine action but rather obstructed labour

It is important to make a diagnosis of labour before admitting the patient to the Labour Ward.

The diagnosis is made when:

 There are painful uterine contractions that are increasing in frequency and intensity
accompanied by
 Cervical effacement and dilatation or
 A show
 Ruptured membranes
 Progressive descent of the presenting part.

On admission a careful history should be taken. All risk factors should be identified. If unbooked,
do booking bloods (HIV, Rh, RPR, Hb) at that time. Document the nature of labour pains, vaginal
bleeding, fetal movements, rupture of membranes and any other important information

On Examination:
General examination: PR, BP, temperature, pallor, psychological state.

Abdominal examination: Inspection, Symphysis-fundal height (SFH), lie, presentation, level

of presenting part in fifths above the pelvic brim, liquor volume, number of fetuses,
auscultate for a fetal heart, assess presence, duration and frequency of contractions per 10
minutes.

Vaginal examination: warts, lesions, discharge. Cervical effacement, position, consistency

and dilatation. Presence of caput and [Link] any rupture of membranes, offensive
liquor and meconium staining.

THE FIRST STAGE OF LABOUR

Progress during the first stage of labour may be measured in terms of:
 Dilatation of the cervix
 Effacement of the cervix
 Descent of the head

8
In the majority of labours the active phase commences when the cervix is 3cm dilated and fully
effaced.
The slowest rate of dilatation acceptable is 1cm per hour in a primigravida and 1.5cm in a
multigravida.
A clear pattern of dilatation should have emerged by the end of 4 hours.

PELVIC EXAMINATION

On admission, a diagnosis of labour is made. If the patient is not in active labour, transfer to
antenatal ward. Encourage ambulation.

Subsequent examinations are carried out 4 hourly if in latent labour,and 2 hourly if in active
labour.
 The same person should perform subsequent examinations - as far as is possible.
 The sister in charge of the delivery unit is named as the person responsible for the
assessment of progress.

The Degree of Dilatation is recorded on the Partogram.

Delay in the active phase of the first stage of labour is diagnosed by:
 Evidence of delay in the progressive dilatation of the cervix.
 Failure of descent of the presenting part.

Any subsequent deviation to the right of the Alert Line, alerts the attendant to a potential problem.

If delay in the active phase is diagnosed (when the rate of cervical dilatation reaches the Action
line) -AN ACCURATE AND THOROUGH assessment by an experienced observer is vital.
This is one of the most DECISIVE points in a woman’s labour.

The fetal condition must be assessed accurately and if there is clear evidence of fetal asphyxia or
CPD at this stage then a Caesarean section is indicated.

The Fetal condition may be assessed by: -

 Listening to the fetal heart before and after contractions.
 Interpreting the cardiotocograph carefully, if available.
 Inspecting the nature of the liquor.
 Assessing for increasing caput and moulding of the fetal skull.

A definite diagnosis of CPD can be made if the head is still high (three or four fifths above the brim
with increasing moulding and no progress in descent).

The Maternal Condition – must be assessed taking note of her: -

 Emotional response to delayed progress.
 Hydration. If dehydrated:
o 5% dextrose water is started.
o If ketones are present add 50 mls of 50% Dextrose.
 Pyrexia.
 Tachycardia and Hypertension.
 Urine output

Those primigravidas who show no evidence of fetal compromise or CPD and are assessed as
having inefficient uterine action should have augmentation of labour.

9
OXYTOCIN USE IN LABOUR

The therapeutic effect of OXYTOCIN is to:

 Improve uterine action

 Cause cervical dilatation
 Cause descent of the fetal head to the 2nd stage of labour.

The decision to use oxytocin is taken by the Sister in charge, without reference to Medical
Staff.

The following criteria must be fulfilled:

 The mother must not be a grand multipara
 The presentation must be vertex.
 Singleton.
 The fetal heart must be regular and the CTG must be normal.
 The membranes must be ruptured and the liquor clear.
 There must be no evidence of CPD

The aim should be to obtain 3 contractions per 10 minutes each lasting between 45 and 60
seconds with resting tone between the contractions.
There should be a rate of cervical change within an hour, proceeding to full dilation, at more than
1cm per hour and good head descent.
A decision on the mode of delivery should be made within 6 hours of commencing the oxytocin
infusion.

Delay may be due to:

 CPD
 Malpresentation
 Primary Inertia
An immediate Caesarean section is indicated if there is:

 Gross CPD
 Malpresentation
 Fetal compromise which is persistent
 Increasing moulding
 High head with moulding
 Failure to progress
If there has been no fetal compromise following 6 hours of Oxytocin and the rate of
cervical dilatation has been less than 1cm per hour with no descent.

THE MULTIGRAVID PATIENT

If the cervicographic progress crosses the alert line in a multigravid patient this is a serious sign.

Oxytocic stimulation should never be used unless there is absolute certainty that there is
no element of CPD present.

 If there is doubt it is better to observe the labour for 2 hours with adequate analgesia and
then re-assess the case.

10
If there is no evidence of CPD and no moulding and if by personal assessment uterine
contractions are inadequate, then oxytocin may be used – 2 units.

THE SECOND STAGE OF LABOUR

Begins at full dilatation (i.e. vagina continuous with the cervix BETWEEN contractions).
Progress of the second stage is measured in terms of Descent and Rotation. It seldom lasts
more than 2 hours.
This is the stage of labour that is associated with the most amount of trauma to both
mother and fetus by obstetric intervention.

The second stage of labour is associated with 2 distinct PHASES.

Phase1: (Descent) Extends from full dilatation until the fetal head
reaches the pelvic floor.
 The head is high in the pelvis
 The occiput is transverse
 The vagina is not stretched and there is no urge to push

Phase2 :(Expulsion) From the time the fetal head reaches the
pelvic floor to delivery.
 The fetal head reaches the pelvic floor
 Vaginal delivery is almost assured
 Compulsive desire to push

Prolonged 2nd stage

 2 hours in a primigravid
 1 hour in a multigravid
 Allow an additional hour if epidural was inserted

ACKNOWLEDGEMENT TO: Prof. R H Philpott

Prof. Kieran O’Driscoll

11
THE THIRD STAGE OF LABOUR

This stage starts immediately after delivery of the fetus and ends with delivery of the placenta.
Active management should be carried out in order to reduce complications and prevent
excessive bleeding.

 Immediately after delivery of the infant, perform abdominal palpation to exclude possibility
of an undiagnosed 2nd twin

 I.M.I. Syntocinon–10iU to be administered to all hospital patients with the birth of the
anterior shoulder

 Clamping of the cord – delayed unless there has been intrapartum fetal distress and
bleeding
 When the uterus is felt to contract, keep steady traction on the umbilical cord with the right
hand while pushing the uterus upward with the left (controlled cord traction)

 Deliver the placenta

 Check the placenta for completeness and any abnormalities

12
OXYTOCIN REGIMEN FOR LABOUR WARD

 Oxytocin may be used for induction or augmentation of labour

 Infusions should be administered via infusion pumps.
 A 20 drops per ml set should be used.

For Multigravidas:

 Add 2 iU of Oxytocin to 1 litre of Ringer’s Lactate.

 Start the infusion at [Link] which is equivalent to [Link].
 Palpate for contractions 20 minutes after starting the infusion and if fewer than 3
contractions are palpated then increase the rate by to [Link]. ([Link]) up to a
maximum of [Link] ([Link])
 Aim for 3 strong contractions (>40seconds) in 10 minutes.
 The maximum infusion rate should be [Link].
 If the infusion rate reaches [Link] and strong contractions are not felt, increase the dose
by starting an infusion of 5iU of Oxytocin in 1l of MRL at 120/180/240 [Link] as described
above, which amounts to a maximum of [Link]

In multigravid patients do not exceed 2units/L at 60 drops/minute

For Primigravidas:
Add 10iU Oxytocin to 1l of Ringer’s Lactate
 Start the infusion at 12ml/hr ([Link]) and increase half-hourly as described above to
[Link] or a maximum of 20mU/min
 Consider delivery by Caesarean section after 6 hours of Oxytocin infusion.

Precautions:
Exclude CPD, fetal compromise, previous CS and grand multiparity (P5)

For Cardiac patients:

Add 2iU of Oxytocin to 200ml MRL

Start the infusion at 12/24/36 and [Link] as described above.

13
 ANALGESIA IN LABOUR

The sister in the Labour Ward has the authority to:

 Administer up to 100mg of Pethidine and up to 100mg of Aterax intravenously or

intramuscularly for the purpose of analgesia in labour.
 This should be limited to 6cm cervical dilation in a Primigravida and 4cm cervical dilation in
a Multigravida patient.
 Narcan 0.1 mg/ kg may be administered to the newborn if there are signs of respiratory
depression, or if delivery occurs within 2 hours of the last dose of Pethidine.
 If a second dose of analgesia is required, the doctor on call must be consulted.

ANAESTHETIC TO THE PERINEUM

Using a dental syringe and needle, a registered midwife may infiltrate the perineum in order to
perform an episiotomy or to suture an episiotomy and 1st or 2nd degree tears.

 She uses not more than 3.6mls ( 2 cartridges) of local anaesthetic, that is, 2% Lignocaine
without adrenaline, for infiltration prior to performing the episiotomy.
 She uses not more than 5.4mls (3 cartridges) for suturing. (Total of 9mls. One cartridge
contains 1.8mls)
 The dental needle is introduced into the skin to its full extent before the anaesthetic is
injected.

The local anaesthetic is only injected as the needle is being withdrawn from the skin.

POSTPARTUM ADMINISTRATION OF ANALGESIA

-The following medication should be prescribed to all patients who have undergone delivery by
Caesarean Section, unless there are contra-indications, in which case alternatives should be
prescribed on an individual basis.

1. Diclofenac Sodium (Voltaren) 75mg in 200mls normal saline over 20 minutes 12 hourly up
to 3 doses.
2. Rescue Morphine 10mg imi (only if pain is not relieved by Voltaren)
3. Panado 1g 4-6 hourly po
4. Tramadol 50mg 8 hourly po
-The following medication should be prescribed to all patients who have undergone vaginal
delivery, unless there are contra-indications, in which case alternatives should be prescribed on an
individual basis.

1. Panado 1g 4-6 hourly po

2. Tramadol 50mg 8 hourly po

ADMINISTRATION OF VITAMIN A TO MOTHERS POSTPARTUM

Vitamin A capsule 2000,00 IU per os given to each mother before discharge from hospital

14
POSTPARTUM CONTRACEPTION

All patients should be offered family planning advice antenatally and again postpartum. Her
choices should be documented in the antenatal records.

Consent should be taken antenatally for Bilateral Tubal Ligation and not while the patient is in
labour or in theatre awaiting Caesarean Section.

The following contraceptive options are currently available at Grey’s Hospital:

 Depo Provera
 Nur-Isterate
 Implanon
 Copper-T
 Triphasil
 Oralcon
 Hi-an
 Male condoms

Condoms must be available to all patients.

Patients should be encouraged and counselled regarding the use of dual contraception (i.e.
Barrier method plus hormonal or other method).

15
GUIDELINES FOR THE USE OF MISOPROSTOL (CYTOTEC)

 Misoprostol should only be administered by Medical Officers, Interns and Senior Sisters,
according to the protocol for either Induction of Labour or Termination of Pregnancy

 Misoprostol may only be inserted after its use has been authorized by a Medical Officer
working in the department

 The patient in whom it has been decided to “ripen” the cervix must be fully evaluated

 The patient should have a non-stress test before insertion of Misoprostol for induction of
Labour.

 Once Misoprostol has been commenced for the induction of labour the patient must be
observed in the Labour Ward and a fetal heart tracing should be obtained before and at
least 1 hour after commencement.

 Oxytocin should only be used a minimum of 6 hours after the last dose of Misoprostol.

USE OF MISOPROSTOL FOR THE INDUCTION OF LABOUR-

PRIMIGRAVADA

 50g (1/4 tablet) Misoprostol is inserted into the posterior fornix of the vagina (vaginal
regimen)
 Follow 6 hours later with the oral regimen.

MULTIGRAVIDA

 Commence oral regimen:

 Dissolve 1 tablet (200g) Misoprostol in 200mls of tap water. This gives a solution of 1g /
ml.
 Administer 20 ml of solution using a syringe at 2 hourly intervals not exceeding 4 doses.

If the patient does not go into labour, wait 24 hours (if possible, depending on the urgency of the
induction) before recommencing the Misoprostol.

If there is tachysystole (> 5 contractions per 10 minutes) or hyperstimulation (contraction lasting

more than 2 minutes)

 Lie patient in left lateral position.

 Administer oxygen.
 Administer Salbutamol 0.5ml (250micrograms) diluted in 9.5ml normal saline and give 1ml
ivi.

16
GUIDELINES FOR THE USE OF OXYTOCIN IN LABOUR WARD

 Oxytocin may be used for induction or augmentation of labour Infusions should be

administered via infusion pumps or a flow rate limitor, if these are available.
 A 20 drops per ml set should be [Link] is best to start at a lower concentration and then to
increase until an effective concentration is reached.
 It may be necessary to subsequently reduce this concentration.
 The starting dose of oxytocin will depend on the parity of the patient.

For Multigravidas:

Add 2 iU of Oxytocin to 1 litre of Ringer’s Lactate.

 Start the infusion at [Link] which is equivalent to [Link].

 Palpate for contractions 20 minutes after starting the infusion and if fewer than 3
contractions are palpated then increase the rate to [Link]. ([Link]) up to a maximum
of [Link] ([Link])
 Aim for 3 strong contractions (>40seconds) in 10 minutes.
 If the infusion rate reaches [Link] and strong contractions are not felt, increase the dose
by starting an infusion of 5iU of Oxytocin in 1l of MRL at 120/180/240 [Link] as described
above, which amounts to a maximum of [Link]

For Primigravidas:

Add 10iU Oxytocin to 1l of Ringer’s Lactate

 Start the infusion at [Link] ([Link]) and increase half-hourly as described above to
[Link] or a maximum of [Link]
 Consider delivery by Caesarean section after 6 hours of Oxytocin infusion.

For Cardiac patients:

Add 2iU of Oxytocin to 200ml MRL

Start the infusion at 12/24/36 and [Link] as described above which is equivalent to 7.2, 14.4 and
[Link] respectively

17
GUIDELINES FOR THE USE OF PROSTAGLANDINS

 Prostaglandins should only be administered by Medical

Officers and Interns.

 Interns may only insert prostaglandins after a Medical

Officer working in the Department has authorized its use.

 The patient in whom it has been decided to “ripen” the cervix must be fully
evaluated.

 The patient should have a non-stress test before insertion of prostaglandins.

 Once prostaglandins have been inserted the patients must be observed in the
Labour Ward and a fetal heart tracing should be obtained at least one hour after
insertion.

 Prostaglandins E2 (0.5 mg. per tablet) may be used paracervically. The dose is 2
mg (i.e. 4 tablets).

 Dinoprostone (Prepidil Gel) is available and may be used intra-cervically. Dose = 0.5
mg.

 If prostaglandins are to be inserted overnight, they must be inserted at 17h00 and

not 6-hourly.

 If the favourability of the cervix has not improved after 3 insertions the chances are
that the state of the cervix will not improve and this must be discussed with the
Consultant.

 Prostaglandins are not on the code for District Hospitals.

18
PROTOCOL ON MANAGEMENT OF PATIENTS WITH CONFIRMED INTRA-UTERINE FETAL
DEATH (IUFD) AFTER 24 WEEKS

Take a detailed history to try to identify risk factors and possible causes for IUFD.

Document the following:

 Presenting complaints, duration of absent fetal movements- delays in seeking medical help
if any, PVB, SROM, PVD, use of herbal medication, OTC medication or overdose of
medication, history of trauma or attempted TOP, symptoms of infection
 Obstetric history: LNMP, booking clinic, date of booking, any early scan less than 22-24
weeks, complications in early pregnancy, outcomes of previous pregnancies, MOD,
condition of alive children, if any.
 Social history: use of alcohol, substances and cigarette smoking.
 Medical history: Hypertension, Diabetes, Thyroid disease and Anaemia
 Family history

Read through the patient’s antenatal file to identify signs of poor fetal growth, weight gain,
ultrasound scan findings and any other risk factors during pregnancy.

Examine the patient thoroughly looking for causes and consequences of IUFD, such as
coagulopathy and sepsis. In patients with hypertension, Abruptio placentae must be excluded.
Document any discrepancy between expected gestational age based on dates or scan and clinical
estimation

Do the necessary blood workup: FBC, U&E, INR. All patients should have routine HIV, Rh and
RPR testing done at booking.

If the patient is stable, has normal blood results and no other abnormalities such as sepsis or
coagulopathy and if she is willing to bear the emotional distress of awaiting spontaneous labour,
offer her expectant management with weekly visits to ANC for check-ups and blood tests (Hb,INR)
for a maximum of 3 weeks. During these visits, observe for coagulopathy and sepsis. Those opting
for immediate IOL with Cytotec should be counselled on the risk of uterine hyperstimulation,
nausea, vomiting, and diarrhea and on rare occasions uterine rupture.

For patients who decide against expectant management, admit to M1 for induction of labour.

IOL in IUFD at 24 weeks:

Cytoctec (Misoprostil) 25µg PV 6 hourly or p.o. 2 hourly to a maximum of 4 doses.

In cases of previous Caesarean section and grand multiparity, do not use Cytotec for IOL. Rather
do a Foley’s catheter bulb induction.

 Insert a 16F trans-cervical Foley catheter past the internal os

 Inflate the balloon with 30 –80 mL of sterile water
 Place the catheter under gentle traction by taping the distal tip to the medial thigh
 To maintain gentle traction, periodic repositioning of the distal tip on the thigh is
necessary
 Await spontaneous expulsion of the bulb

19
Oxytocin may be used to further augment labour if needed. Do not rupture membranes.

Follow standard delivery protocols eg. AMTSL

Morphine 10mg imi should be given for pain relief during labour.

Karyotyping should be done on all cases of unexplained IUFD.

A follow-up date should be given to parents to review results of karyotyping.

For deaths of fetuses weighing >500g, fill in a PPIP form.

Transfer patient to M1 (antenatal ward) for postnatal care including breast-milk suppression if
needed, family planning advice, grief counselling. Provide a detailed discharge summary and
appropriate counselling to patient.

20
PROTOCOL ON INDUCTION OF LABOUR

Indications:

 Gestational age >41/40 in an otherwise uncomplicated pregnancy

 Prelabour rupture of membranes
 Pre-eclampsia > 34/40
 IUGR
 Previous unexplained IUFD at >28/40, induce at 38/40
 Chorioamnionitis
 Well controlled Diabetes at 38/40

Contra-indications:

 Malpresentation
 Cephalo-pelvic disproportion
 Placenta praevia
 Previous C/S x 2
 Cord presentation
 Active genital herpes
 Maternal convenience

For patients with one previous C/S or high parity do not induce with Misoprostol (Cytotec).
Rather use a bulb induction if no contraindications exist.

Before IOL, do a CTG.

If this is normal, proceed with IOL. Repeat CTG within 30 minutes of commencing IOL
If CTG abnormalities arise, stop the IOL:
For tachysystole (>5 contractions in 10 minutes) or hypertonus (single contraction lasting
longer than 2 minutes) commence Intra-Partum Resuscitation (IPR) and tocolyse the
patient with Salbutamol.

If the patient is not in labour 24 hours after commencing IOL, reassess the indication for IOL.
Options include:
 Stop IOL, restart on the next day
 Choose another method of IOL eg., Bulb, Oxytocin or amniotomy
Regimens:

 Misoprostol 50ug PV followed by 20mg 2-hourly p.o. for 4 doses if primigravida with no
rupture of membranes

 Misoprostol 20 ug 2-hourly p.o. for 4 doses if multigravida

 Commence Oxytocin 6 hours after last dose of Misoprostol.

 Bulb induction
o Insert a 16F trans-cervical Foley catheter past the internal os
o Inflate the balloon with 30 –80 mL of sterile water
o Place the catheter under gentle traction by taping the distal tip to the medial thigh
o To maintain gentle traction, periodic repositioning of the distal tip on the thigh is
necessary
o Await spontaneous expulsion of the bulb
21
ASPHYXIA

Reduction of 02 supply to the fetus may be Acute

Chronic

Avoiding perinatal hypoxia:

 Avoids death of the fetus before labour, during labour or in the neonatal period
 Is important to avoid permanent neurological damage, mental retardation etc.

Perinatal Mortality in the developed world is 10/1000

 32% - due to congenital abnormalities

 19% - in the neonatal period
 7% - during labour
 42% - prior to the onset of labour

The condition of a baby at birth is dependent on many factors

 The baby must be genetically and constitutionally intact.

 The foetus must have been provided with a supply of nutrients and 0 2 from the mother.
 Poor placental function – results in IUGR and foetal compromise.
 Babies may become asphyxiated over a period of time.
 Chronic Asphyxia: the signs may be subtle such as a change in foetal movement – or there
may be no sign at all.
 Other babies suffer acute compromise with conditions such as placental abruption, acute
cord prolapse and uterine rupture.

Acutely asphyxiated babies behave in different ways after birth.

The mechanisms that may lead to critical cerebral damage are essentially hypoxia and ischaemia
(poor perfusion) leading to tissue damage.

The foetus can compensate for asphyxial insult up to a certain threshold. Any asphyxia exceeding
this threshold can cause organ damage, motor defects and cognitive defects.

Anoxia> 10 minutes results in:

 Profound hypoxemia
 Metabolic acidosis
 Hypotension
 Cerebral damage to: Thalamus
Brain stem
Basal Ganglia

22
Evidence suggests that an anoxic insult of less than 8 minutes duration may not cause damage.
More than 10 minutes of anoxia results in neuropathological findings. The foetus does not survive
20-25 minutes of anoxia.

RESPONSE OF THE FETUS TO ASPHYXIA:

 Increase in arterial pressure and increased systemic vascular resistance.
 Blood flow to the gastrointestinal, renal and pulmonary flow is reduced.
 Blood flow to the heart, brain and adrenal glands is increased.
 There is a rapid fall in pH.
 If the hypoxia is resolved within a reasonable period of time, there will be return to normal
cerebral blood flow over the next 24 hours.

The human foetus exposed to acute severe asphyxia will have a low heart rate and a delayed
onset of respiration. Those foetuses asphyxiated for longer than 25 minutes die in the ICU due to
multi-organ failure and heart failure due to myocardial damage.

FACTORS AFFECTING OXYGENATION

Maternal
Mothers may be deprived of 02 (a) low oxygen pressures at high altitude and reduced 02 in the
air.

Anaesthetic Accidents

Airway Obstruction

 Convulsions
 Eclampsia
 Hypoglycemia
 Inhalation of gastric contents

Pulmonary Diseases

 Chronic or miliary TB
 Chronic Bronchitis
 Bronchospasm
 Respiratory spasm
 Pneumothorax
 Embolism

Maternal Heart Disease

Smoking in Pregnancy
Severe Haemorrhage

23
Maternal Circulation

 Severe hypertension results in chronic placental insufficiency, left ventricular failure and
massive cardiovascular accidents.
 There will be acute asphyxia of the infant in-utero.

Placenta

 Is the essential exchange point between the maternal supply of oxygen to the foetus and
the foetus’ ability to accept this oxygen supply?
 Abrupt separation of the placenta results in acute asphyxia. There is a strong association
with essential hypertension and pre-eclampsia.

Cord Problems
 Stretching
 Compression
 True knots
 Prolapse
 Change in temperature on prolapse
 Cord rupture during delivery or induction

Vasa Previa

 Where there is velamentous insertion of the cord. Severe haemorrhage may result in foetal
death.

Foetal Problems
 Anomalies of the fetus may result in inability to use oxygen,
e.g. Cardiac anomalies
 Severe anaemia – Haemolytic anaemia

Foetal Anemia
 Arises as a result of fetal haemorrhage - commonly due to haemorrhage from the fetus into
the maternal circulation or transfusion to a second twin, if there is a multiple pregnancy.
 More commonly fetal anaemia arises from haemolysis from Haemolytic Disease due to
incompatible blood groups.

24
SEVERE ASPHYXIA
 Profound metabolic/mixed acidaemia pH <7 on umbilical artery blood sample.

 Persistent Apgar score of 0 to 3 lasting longer than 5 minutes.

 Evidence of neurological sequelae (e.g. coma seizures, hypotonia) as well as
cardiovascular, gastrointestinal, pulmonary, haematological and renal tract damage.

A grading system has been introduced to describe neurological abnormality.

Grade 1 – Irritability - starting with mild hypotonia and poor sucking. These babies do not have
seizures.

Grade II - Lethargy, marked abnormalities of tone, tube feeding and seizures.

Grade III - Coma, severely hypotonic and requiring artificial ventilation.

Grade II and III confer an increased risk of death from serious handicap.

The American College of Obstetricians and Gynaecologists (ACOG) has defined that birth
asphyxia severe enough to cause severe ischaemic encephalopathy should have the following:

 Profound umbilical artery metabolic acidosis, defined as a pH< 7

 Persistence of a low APGAR score < 3 for more than 5 minutes.

 Abnormal neurological signs during the neonatal period.

 Evidence of hypoxic damage to other body systems such as cardiovascular, pulmonary,

gastrointestinal, renal and haematological systems.

The entry CTG is important. It must be critically read and assessed. If there is evidence of
decelerations we must act with:-

 Intensive observation
 Delivery

25
DEPARTMENTAL POLICY ON STILLBIRTHS

 Foetuses weighing 500g and less are considered abortions.

 Foetuses born dead weighing more than 500g are considered stillbirths.

Dealing with parents who have lost a baby is a very delicate matter and must be handled with the
utmost sensitivity.

26
VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC)
A patient should be admitted for trial of labour after Caesarean section.

 After a careful history has been taken about her previous Obstetric history.
 If possible her old notes should be reviewed.
 A pelvic examination should be done to assess the pelvic size and favourability of the
cervix.
 Preferably assess patient for VBAC and decide mode of delivery antepartum and not
intrapartum

Patient Selection for Vaginal Delivery

Contra-indications:

 Previous vertical incision on the upper or lower segment

 Previous T-incision
 Two previous lower segment incisions
 Previous Hysterotomy
 Previous Cornual resection
 Repaired uterine rupture
 Placental implantation on Scar
 Obstetric contra-indications eg. CPD, Placenta Praevia
 Previous post -operative infection
 Previous uterine perforation
 Advice of previous surgeon
 A patient who wants to have a repeat CS delivery, despite being a suitable candidate for
VBAC, should not be forced by any doctor or nurse. The patient should be informed and
should make the choice.

Favorable Factors

 One previous lower segment transverse incision

 Active labour with progress in previous labours
 Engaged vertex presentation confirmed at the onset of labour
 Normal CTG
 Favourable cervix
 Previous vaginal birth

Exclusions

 Obstetric complications requiring planned delivery

 Maternal medical disorders contradicting a trial of labour e.g. Cardiac Disease

Consent Prior to VBAC

The patient’s consent is required before a trial of scar is embarked upon.

The consent must be taken in the Antenatal Clinic when the patient is being assessed for trial of
scar. Consent cannot be taken when the patient is in labour.
Counselling should include risks and benefits of VBAC, elective and emergency CS

27
Induction of Labour
Patients with previous CS should not be induced with Misoprostol. Mechanical induction by means
of bulb induction may be attempted after consulting with a specialist.
First stage

 Prepare the patient for Caesarean section, in the event of an emergency CS being
necessary.
 Insert an ivi line, take blood for FBC, Type and screen.
 Continuous electronic fetal heart rate monitoring should be performed if possible.
 Consider use of epidural analgesia.
 Plot the progress of labour on a partogram. Progress of labour should be good and there
should be descent of the fetal head. There should be early recourse to Caesarean section
if progress is slow. If the patient has not progressed after 8 hours in the latent phase then
prolonged latent labour may be diagnosed and patient should be taken for emergency CS.

Second stage

 If there is any delay in the second stage assistance with forceps may be advisable, but
assisted delivery is not mandatory
 Exploration of the uterine scar should be carried out immediately after delivery of the
placenta if patient has vaginal bleeding, abdominal pain, or unexplained maternal collapse
to assess for possible scar dehiscence or uterine rupture.

Documentation

Clear and concise notes should be made in the patients file on the important findings and
management in the current pregnancy and any advice for subsequent pregnancies. This will assist
with management of subsequent pregnancies.

28
CLASSIFICATION OF URGENCY FOR CAESAREAN SECTION

Category Definition Timing of Time target

delivery to delivery
1 immediate threat to the life of the Emergent <30 minutes
woman or fetus

2 maternal or fetal compromise which is Urgent <75 minutes

not immediately life-threatening

3 no maternal or fetal compromise but Unscheduled Within hours

needs early delivery
Debate
logistics
Examp
4 delivery timed to suit woman or staff Elective Working les of
(elective) hours each
Categ
ory:
Category 1:Abruptio placentae with viable baby, cord prolapse with fetal bradycardia
Category 2:Cord prolapse without fetal compromise.
Category 3:The eclamptic whose convulsions have been aborted, is maintaining a patent airway
and requires transfer to a higher level of care.
Category 4:A patient with a previously scarred uterus at term

NOTES ON THE ABOVE

1. The categories are to be assigned by the obstetrician
2. The time of the booking needs to be put on the booking board as the case is booked
3. The time targets are guidelines rather than rules. They are intended for audit purposes.

16th May 2014

David Bishop

29
POLICY REGARDING:

PREMEDICATION FOR ELECTIVE / EMERGENCY CAESAREAN SECTION

All patients requiring elective or emergency caesarean section to be given premedication as

follows:

 Clopamon (Maxalon) 10 mg IVI

 Sodium Citrate 30mls orally

PROPHYLACTIC USE OF CEFAZOLIN- EMERGENCY C/S

 All Caesarian section patients are to be given Cefazolin 2g if > 60KG or 1g if < [Link]
equivalent intravenously at induction of anesthesia.
 This is a prophylactic measure and is NOT to replace a full course of antibiotics if clinically
indicated.

30
 ANTEPARTUM HAEMORRHAGE

Antepartum haemorrhage (APH) is defined as bleeding from the genital tract from viability (24
weeks) of pregnancy up to delivery of the baby.

Causes
Obstetric causes Non-obstetric causes
Placenta praevia Trauma
Abruptio placenta Cervical cancer
Uterine rupture Cervicitis, vaginitis
DIC Cervical polyps
Vasa praevia Vaginal lacerations

If no cause can be found, a diagnosis of APH of unknown origin is made

All patients presenting with APH must be regarded as obstetric emergencies until properly
assessed.

Signs and symptoms

Pallor, clammy skin, restlessness, dyspnoea, agitation, confusion
Tachycardia, hypotension, thread pulse, oliguria

Management

 Call for Help

 Assess Circulation, Airways, Breathing (CAB)
 Position the patient in a left lateral position to maximize venous return
 Insert 2 large- bore (16G or larger) iv lines, take blood for FBC, U&E and Type and screen
 Start an intravenous infusion of Ringers-Lactate solution
 If the mother is in shock, resuscitate with 1-2 L of Ringers-Lactate
 Insert a urinary catheter to monitor urine output
 Do not do a digital vaginal examination, unless placenta praevia has been excluded by a
ultrasound scan
 Perform immediate caesarean section for massive haemorrhage or fetal compromise,
unless delivery is imminent eg. patient is fully dilated.
 Vaginal delivery is preferred before 26 weeks or for fetuses weighing less than 1000g in
which case AROM and augmentation should be done.
 If no placenta praevia, examine the cervix by vaginal speculum examination
 Further management depends on the cause (below)
 Need for blood transfusion will be determined by the clinical picture

If no ultrasound scan can be done, and delivery is being considered, vaginal examination should be
performed in theatre with staff and equipment ready for immediate caesarean section, in case of a
severe bleed caused by placenta praevia.
Digital vaginal examination must never be done with antepartum hemorrhage until placenta
praevia has been excluded on history, abdominal examination and ultrasound scan

31
ALGORITHM FOR MANAGEMENT AND DIAGNOSIS OF ANTEPARTUM HAEMORRHAGE

ANTEPARTUM HAEMORRHAGE

Ringer-Lactate IV infusion

Assess blood loss

Check fetal heart

Massive haemorrhage or fetal No massive haemorrhage and no fetal

compromise
compromise

Abdominal examination
Resuscitation
Ultrasound examination
Blood transfusion

Urgent caesarean section

or delivery

Placenta Praevia Abruptio Placentae

No cause found

Speculum
examination

APH of unknown Cervical or Vaginal

origin lesion

32
DIFFERENCES BETWEEN ABRUPTIO PLACENTAE AND PLACENTA PRAEVIA

Abruptio placentae Placenta praevia

Patient Often hypertensive Often previous C/S

Symptoms Pain is almost always Usually painless. Fetal

present. Fetal movements are usually

movements may be normal

absent or reduced

Abdominal examination Hard, tender uterus, large Soft, non-tender uterus,

for expected dates often with malpresenta-

tion or high presenting

part

Bleeding Dark blood with clots Bright red blood

Usually follows after pain;

there may be no external

bleedinq

Ultrasound Fetus may be dead, Placenta is implanted

placenta is normally close to or over the cervix

situated. Retroplacental

clot may be seen

33
ESSENTIALS IN MANAGEMENT OF ABRUPTIO PLACENTAE

 Correct hypovolaemia
o Infuse normal saline / Ringer’s lactate
o Indwelling catheter– aim for a urine output of [Link] or [Link]
o Laboratory Investigations
 Full Blood Count: Hb, Hct, Plt
 Urea and Electrolytes
 INR

 Correct anaemia as soon as blood available  [Link]

o Crossmatch 3 units packed cells.

 Correct coagulopathy
o Administer FDP’s

 Analgesia with Morphine in cases of grade 3 Abruptio

 Maintain resuscitation
o Repeat bloods 4-6 hrs

 Further management will depend on the grade of Abruptio

o Grade 1: diagnosis made in retrospect
o Grade 2: Abruptio with a live fetus
o Grade 3 (A): AP with a dead fetus and no coagulopathy
o Grade 3 (B): AP with a dead fetus and coagulopathy

 Deliver patient.
o Individualize mode of delivery
1. For grade 2 patients not in labour, deliver by emergency CS
2. For grade 2 patients imminently deliverable, perform assisted delivery
3. For grade 3: aim for delivery by the vaginal route unless contraindications
exist (see below)

 After 2 hours the patient should be fully resuscitated. Decision to be taken about mode of
delivery. The vaginal route is preferred unless
 Scarred uterus
 Major malpresentation
 Extremely unfavourable cervix
 Cannot keep up with resuscitation
 Recurring coagulopathy
 Uncontrollable hypertension
 Acute renal failure with oliguria / pulmonary oedema

 Perform a vaginal examination and rupture membranes.

34
 Observations

 Cardiovascular System
Pulse rate and blood pressure half- hourly

 Respiratory and metabolic function

Frequent clinical assessment of lung fields, observe for pulmonary oedema

Respiratory rate half- hourly

Acid base status

 Renal Function
Urine output – should be 30mls/ hour

 Haematological Function
Clotting defect : If the clotting time exceeds 10 minutes – hypofibrinoginaemia
exists. Patient should be delivered between 6 – 8 hours.

Important
 After 4 hours assess the progress of labour and consider the use of oxytocin.
 After 6 hours review the progress of labour.
 Delivery of the patient should be achieved within 6 – 12 hours after admission.
 Inform the consultant who will decide further management

DO NOT RUPTURE MEMBRANES UNTIL THE PATIENT IS FULLY RESUSCITATED

 Active management of 3rd stage of labour

 Prevent post-partum hemorrhage with 20iU Syntocinon in 1l of Ringer’s Lactate
 Observe closely for primary PPH

35
MANAGEMENT OF PLACENTA PRAEVIA

At less than 38 weeks with a major degree placenta praevia admit to hospital and do not
discharge even if bleeding stops.

 Do FBC
 Ensure blood is typed and screened in blood bank in the event of sudden bleeding.
 Counsel patient on warning signs eg. PVB, SROM, contractions, reduced fetal
movements. No PV examinations to be done. Inform staff when going to bathroom, do
not lock door to bathroom in the event of an emergency
 Give steroids if less than 34 weeks
 Plan for elective CS at 38 weeks unless bleeding occurs before then.
 If suspected morbid adherence plan delivery at 36-37 weeks. Involve a multi-disciplinary
team including anaesthetics, ICU, surgeons, urologists, interventional radiologists as
needed, depending on results of imaging studies
 If patient has a second bleed after the initial (herald) bleed has stopped, deliver by
emergency CS.
 Counsel patient on risk of massive haemorrhage at theatre and possibility of
hysterectomy if bleeding cannot be controlled.

APH of UNKNOWN ORIGIN

No signs of Abruptio placentae, Placenta praevia or local causes.

If >38 weeks, do IOL

If <38 weeks admit for CTG, FKCC, pad checks and bloods

If bleeding stops for 48 hours consider discharge and IOL at 38 weeks

Monitor fetal growth during ANC care and continue to monitor fetal

36
POST-PARTUM HAEMORRHAGE

Post-partum haemorrhage is the 2nd commonest cause of maternal death in South Africa,
according to the Saving Mothers’ Report of 2008-2010.

Primary PPH is any amount of blood loss up to 24 hours post-delivery that renders the patient
haemodynamically unstable.

Secondary PPH occurs from 24 hours to 6 weeks post-delivery.

Main causes

 Atonic uterus
 Trauma to the genital tract
 Retained placenta

Rare causes include

 Clotting abnormalities
 Uterine inversion

Causes of secondary PPH include all of the above and infective causes e.g. endometritis

Predisposing Factors

 APH - Abruptio Placentae / Placenta Praevia

 Past history of PPH
 Precipitate labour
 Full bladder
 Anaemia
 Multiple pregnancy
 Polyhydramnios
 B2 stimulant therapy/Uterine relaxant (anaesthetics) Drugs
 Prolonged labour with uterine inertia
 Uterine fibroids
 Big baby > 4kg
 Grand Multipara
 Instrumental delivery
 Failure to perform active management of the third stage of labour (AMTSL)

MANAGEMENT

Call for Help - a team approach is required

Resuscitation
 Assess circulation, airways and breathing (CAB)
 Insert 2 large-bore iv lines with Ringer’s lactate
 Commence Oxytocin infusion – 20 units in 1l MRL at [Link]
 Take blood for FBC, U&E, Obtain blood for cross match on emergency
 Insert Foley Catheter
 Monitor BP, PR and urine output
 Identify and treat the cause

37
Retained placenta

 Check placenta
o Is it delivered? Is it complete?
 If not delivered and patient bleeding actively, attempt manual removal under intravenous
sedation.
 Should removal fail, achieve uterine contraction by the following measures and arrange
for a manual removal in theatre under anaesthetic.
 Rub up uterus to ensure contraction
 ContinueSyntocinon infusion
 Administer Ergometrine 0.5mg imi if the uterus is still atonic after Syntocinon
 Misoprostol 600ug sl stat

Atonic Uterus

 Syntocinon 20iU in 1l MRL at [Link]

 Syntometrine 0.5mg imi
 Misoprostol 600ug sl
 Prostaglandin F2α
 Administer transabdominal intramyometrial Prostaglandin (5mg F2α in
10mls of sterile water). Inject 1ml directly into uterus through abdominal wall.
If no response, repeat.
 Consider balloon tamponade with a Bakri balloon if uterus remains atonic
 If above fails, do bimanualcompression of the uterus, while arranging for
theatre.
 At theatre:
 B-Lynch compression suture
 Stepwise devascularisation
 Hysterectomy which may be total or sub-total

Trauma to the genital tract

 Place patient in lithotomy position
 Have good light source
 Inspect vulva, vagina and uterus
 Look for tears in the cervix
 All tears in the vagina and cervix must be sutured
 Minor abrasions and lacerations, which are actively bleeding will require packing, usually
with 9-inch gauze
 Commence antibiotics
 Remember to remove pack within 24 hours

38
 ALGORITHM FOR MANAGEMENT OF POSTPARTUM HAEMORRHAGE

POSTPARTUM HAEMORRHAGE

 Call for Assistance

 Rub up the uterus
 Ensure placenta is complete
 Give oxytocin 20 units in 1L Ringer-lactate
over 8 hours
 Insert a urinary catheter
 Restore and maintain blood pressure with IV
fluids &/or blood

Abdominal Examination

Placenta Retained Placenta delivered

Uterus large and soft Uterus well contracted Uterus not felt
Manual removal /
evacuation

Atonic Uterus Lacerations Inverted Uterus

 Give ergometrine Find source of bleeding: Reduce immediately

0.5mg IM, repeat once uterus, cervix, vagina
if needed perineum
 Continuous massage
of uterus
 Evacuate clots
 Misoprostol 600 Repair Lacerations
micrograms sublingual
 Laparotomy

39
BLEEDING AFTER CAESAREAN SECTION

If uterus atonic, follow management as described above

For bleeding from uterine incision, insert haemostatic sutures. If these fail to control bleeding, do
stepwise devascularisation and STAH as a last resort if bleeding cannot be controlled.

If there is bleeding along the entire uterine incision, open the incision and identify the bleeders.
Suture these. If this fails, do stepwise devascularisation or STAH.

If uterine tears are present extending laterally, do uterine artery ligation.

For inferior tears, secure the apex and suture from there. Be careful not to injure the ureters which
may lie just lateral to the tear.

If the uterus is ruptured, repair or do TAH.

For placental site bleeding insert mattress sutures, if this fails try uterine artery ligation, stepwise
devascularisation, balloon tamponade and TAH/STAH if bleeding cannot be controlled.

For bleeding that is due to Placenta Accreta, it may be necessary to proceed directly to STAH.

Do not delay at each step as bleeding patients may decompensate quickly. If needs be proceed
directly to hysterectomy.

40
PREVENTION OF POSTPARTUM HAEMORRHAGE (PPH)

Detect and Treat Anaemia antenatally:

All antenatal patients should have a Haemoglobin (Hb) done at booking and repeated at 32-34
weeks if initial Hb was [Link] or more.

Hb of <[Link] should be investigated, ideally before treatment is commenced.

All pregnant women should receive routine iron and folate supplementation.

Management of labour:

All patients should have Hb checked at the onset of labour.

Patients who have a Hb of 8 or less at the onset of labour should have a cross match done in the
event of blood being needed for transfusion. Transfusion will be at the discretion of the attending
doctor.

The partogram should be correctly and completely filled in for all patients to prevent prolonged and
obstructed labour.

Oxytocin should not be used in cases of CPD or malpresentation.

Postpartum care:

Active management of the third stage of labour should be done.

Early-Warning charts should be used.

41
OBSTETRIC EMERGENCIES

Foetal Compromise
NICE classification of CTGs:

Category Definition
Normal all 4 features fall into the reassuring
category
Suspicious features fall into 1 of the non-reassuring
categories
and the remainder of the features are
reassuring
Pathological features fall into 2 or more non-
reassuring categories
or 1 or more abnormal categories

Feature Baseline (bpm) Variability Decelerations Accelerations

Reassuring 110-160 >5 None Present
Non- 100-109 <5 for >40 to Early
reassuring 161-180 <90 minutes deceleration
Variable
deceleration
Single
prolonged Absence of
deceleration accelerations
up to with an
3 minutes otherwise
Abnormal <100 <5 for >90 Atypical normal CTG is
>180 minutes variable of uncertain
Sinusoidal Late significance
pattern for >10 decelerations
minutes Single
prolonged
deceleration
>3 minutes

Management of Foetal Compromise

 Counsel the patient

 Lie the patient in a left lateral position
 Give oxygen by face mask at 6 L/minute
 Start an intravenous infusion of MRL to run at 240 ml/hour
 Perform vaginal examination for cervical dilatation and to exclude cord prolapse.
 If vaginal delivery is imminent (cervix fully dilated), deliver immediately, by assisted delivery
if necessary
 If vaginal delivery is not imminent, give Salbutamol 500 micrograms in 9ml normal saline
and inject 1ml of this ivi and prepare for immediate Caesarean section. Transfer urgently
from a community health center to hospital

42
Cord Prolapse

If the foetus is alive (foetal heart heard) and estimated weight is >1 kg:

Call for assistance

 Counsel the patient

 Perform vaginal examination:

If the cervix is fully dilated and the fetal head has engaged in the pelvis, immediately
deliver the baby, by vacuum extraction if necessary
If the cervix is not fully dilated, make arrangements for urgent Caesarean
section and/or transfer to hospital and proceed as follows:
 Replace the cord in the vagina or wrap it in warm wet towels
 Place a sanitary pad
 Handle the cord as little as possible
 With the fingers, push the presenting part off the cord
 Do not remove the fingers from the vagina if the presenting part compresses the cord
 Give oxygen to the mother by face mask at 6 L/minute
 Start an intravenous infusion of Ringer-Lactate
 Give Salbutamol as previously described
 Insert an indwelling urinary catheter, fill the mother's bladder with 500 mL of saline and then clamp
the catheter
 Place the mother in a left lateral Sims position*
 Inform NICU
 Before starting the Caesarean section, check for signs of fetal life (heartbeat, cord pulsation)
 If the baby is dead or not yet viable, and there is no other indication for caesarean section, await
vaginal delivery

* If the head is engaged in the pelvis or bladder filling fails to relieve cord compression, put the mother in a
knee-elbow position

Shoulder Dystocia

This occurs when delivery of the head is not followed by delivery of the shoulders. Emergency
management is as follows:

 Call for Help

 Counsel the patient
 Immediately move the patient to the edge or end of the delivery bed. Her knees should almost
touch her shoulders
 Cut a wide episiotomy
 Apply suprapubic pressure so as to force the anterior shoulder under the
symphysis pubis
 Hold the head with 2 hands but do not apply strong downward traction to avoid brachial plexus
injury.
 If unsuccessful at this stage, deliver the posterior arm by locating the posterior shoulder in the
vagina and sweeping the arm in front of the fetal chest. Once the posterior arm is delivered,
proceed to deliver the anterior arm as mentioned above
 If this fails, rotate the baby through 180 degrees through a face-to-pubis position, so as to bring the
posterior shoulder forward and make it anterior. It is important to hold both the arm and head
together to facilitate rotation and reduce the risk of injury

 If delivery has not been achieved so far, the baby is likely to die. If the baby is dead, await
spontaneous delivery, although breaking the clavicle(s) may assist the process

Anticipation and early recognition of shoulder dystocia will give more time for emergency
procedures and prevent fetal asphyxia and death
43
A GUIDE TO HIGH RISK PREGNANCY

The risk factors listed below are intended as examples only and the list is not exclusive.

Pregnancy at High Risk

Pregnancies compounded by complications that place the mother/ and or the fetus in danger.
Wherever possible, these patients should be transferred to a regional / tertiary hospital for
intensive care and delivery.

 DIABETES
 RENAL DISEASE
 PREMATURE RUPTURE OF MEMBRANES (± SEPSIS)
 PROLONGED RUPTURE OF MEMBRANES MORE THAN 6 HOURS
 HYPERTENSION
 PREMATURE LABOUR, IUGR
 WT GAIN of 4KGS BY 30/40
 HEART DISEASE
 APH
 CERVICAL INCOMPETENCE / RECURRENT MISCARRIAGES (>3)
 HYDRAMNIOS, POST-DATE PREGNANCY (42 weeks+)
 HISTORY OF PRIOR STILLBIRTH OR NEONATAL DEATH
 MATERNAL OBESITY
 SIGNIFICANT TOBACCO, ALCOHOL, DRUG INTAKE
 RHESUS ISO-IMMUNIZATION
 MULTIPLE PREGNANCY
 PRIMIGRAVIDA (age 17 and below, 35 and above)
ADVANCED MATERNAL AGE
 HISTORY OF GENETIC OR METABOLIC DISEASE IN FAMILY
 (Genetic Amniocentesis or Counselling required)
 ANAEMIA NOT RESPONDING TO IRON THERAPY (< 10 g%)
 PREVIOUS HX. OF GROWTH RESTRICTION, PREMATURE LABOUR, OR CAESAREAN
SECTION

44
SCREENING FOR DIABETES

Clinics and District Hospitals that provide an antenatal service must screen for Diabetes in
pregnancy.
In the clinic setting if a fasting or 2-hour post-prandial blood glucose is > 6 mmol/L or within two
hours of a meal > 7.0 mmol/L - arrange for a 75g oral glucose tolerance (screening glucose
tolerance test) test at your nearest District Hospital.

At the District Hospital if the patient is found to be Diabetic and glucose levels cannot be controlled
by dietary measures or Insulin - refer to

 The nearest Provincial Regional Hospital which has an Obstetrics & Gynaecology Department

OR

 Grey’s Hospital, Department of Obstetrics which provides tertiary services and has a Diabetic
clinic on a TUESDAY - Tel. 033-897 3350

Screening tests are to be performed on the following patients:

 First degree relative with Diabetes.

 Previous Gestational Diabetes.
 Previous baby > 4 kg.
 Unexplained stillbirth.
 Baby with congenital abnormality.
 Poor Obstetric history.
 Glycosuria on 2 or more occasions.
 Polyhydramnios.
 Early PET.
 Ethnic – High incidence among Indian patients.
 Obese patients (>90kg or BMI of 30)
 Age > 35

SCREENING PROTOCOL FOR GESTATIONAL DIABETES

 Check for glycosuria at each antenatal visit.

 Check a timed random plasma glucose:

o Whenever glycosuria is detected

o At booking and at 28 weeks gestation.

 If fasting or 2 hour postprandial > 6.0 mmol/L or within 2 hours of food > 7.0 mmol/L then
arrange for a 75G oral glucose tolerance test.

45
 PLASMA GLUCOSE
FASTING (MMOL/L) 2 HOURS (MMOL/L)
DIABETES >8 > 11

GESTATIONAL 6-8 9 – 11
IMPAIRED GLUCOSE
TOLERANCE
NORMAL <6 <9

If the 2 hour post-glucose load level is >7.8 do a Full Glucose Tolerance Test (FGTT) using 100g
of glucose. Measure glucose levels at fasting, 1, 2 and 3 hours post glucose load. If any 2 of the
values are more than 5/ 9.1/ 8/ 6.9, a diagnosis of Gestational Diabetes can be made.

MANAGEMENT OF DIABETES IN PREGNANCY:

 Team Approach – Obstetrician, Dietician and Diabetic Specialist Midwife

 Record – pre-pregnancy Insulin requirements
 Fundoscopy - refer to Ophthalmologist (only overt diabetics)
 Diabetic Nephropathy - 24-hour urine collection for measurement of proteinurea &
creatinine clearance
 Screen for other medical diseases
 See every 2 weeks until 34 weeks, then weekly until delivery.
 If patient has Glucometer available, blood glucose should be measured 3 x weekly prior to
and after meals and snacks
 Random blood glucose at clinic
 Screen for and treat all infections with therapeutic antibiotics

Insulin : 3 short acting per day

1 intermediate acting or long acting at bedtime

TIME ACTION IN HOURS

ONSET PEAK
IN Insulin DURATION
ACTRAPID (NOVO) 0.5 2.5 - 5 8

Long-Acting

PROTOPHANE (NOVO) 1.5 4 - 12 24

46
Foetal Surveillance
 Booking scan Dating
 Anomaly scan at 18-22 weeks
 Growth assessment at 32 – 34 weeks
 More frequent scans if abnormalities detected

Delivery

 If diabetic control has been good, good obstetric history, average size fetus and no
disproportion then await spontaneous onset of labour, but do not go beyond 40/40

 If diabetic control is poor, bad obstetric history, macrosomia or co-morbid medical disorder,
then induce labour at 38/40 or earlier if indicated, once fetal lung maturity is established
(LSAR>2.5;PG’S ++).

 An elective caesarean section is indicated when there is disproportion, malpresentation,

IUGR, BOH, severe Polyhydramnios or previous Caesararean section

Management in Labour: Insulin requirements

 Start an infusion of 7.5% Dextrose (made up by adding 50mls of 50% dextrose to 1 litre of
5% dextrose)

 Adjust rate to provide 1 litre per 8 hours ie 30 drops per minute.

 If patient is insulin treated diabetic ½ her normal morning dose of soluble insulin should be
given. If she is receiving only isophane insulin ½ the dose should be given as soluble
insulin.

 20 units of soluble insulin (0.2mls of 100 units per ml) of 0.5mls of 40 units per ml strength)
should be mixed with 19.8 or 19.5 mls of normal saline in a 20 ml syringe = to 1 unit pr cc.

Before and During Labour

 Estimate plasma glucose concentration before insulin infusion.

 In initial blood glucose is less than 7mmol/litre, give 1 unit of insulin per hour. If greater than
7mmol/litre give 2 units per hour.

 Glucose estimations to be done hourly. Stabilise glucose level between 4.5 and 5.5 mmol
per litre.

 If the concentration falls below 3.5mmol glucose infusion rate should be increased.

The decision for vaginal delivery will have been taken by a senior member of the staff. If the
patient is not in established labour within 6 – 8 hours or delivery is not imminent within 10 – 12
hours of rupturing membranes, a caesarean section should be performed.
47
Management after Delivery

Insulin requirements fall after delivery. This is usually half the dose necessary before delivery. The
following sliding scale can be used to assess the 24-hour Insulin requirement:

BLOOD GLUCOSE SOLUBLE INSULIN

(Actrapid)

0-10mmol Nil
10-12mmol 2 units
12-14mmol 4 units
14-16mmol 6 units
16-18mmol 8 units
18-20mmol 10 units

PROTOCOL FOR OBSTETRIC DIABETIC PATIENTS – INPATIENTS

All diabetic in-patients must have the following:

 Blood glucose monitoring pre and 2 hours post meals

 Full blood count (FBC)
 Urea & electrolytes
 Mid-stream urine sample for microscopy and culture
 24 hour urine protein & creatinine clearance
 High & low vaginal swabs for MC&S
 Fundoscopy (if patient is an Overt Diabetic)
 Dietician consult
 Ultrasound (as per protocol or for obstetric indications
 4 Hourly BP monitoring & daily urine dipstix testing (especially looking for ketones and
glycosuria).
 All patients must be on a Diabetic diet.

Blood Glucose Profiles

The blood glucose must be checked pre-prandially (before meals) and post-prandially (after

meals).

 Preprandial levels must be checked 1 hour before each meal.

 Postprandial levels must be checked 2 hours after each meal.
 Another blood glucose level needs to be done at 2 am (if patient on insulin regimen – on
protophane nocte).

48
Target Levels:

 Preprandial = 3,5 to 5,5 mmol/l

 Postprandial = 4,5 – 6 mmol/l

INSULIN REGIMEN

Total daily insulin dose:

 First trimester = 0.5u/kg bodyweight
 Second trimester = 0.6u/kg
 Third trimester = 0.7u/kg given subcutaneously

2 types of insulin used = Actrapid (Short-acting) &Protophane (Long-acting)

Short-acting insulin comprises 50% of total daily insulin dose (administered in 3 equal doses
30 minutes before each meal.).
Long-acting insulin comprises the other 50% of total daily insulin dose (administered as a
single dose either in the morning or at night 22h00).

Insulin Adjustments

Insulin therapy is adjusted according to the blood sugar levels.

 Short-acting insulin adjusted according to the postprandial levels.
 Long-acting insulin adjusted according to the 22h00 or morning reading.
 Insulin dose is increased / decreased by 2units for every 1 mmol/l above or below the target
blood sugar levels, respectively.

NOTE:

All patients on Insulin must be counselled regarding symptoms of hypo- and hyperglycaemia.
 Patients must keep glucose sweets with them in case of hypoglycaemia.
 The doctor must be notified if the patient ishypoglycaemic (GR <3 mmol/l)
orhyperglycaemic (GR > 20 mmol/l) or if patientvomitingor comatose.
 If patient comatose from hypoglycaemia administer 50ml of 50% dextrose as an IV bolus.
 Use corticosteroids with caution in diabetic patients. Their use must be discussedwith
aconsultantbefore commencement - as they do not reduce perinatal mortality in babies of
diabetic patients.

FETAL MONITORING:

 Daily non-stress tests (CTG) once viability reached. More frequent if indicated.
 Fetal kick count chart for every baby (once viability attained)

49
CARDIOVASCULAR DISEASE IN PREGNANCY

ANTENATAL MANAGEMENT

 Manage as a multi-disciplinary team – Obstetrician, Cardiologist, Neonatologist and

Anaesthetist
 Investigations:
- FBC, CXR, ECG, Echo, urine dipstix
 ANC visits should be more frequent – look for IUGR
- 2/52 until 28wks
- 1/52 until term
 Exclude fetal cardiac abnormalities if patient has congenital heart disease. Do nuchal
translucency (NT) scan at 11-13 weeks and detailed fetal cardiac scan at 22 weeks
 Prevent and treat Anaemia by checking Hb and treating with haematinics
 Penicillin prophylaxis should be given to patients with Rheumatic heart disease.
 URTI and UTI – look for and treat infections
 Advise on smoking cessation and bed-rest
 Patients must be regularly assessed for arrhythmia /heart failure / oedema
 Review all medication, including anti-coagulation
 A clear delivery plan should be made by the multi-disciplinary team and this should be
documented in the file
 Patient may have to be admitted between 36 – 39 weeks
 Assess pelvis for mode of delivery, by CT pelvimetry
 Family planning to be discussed with patient antenatally and her decision should be clearly
documented. If permanent form sought ,consider vasectomy in partner. Sign BTL forms
antenatally if agreeable.

MANAGEMENT OF LABOUR

 Induction of labour only for obstetric reason

 Therapeutic antibiotics to prevent bacterial endocarditis

 Augmentin 1,2 g 8-hourly IVI x 24 hrs or
 Penicillin G 6 million units 6 hourly IVI
 Gentamycin 240 mg daily IVI x 24 hrs

 Strict monitoring of fluid balance, BP, PR and RR with auscultation of lung bases regularly.
I.V. fluids to be restricted. (Use 200 mls normal saline) to prevent cardiac failure
 Position – Fowlers Position for delivery
50
  Oxygen by face mask

 Pain relief - epidural is preferred unless contraindicated

 Shorten the second stage -assist delivery – avoid vacuum

 Avoid Syntometrine – causes powerful uterine contractions and hypertension

 Use Syntocinon in a concentrated solution (20u in 200 mls at 10 mls/hr)

 Lasix 20 mg IVI ffg. delivery of the anterior shoulder

 Observe in labour ward for 1 hour following delivery and high care for 24 hrs post delivery

 Ensure that Cardiac Resus trolley is fully equipped and functional and at the patients side at all
times

MITRAL VALVE STENOSIS

 This is the commonest complication of Rheumatic fever

 The severity of the stenosis is graded according to the valve area:
o >1.5cm2 = mild
o 1.1-1.5 = moderate
o < 1.0 = severe\
o <0.8 = critical
 Bedrest
 Beta-blockers in symptomatic patients (caution in patients with severe pulmonary hypertension)
 Diuretics if needed to relieve pulmonary oedema
 Vaginal delivery may be attempted in patients with mild to moderate MS. Patients with severe and
critical disease are not suitable candidates for NVD. Manage as a multi-disciplinary team.

MECHANICAL VALVE PROSTHESIS

 Pregnancy is usually well-tolerated in patients with normally functioning valves.

 Warfarin is changed to Unfractionated Heparin (UFH) from 6-12 weeks
o Patients should be admitted for 6 weeks for Heparin ivi infusion
o Target aPTT is 2 X normal, taken 6 hours after dose adjustment
 Warfarin is recommenced from 12-36 weeks maintaining INR at 2.5-3
 Stop Warfarin at 36 weeks and change to UFH until delivery.
 If Caesarean section is planned then stop UFH 6 hours before (unless otherwise specified by
anaesthetic team)
 Restart UFH 6 hours post-delivery provided there is no bleeding.
 Recommence Warfarin on Day 1 post-op if not bleeding
 If patient is planned for IOL, stop UFH as soon as in active labour.
 Should a patient go into labour while on Warfarin, stop Warfarin, reverse anti-coagulation with
FDP’s and deliver by CS as soon as INR is normal.
51
EMERGENCY MANAGEMENT OF ACUTE PULMONARY OEDEMA DUE TO LEFT
VENTRICULAR FAILURE

Symptoms and Signs of LV Failure

 Tachycardia
 Fatigue on exertion
 Dyspnoea on mild exercise
 Intolerance to cold
 Paroxysmal nocturnal dyspnoea cough with the recumbent position
 Occasionally bronchospasm & wheezing
 Cough may be prominent, may be pink tinged or brown due to presence of blood
 Diffuse laterally displaced impulse palpable and audible ventricular S3, atrial gallop (S4)
 Accentuated pulmonary sound and basilar rales
 Right-sided pleural effusion is common

Acute Pulmonary Oedema

Life threatening manifestation of acute LVF secondary to the onset of pulmonary venous
hypertension

The patient presents with extreme dyspnoea cyanosis, tachypnoea, and hyperpnoea restlessness
with a sense of suffocation

Pulse may be thready. BP difficult to [Link] are widely dispersed over both lung fields
anteriorly and [Link] patients manifest marked bronchospasm (cardiac
asthma).Hypoxaemia is severe and cyanosis deep.

Management

 It is a medical emergency.
 Major goal is to reduce preload and maintain oxygen.
 Morphine sulphate 4mg to 6mg IV, or 10-15mg IM.
 Sublingual nitroglycerine 0.5 mg is effective in inducing veno-dilatation and redistributing
blood volume away from the chest.
 Rotating tourniquets are effective with B.P. cuffs applied to 3 limbs: inflate midway between
systolic and diastolic – deflated every 10-20 minutes.
 Rapid removal of 300-500mls of blood may have a dramatic effect (Ready Vac bottles).
Only if patient not anaemic.
 Intravenous administration of a rapidly acting diuretic (e.g. Furosemide 40 mg IV) can
initiate diuresis in 15-20 minutes.
 Intubation and ventilation may be indicated
 Consult Physicians

52
HYPERTENSION IN PREGNANCY

Hypertensive conditions in pregnancy, particularly Pre-eclampsia are multi-organ

diseases requiring the monitoring of renal, liver, central nervous system and placental
functions.

 Pre-eclampsia is defined as hypertension and proteinuria (>300mg in 24 hours) developing

in a previously normotensive patient at or after 20 weeks gestation with complete resolution
at 6 weeks post-delivery.
 BP should be measured on two occasions at least 4-6 hours apart. Systolic
pressures of >140 and/or diastolic pressures > 90mmHg are diagnostic of
hypertension.
 Severe Pre-eclampsia is characterised by BP 160/110 with proteinuria or evidence of end-
organ damage.
 Gestational hypertension is not accompanied by significant proteinuria.
 Hypertension that is present in the first 20 weeks of pregnancy is termed “Chronic
Hypertension” and if significant proteinuria is present a diagnosis of “Chronic Kidney
Disease” may be made.
 If a Chronic hypertensive develops proteinuria in the second half of pregnancy, this
is termed “superimposed Pre-eclampsia”.

 If the BP in the first 20 weeks was unknown (eg. Patient booked late), this is termed
“unclassified hypertension”.

Treatment

If BP is >140/90, commence treatment with Aldomet (Methyldopa) at a dose of 500mg 6 hourly

or 8 hourly depending on BP. Should the BP be poorly controlled on Aldomet ie. 2 BP spikes in
24 hours requiring use of a rapid-acting agent, add a second agent.

Adalat (Nifedipine) starting at 10mg 8 hourly up to a maximum of 20mg 6-hourly

Hydralazine is the third-line agent and can be started at a dose of 1mg 8 hourly up to a
maximum of 7mg 8 hourly.

BP > 170/110 - should be treated as a hypertensive emergency

 Start a Labetolol infusion: 200mg in 200mls normal saline at 20/40/80 [Link] titrated
against the BP every 30 minutes. Caution in patients with tachycardia.
 Alternatively administer Nifedipine capsules 10 mg orally immediately, and if necessary
20-30 minutes later. Avoid sublingual Nifedipine.

The goal should be to lower BP to 140/90 – 150/90.

Avoid ACE inhibitors, Reserpine and diuretics in patients with Pre-eclampsia. Beta-blockers
should only be used for very specific indications.

MgSO4 according to protocol should be administered to all eclamptics and imminent eclamptics
for 24 hrs post-delivery.

53
MANAGEMENT OF ECLAMPSIA

Immediate Management

 Check circulation, airways and breathing

 Place the patient in the left lateral position
 Administer oxygen – 6 to 8L / per minute
 Give Magnesium Sulphate for treatment and prevention of further seizures (see protocol)
 Reduce blood pressure as per regimen

Check the following signs every 4 hours before commencing the next dose of magnesium
sulphate.

 Presence of peripheral knee or arm reflexes

 Respiratory rate above 16 per minute
 Urine output of more than 30 mls per hour

Monitor

 Blood pressure recording every 10-20 minutes.

 ½ Hourly pulse and urine output.
 Pulse oximeter if available

Magnesium Sulphate Levels

 Normal range 0.7 – 1.0mmol/L

 Therapeutic Level 1.25 – 3.25 mmol/L
 Reflexes disappear 4-5 mmol/L
 Respiratory depression 6-8 mmol/L
 Cardiac Arrest > [Link]/L

Toxicity Manifests with:

 Loss of patellar reflexes

 Weakness; Drowsiness
 Nausea
 Muscle paralysis
 Respiratory Depression

Investigations

 Full blood count.

 Urea and electrolytes
 DIC screen if platelets are low
 Blood gas analysis.

Should respiratory depression occur, the antidote is 10% Calcium Gluconate administered 10-20
mls by slow IVI.

Indications for Ventilation of Eclamptic Patients

54
• ↓ GCS < 9\15 Glasgow coma scale
• Restless after sedation
• Poor blood gases / acidosis with a Base Excess more than -5. This is associated with
severe cerebral oedema.
• Aspiration
• Pulmonary Oedema
• Recurrent fits
• Laryngeal oedema
• Multiple seizures or seizures lasting more than 30 minutes (Status epilepticus)
• C.V.A. (Cerebral Vascular Accident)

There is no urgency to rush the patient into theatre to deliver the foetus.

The patient must be stabilised in terms of blood pressure, fluid balance, blood gases,
biochemistry, and coagulopathy.

This may take 2 to 3 hours.

On no account should a diuretic be given unless the patient is in cardiac failure or has pulmonary
oedema.

Intrapartum Fluid Regimen

 Insert a Foley catheter and start input/output charting

 Start MRL at [Link]
 If urine output decreases to <30ml/hr, give a 200ml fluid challenge
 If urine output is still less < 30ml/hr restrict fluids to [Link] or 1ml/kg/hr• Insert a CVP if
there is difficulty in monitoring fluid balance or associated haemorrhage or Creatinine is
high
 If hypovolaemia persists when the CVP< 4 cm. A further 400 ml of fluid is given over 30
minutes
 Restrict crystalloids to 75 – 100 ml per hour.
 If CVP 4 - 8 cm / H₂0 → Manage expectantly. 200 ml of colloid if urine output < 100 ml /
4 hours
 If CVP > 8 cm and signs of pulmonary oedema → Furosemide (Lasix) 40 mg IVI

Obstetric Management

• Vaginal delivery may be contemplated if the patient is near term, the cervix “ripe”, and the
convulsions are controlled. Rupture membranes and augment labour

• If the cervix is unripe, stabilise patient and deliver by Caesarean Section

• If there is evidence of impaired placental function, prematurity, suspected disproportion,

breech, previous Caesarean Section, twin pregnancy, older parous women, elderly
primigravida, the management is Caesarean Section

• Whatever method of delivery is chosen, ensure haemostasis. Because of the pre-existing

hypovolaemia eclamptics tolerate blood loss very badly. Any loss greater than 250 mls
should be replaced by transfusion

55
Control of convulsions

•Maintain adequate airway

Do not force mouth open during a spasm, but between spasms open the mouth with a gap or
depressor. Insert an oral airway. Support the chin

• Prevent inhalation

Turn patient on to her left side.

Head down.

Gentle suction if available.

• Prevent trauma

Insert mouth gap or padded spatula.

Restrain manually, if necessary temporarily

• Administer oxygen

Utilize a face mask immediately after convulsions.

Drug therapy

Administer loading dose of MgSO4. If a patient has a seizure while on MgSO4, administer a further
2g of MgSO4.

 Reduction of blood pressure

Principles

• Reduce SLOWLY to a safe level

 Avoid hypotension

• A diastolic of above 100 mmHg requires treatment

• Assess the effect of the anticonvulsant regime (or epidural if applicable) before
commencing antihypertensive therapy

• Graduated intravenous titrated dosage is usually safer and more effective than intermittent
intramuscular therapy

• Dosages can be reduced immediately after delivery and can usually be discontinued within
24 hours of delivery

 Start a Labetolol infusion if the patient cannot take oral medication or BP cannot be
controlled on oral medication

56
Low Urine Output

Defined as < [Link]

 First check for obstruction of the Foley catheter, change if necessary

 Start a fluid challenge with 200mls Ringer’s Lactate over 20 minutes
 If no response, repeat the fluid challenge
 If still no response, reduce fluid intake to [Link]
 Insert a CVP if urine output remains low
 If CVP reads <5cm give a repeat fluid challenge
 If the CVP is 5-12cm and there is still no urine output, give a bolus of Lasix 40mg ivi

PROTOCOL FOR ADMINISTRATION OF MgSO4

At clinic or district hospital level:

Loading dose 14g as follows:

• 4g in 200mls N. Saline given over 20 minutes IVI
• 5g imI in the upper outer quadrant of each buttock (10g total)
• If eclamptic seizures continue after loading dose given, give another 2g of MgSO4 IV over at
least 5 minutes.

Document in patient’s chart the date and time when the loading dose was given
Arrange referral to regional/tertiary hospital
While awaiting transfer, keep in a “high care” setting where close monitoring can be maintained

At Regional/Tertiary hospital:
When patient has already received loading dose as above at District or PHC level:
Continue maintenance MgSO4 as follows:

• Wait for 4 hours from the time the loading dose was given
• Confirm that there has been at least 100mls of urine output in the past 4 hours, and that reflexes
are present, and respiratory rate is 16 breaths per min or more
• If so, administer MgSO4 infusion in N Saline at a rate of 1g per hour
• Alternatively give 5g MgSO4 im every 4 hours, alternating between right and left buttock
• During maintenance MgSO4 period, recheck urine output, reflexes and respiratory rate every
four hours if using im maintenance, or hourly if using iv infusion, before continuing with MgSO4
• If urine output is less than 25mls per hour or 100mls per 4 hours, or reflexes are absent, or
respiratory rate is below 16 breaths per minute, stop the MgSO4 infusion, or withhold the next im
dose. Only continue with maintenance MgSO4 if urine output, reflexes and respiratory rate
returnabove the cut-off values

57
• Continue MgSO4 maintenance until 24 hours after delivery, or 24 hours after the last eclamptic
seizure if this occurred post-delivery

If the loading dose is to be given at the regional/tertiary hospital, the same regimen as for the
district hospital (see above) may be used or alternatively:

• Loading dose of 4g MgSO4 in 200mls N. Saline given over 20 minutes IV

• Follow immediately with a maintenance infusion of MgSO4 in [Link] at a rate of 1g per hour
• If eclamptic seizures continue after loading dose given, give another 2g of MgSO4 IV over at
least 5minutes
• Continue further maintenance as above

MgSO4 for the prevention of eclampsia:

The regimens are the same as for the management of eclampsia. However, the total duration of
MgSO4 administration from the time the loading dose is given is 24 hours irrespective of when
delivery occurs.
Weather MgSO4 is used either for severe pre-eclamptics or eclamptics, all such patients should
be managed at regional level under specialist care.

58
PRETERM RUPTURE OF MEMBRANES

Pre-labour spontaneous rupture of membranes from 34 weeks to 36 completed weeks

 Avoid vaginal examination – unless unstable lie / abnormal fetal heart rate.

 Confirm diagnosis by collection of fluid specimen at vulva and on speculum examination.

 Monitor with pad checks, maternal pulse, temperature, uterine tenderness and fetal heart
rate four hourly.

 12 hourly white cell count.

 Avoid tocolytics.

 Corticosteroid therapy for 24 hours if 26-34 weeks

 Regular ultrasound assessment – presentation, growth, fetal breathing, movement and

amniotic fluid volume.

 Immediate delivery (+antibiotics) if there are clinical signs of infection.

 Vaginal Examination at onset of labour.

 Caesarean Section in breech presentation.

Preterm Premature rupture of membranes less than 32 weeks gestation.

 Give antibiotic cover – use Erythromycin (avoid augmentin i.e. amoxicillin with clavulanic
acid as increases risk of necrotizing enterocolitis in newborn).
 Give corticosteroids for 24 hours.
 Administer Augmentin 1,2g IVI 8 hourly if prolonged rupture of membranes (i.e. ROM >
17 hours).

BE ABSOLUTELY VIGILANT FOR SIGNS OF INFECTION

59
TOCOLYSIS

Tocolysis is indicated for:

 preterm labour while steroids are being administered

 in-utero transfer from a referral hospital
 hyperstimulation in a patient undergoing induction of labour
 fetal compromise in a labouring patient

Regimens used:

Salbutamol 250ug diluted into 9.5ml of normal saline, 1ml of this solution given intravenously.

Nifedipine (Adalat) 20mg po stat, after loading with 500ml fluid ivi. If contractions persist 30
minutes later, a further 10mg po may be given. Maintain tocolysis with 10mg Nifedipine every 6
hours up to a maximum of 48 hours. After completion of steroids, stop tocolysis and allow labour
to progress.

Adverse effects

Tocolytic agents are associated with the following S/E:

 Salbutamol: palpitations, tremor, nausea and vomiting, headache, chest pain, dyspnoea
and pulmonary oedema
 Nifedipine: flushing, palpitations, hypotension, can cause pulmonary oedema in multiple
pregnancies and Diabetics. Contra-indicated in cardiacs.

In patients with cardiac disease, hypertension or tachycardia

monitor vital signs while on tocolysis due to the risk of hypotension and tachycardia

Contra-indications to tocolysis

Antepartum haemorrhage
Fetal compromise
Active labour
Severe Pre-Eclampsia
Chorioamnionitis
Congenital abnormalities not compatible with life

60
ANTENATAL CORTICOSTEROIDS TO PREVENT RESPIRATORY DISTRESS SYNDROME

Respiratory Distress syndrome affects 40-50% of babies born before 32 weeks.

Evidence is available that the administration of Corticosteroids prior to delivery reduces the
incidence of Respiratory Distress syndrome (RDS).
There is evidence of a benefit in all-major sub-groups of preterm babies irrespective of race or
gender.
Time Interval of Delivery
The effect of treatment is optimal if the baby is delivered more than 24 hours and less than seven
days after treatment.

Indications for Antenatal Corticosteroid Therapy

 Gestation between 26 – 34 weeks
 Threatened Preterm Labour
 Preterm Rupture of Membranes
 Any condition requiring Elective Preterm Delivery
Contra-indications
 Clinical suspicion of intra-uterine infection
 Tuberculosis
Administer with Caution:
 Cardiac patients
 Multiple pregnancy
 Diabetics
 HIV + (Be vigilant for signs suggestive intrauterine infection).

Precautions
 If Beta Sympathomimetics are being used for suppression of labour, the volume of
intravenous fluid should be kept to a minimum.

 Chest pain, dypsnoea and cough should lead to an immediate cessation of beta agonists.

 Women with ruptured membranes should be closely observed for signs of chorioamnionitis.

 Women who have had repeated doses should have a glucose tolerance test.

 Diabetics receiving steroids should be monitored in High Care.

 The extremely rare complication of adrenal insufficiency should be considered in the

differential diagnosis of unexplained collapse in a woman or baby who has been exposed to
repeated doses of antenatal corticosteroids.

Dose and Route of Administration

 Two doses of Betamethasone 12 mgs given intramuscularly 12 hours apart
or
 Dexamethase 8mgs given intramuscularly 8 hours apart x 3 doses for 24 hours
 Deliver 48 hrs after 1st dose or 24 hrs after last dose of Betamethasone
 Deliver 36 hrs after 1st dose of Dexamethasone

61
ULTRASOUND PROTOCOL

Low –Risk Pregnancies

 All pregnant ladies require ultrasound scan at booking (staffing permitting).

 Ideally at 16 to 22 weeks (fetal anomaly and dating ultrasound).
 No further follow-up ultrasound scan required unless obstetrically indicated.

High- Risk Pregnancies

 Diabetes
 Booking scan  dating
 Anomaly scan at 20-22/40
 Growth assessment at 32 – 34/40
 More frequent scans if abnormalities present

 Pre-Eclampsia & IUGR

 2 weekly scan for growth
 Routine uterine artery doppler
 If no diastolic flow, then do MCA & Ductus venosus

 Multiple Pregnancy
 For chorionicity and early diagnosis at 12 weeks
 >10 % difference in weight of fetuses then scan every 2 weeks
 Also do uterine artery Doppler and fetal biometry looking for discordancy of
growth in the multiple pregnancy
Separate placentasSeparating membranes

 Placenta Praevia
Done at 32 – 34 weeks for diagnosis - Must have full bladder
Exclude morbid adherence (particularly if previous caesarean section and highly
parous)

 Medical Problems (cardiacs,epileptics,thyroid disease)

 scan at booking to exclude abnormalities
 follow-up scans at 34 to 36 weeks for growth.

NOTE: ALL OTHER ULTRASOUND SCANS FOR OBSTETRIC REASONS ONLY.

62
 PROTOCOL ON PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM (VTE)
IN PREGNANCY

Patients receiving Warfarin pre-pregnancy for the management of VTE should be changed to
LMWH during pregnancy.
 Prophylactic doses of LMWH should be prescribed according to weight:
o < 50 kg = 20 mg daily
o 50–90 kg = 40 mg daily
o 91–130 kg = 60 mg daily
o 131–170 kg = 80 mg daily
o > 170 kg = 0.6 mg/kg/day (Clexane)

 Treatment doses are 1 mg/kg 12hourly subcutaneously

Acute VTE

Continue LMWH throughout pregnancy, including 6 weeks postnatally for a minimum duration of 6
months.

Patients should be counselled on stopping LMWH when they go into labour or if they start
bleeding.

In patients with VTE at least 2 weeks before term, delivery should be planned by induction of
labour (IOL) (if there are no contra-indications to vaginal delivery) to avoid complications related to
full anticoagulation.

 IOL should be planned for 24 hours after the last therapeutic dose of LMWH.

Within 2 weeks of the acute event, IOL and delivery should be avoided for as long as possible in
patients with VTE at or near term.

If a patient needs delivery or labours during this period, switch to intravenous Unfractionated
Heparin (UFH) at the onset of labour and aPTT should be carefully monitored.

Protocol for use of UFH:

Loading dose: 5000iU in 200mls normal saline over 30 minutes

Maintenance dose: 20 000iU in 200mls normal saline at [Link] titrated against aPTT every 6
hours.

In active labour, the UFH infusion should be stopped and, provided 6 hours have passed, regional
anaesthesia is possible.
63
Should Caesarean Section become necessary, this should not proceed while the patient is fully
anticoagulated, as it can lead to uncontrolled bleeding. The effect of UFH should be reversed with
Protamine Sulphate and FDP’s

Heparin should be restarted 6 to 8 hours following vaginal delivery and 12 hours after Caesarean
Section.

Prevention of VTE

Antenatal prophylaxis

Patients with previous VTE which was:

 Recurrent
 Unprovoked
 Oestrogen or pregnancy-related
 With a history of VTE in a first-degree relative
 Associated with a thrombophilia should be offered antenatal prophylaxis with LMWH.

Women with recurrent VTE associated with either Anti-thrombin deficiency or the Anti-
phospholipid Syndrome require antenatal and 6 weeks post-natal higher-dose prophylaxis
with LMWH (12 hourly).

Prophylaxis during labour and delivery

1. >12hrs before any regional procedure (placing spinal or epidural) or removing epidural.
2. >4hrs before starting LMWH after any regional procedure (placing spinal or epidural) or
removing epidural.

Therapeutic dose LMWH:

1. > 24 hours before inserting or removing an epidural catheter, and the same 4 hours before
giving the LMWH as above.
2. >4hrs before starting LMWH after any regional procedure (placing spinal or epidural) or
removing epidural.

Postnatal prophylaxis

The following patients should receive LMWH for 7 days after delivery:

 BMI > 40
 Asymptomatic Thrombophilia
 Prolonged immobilisation
 All women who have had a Caesarean Section who have one or more additionalrisk factors
(such as age over 35 years, BMI > 30) should be assessed for possible LMWH.

64
The following patients should receive LMWH for 6 weeks postpartum:

 Previous VTE
 Women receiving LMWH antenatally.
o If they are receiving long-term anticoagulation with Warfarin, this can be restarted
when the risk of haemorrhage is low.

Contra-indications to LMWH

 Antenatal or postpartum bleeding

 Risk of major haemorrhage (such as Placenta Praevia)
 Bleeding diathesis, such as von Willebrand’s disease, Haemophilia or acquired
coagulopathy
 Thrombocytopenia (Platelets <75)
 Acute stroke in the last 4 weeks (ischaemic or haemorrhagic)
 Severe renal disease (glomerular filtration rate less than 30 ml/minute)
 Severe liver disease
 Uncontrolled hypertension

65
PROTOCOL ON MANAGEMENT OF SUSPECTED OR CONFIRMED EBOLA IN PREGNANCY

Ebola Hemorrhagic Fever (EHF) is a viral infection transmitted through direct contact with body
fluids of an infected person or animal. The risk of transmission persists even after the patient or
animal demises. Types of body fluids include blood, saliva, sperm, tears, faeces, urine, amniotic
fluid, breastmilk and vomitus.

There is currently no known cure, but supportive care can improve chances of survival.

Mortality is known to be particularly high in pregnant women, both for mother and fetus.

The risk of transmission to a health care worker, other patient or any other contact is high during
delivery, especially if delivery-related procedures are performed. This is due to the risk of contact
with body fluids such as blood and amniotic fluid.

Presenting complaints develop between two days and three weeks after contracting the virus.
These include: bleeding, fever, sore throat, muscle pain, headaches, vomiting, diarrhea and rash.
Patients may develop liver and renal failure.

Delivery by Caesarean section is contra-indicated because the risk of transmission to staff is

unacceptably high.

Differential diagnosis includes: Malaria, Cholera, Typhoid fever, Meningitis and other Viral
Haemorrhagic fevers (VHF).

Delivery should be conducted in a designated delivery area within the Ebola Haemorrhagic Fever
(EHF ward -ANC at Grey’s).

Even if a patient has a negative viraemia result, deliver her in the EHF ward as the amniotic fluid
and placenta will still be positive for Ebola.

Follow standard EHF Infection Control measures (hand washing, gloves and gowning).

Insert an iv line early in labour to avoid needle stick injuries when attempting to insert such lines in
agitated patients. Avoid imi and ivi routes for administration of medication. Use oral routes
wherever possible.

Avoid Induction of Labour (IOL) in Ebola patients. If IOL is necessary, wait for results of viraemia
studies to be negative before commencing. Rather await spontaneous labour. Misoprostol may be
used to induce labour. Oxytocin should be avoided as it requires continuous monitoring which is
not feasible in Ebola patients. Do not perform artificial rupture of membranes and limit vaginal
examinations.

Give antibiotics and anti-malaria treatment routinely from admission until 5 days post-discharge.

Provide iron and multivitamin supplementation.

Do not perform invasive procedures during labour and delivery; manage obstructed labour
expectantly as far as possible. Do not perform Caesarean section and/or laparotomy. Do not

66
perform episiotomy, vacuum, forceps or any destructive procedure. Do not perform controlled cord
traction of the placenta.

Most babies born to EHF mothers will be stillborn. As such, no fetal monitoring should be done,
whether by electronic means or by auscultation, since no intervention will be taken in the event of
fetal compromise. Ask the patient if she feels fetal movements.

When delivering the placenta, stay at the side of the mother to prevent splashes, cover the area as
much as possible. When the baby is live born or in cases of retained placenta, the cord can be
clamped with 2 plastic cord clamps and cut with disposable scissors. Do not do cord clamping for
stillborn babies.
Placentas and stillborn babies are to be placed onto an absorbable cloth, sprayed with chlorine,
wrapped in more cloth, sprayed again, and then placed into a baby body bag. Breastmilk
suppression should be given.

Misoprostol 600ug po should be given to prevent PPH. In the event of PPH, do not do bimanual
compression. Do not attempt manual removal of placenta. Do not attempt to reduce an inverted
uterus. Manage RPOCs with Misoprostol. Do not perform MVA or curettage.

Do not suture any tears due to the risk of needle stick injury.

Do not operate on Ebola patients: in cases of CPD, ectopic pregnancy, malpresentation, ruptured
uterus, manage conservatively with compassionate care and analgesia.

Waste should be disposed of in accordance with standard EHF measures.

Any material that comes into contact with the patient is to be discarded by incineration. Disposable
equipment should be used as far as possible, such as drapes, cord clamps and scissors. Metal
scissors or blades used must be discarded as per EHF guidelines for disposal of equipment. Only
items that can be sterilized with chlorine should be retained, if needs be.

Infant feeding

Mothers who are able to breastfeed should do so. Formula should be used for those babies whose
mothers cannot breastfeed.

Discharge from EHF ward

A patient may only be discharged when her viraemia results are negative and she is in a good
clinical condition. Following delivery patients should be monitored for 24 hours.

Family planning

Advise survivors of Ebola on FP for at least 3-6 months, including use of condoms.

67
68
GYNAECOLOGY

69
ADMISSION AND DISCHARGE CRITERIA

GYNAECOLOGY

HYSTERECTOMY

General indications:

 For abnormal uterine bleeding

 Fibroids
 Carcinoma of the Endometrium /ovary
 CIN III
 Prolapse

Investigations and work up done as outpatients in the Gynaecology clinic.

Patients admitted the day prior to surgery.
If there are other complications – co-morbid medical disorders or bowel prep is required, patients
are admitted 3 days before surgery to stabilize patients.

DISCHARGE CRITERIA

 Patients are only discharged once the senior doctor in ward, supervised by consultant is
satisfied that patient is fit for discharge.
 The patient/family should be adequately counselled regarding in ward management
including surgery, and the follow up plan.
 The necessary follow up plan should be finalised prior to discharge.
 Follow up appointments should be made by interns/nursing staff/registrars.
 A detailed discharge summary should be completed by the registrar. Interns should
accompany the registrar and may fill these under direct supervision. Please include clear
history, what has been done for patient, what follow up is required and histology and other
lab numbers in the summary to facilitate follow up in the clinic. A short summary of surgery
or procedures should be included. Blood results and findings of investigations should be
written out and not just ticked as done.

70
BLOOD TRANSFUSIONS:

Transfusion of blood and blood products should be taken seriously. Each transfusion should be
medically indicated and appropriate. The trigger to order a blood transfusion may vary. It will be
determined by the clinical condition of each patient, whether pre-operative, post-operative, age,
medical comorbidities and whether there is ongoing blood loss. When in doubt, please get a
second opinion.

MANAGEMENT OF PATIENTS WHO REFUSE TRANSFUSION OF BLOOD COMPONENTS

(e.g. JEHOVAH’S WITNESS PATIENTS)

 Jehovah’s Witness patients will refuse standard blood components such as RBC
concentrates, FFP and platelets, including PAD. Fractionated products are matters for personal
decision by each individual.
 Please contact Dave Erasmus on 0832592358 when an individual JW patient is undergoing
treatment or surgery that has a high likelihood of requiring transfusion support so that
strategies that minimise the chances of requiring blood products can be developed for the
individual patient. If he cannot assist he will provide further contact details for the
Pietermaritzburg area.

Management of adverse reaction to blood transfusion:

 Stop the transfusion immediately.

 Maintain venous access with normal saline in a new drip set.
 Contact the transfusion service for advice. Blood bank available on site at Edendale Hospital
only. From Greys Hospital dial 6995. From other areas contact via switch board.
 Whilst the investigation of the transfusion reaction proceeds, venous access should be
maintained with a crystalloid solution for further transfusion therapy if required.
 Suitable therapy to combat the effects of the reaction.

Monitoring

The basic monitoring of the patient prior to the initial transfusion and during subsequent
transfusion should cover:

 Monitor vitals
 Strict intake and output monitoring.
 Any abnormal symptoms existing at the start of transfusion should be noted e.g. dyspnoea,
chills, oliguria, etc.
 Send appropriate samples, clearly labelled – a minimum requirement will include:
 Clotted blood sample.
 EDTA tube.
 Perform a dipstix on post transfusion urine sample for haemoglobinuria.
 Return the suspect unit/s, empty blood bags and drip set to the nearest blood bank.
 Complete the reaction report form specifying patient details, reason for transfusion,
 Pre- and post-transfusion signs and symptoms.

71
GENERAL GYNAECOLOGY

MISCARRIAGES

DESCRIPTION

An ending of a pregnancy before the foetus is viable. SA law - 28 weeks after the last normal
menstrual period. WHO- ending of pregnancy before 20 weeks or less than 500g. Miscarriages
are classified as threatened, inevitable, incomplete, complete, missed/silent, uncomplicated and
septic.

CLINICAL PRESENTATION AND MANAGEMENT:

THREATENED MISCARRIAGE
 Missed period
 Light per vaginal bleeding
 +- back ache
 +- lower abdominal pain
 Foetus is alive
 Cervix is closed

Management:
 Conservative
 Reassurance that foetal heart is present, 90% chance that pregnancy will continue.

INEVITABLE MISCARRIAGE:
 Vaginal bleeding
 Pain increasing intensity
 Tender uterus
 Cervical dilatation
 No passage of foetus

Management:
 Insert an ivi line with oxytocin 20 units in 1L Modified Ringers Lactate if actively bleeding.
 If in shock, actively resuscitate the pt with ivi fluids. (MRL and Gelufusine).
 Do ward HB and Rh
 FBC, U&E, Type and screen/cross match according to clinical condition
 Appropriate Blood transfusion to correct anaemia.
 Antibiotics if suspect infection.(as for PID)
 First trimester-suction curettage/manual vacuum aspiration(MVA)
 Second trimester- analgesics (morphine 10mg imi 4 hrly) and oxytocin as above.
 Pt to abort spontaneously first -› evacuation of uterus.
 Counsel the patient on findings and management.

INCOMPLETE MISCARRIAGES
 Passing of products of conception
 Uterus smaller than expected for gestational age.
 Cervical is is open and products are felt.

72
Ultrasound
 If a patient gives a clear history that she has passed a fetus, and the examination reveals
an open os with palpable products-DO NOT request an ultrasound.
 US have a place in areas where it is not clear if patient has a threatened miscarriage or
complete miscarriage when the os is closed.

Regarding endometrial thickness

 >10mm with os closed-give 400mcg cytotec pv to prime the cervix. After 4 hours proceed
with evacuation of uterus.
 < 10mm, in the absence of infection, heavy bleeding and a patient that is well
(haemodynamically stable) can receive cytotec and be discharged home, with follow up
after 1 week to assess completeness of miscarriage.
 > 10mm with open os – proceed with an evacuation procedure as per gestational age.

These patients are usually admitted as emergencies.

If the patient arrives before 19h00, the uterus is evacuated the same evening and patient is
discharged in the morning.
If the patient arrives after 19h00, is not bleeding and is haemodynamically stable the evacuation of
the uterus is done the next morning and patient is discharged in the afternoon.
Patients that are - ≤ 12 weeks – manual vacuum aspiration
- >12 weeks –evacuation of the uterus
Ensure the Rhesus statuses of all patients are checked, RPR, FBC,
Administration of Anti- D immunoglobulin to Rh Neg patients. 100mcg imi as single dose.

SEPTIC MISCARRIAGES
 Hypotension, offensive products, tachycardia, pyrexia, tachypnoea

Management:
Must be discussed with the consultant on call, these cases must be managed as acute
emergencies and there should be no delay.
 Resuscitate: x 2 ivi lines, urinary catheter to monitor urinary output
 Bloods -FBC, U&E,RH,RPR
 ABG
 CXR as appropriate
 Appropriate referral to ICU if indicated
 Therapeutic antibiotics. - Augmentin 1.2g 8hourly + Gentamycin 240mg daily.
 Evacuation to be done by senior medical officer or registrar.
 Counsel patient on condition and management.

If all above normal then for colpo-puncture prior to evac, if pus present then for laparotomy.
If more than 1 organ failure, dusky or gangrenous cervix, generalized peritonitis or uncontrollable
bleeding then for hysterectomy, unless consultant decides otherwise. An oophorectomy need not
be performed unless ovaries are involved in adnexal abscesses.

73
COMPLETE MISCARRIAGE:
 The miscarriage process is complete with resultant empty uterus. This can only be
diagnosed if the doctor has seen the products himself and confirmed that they are
complete.

Management
 Counsel the patient.
 Grief counselling.
 Discharge the patient if all findings are normal.

MISSED/SILENT MISCARRIAGE:
 Mum is asymptomatic
 Fetus has died in utero but has not expelled
 Coincidental finding on ultrasound.

Management
 As for TOP. See page
 Don’t forget to counsel the mother.

All patients to be offered appropriate family planning and HIV testing +- CD4 count prior to
discharge.

74
PROTOCOL FOR EVACUATION OF THE UTERUS

Patients presenting at Outpatients may be assessed by Primary Health Care Nurses or Interns.

Management
 All patients are graded either as low or high risk

Low Risk/safe
 Uterus size < 12 weeks
 Temperature < 37.2
 Systolic blood pressure >100mmhg
 Pulse <90
 Respiratory rate <20/minute
 HB >10g/dl
 POC not foul smelling
 No clinical signs of infection
 No system or organ failure or dysfunction.
 No suspicious findings on evacuation,

High Risk
 Patients with a uterus size > 14 weeks
 Heavy active bleeding
 Hypotensive, tachycardia, pyrexia
 Anaemia
 Signs of Peritonitis
 Evidence of mechanical injury
 Signs of infection
 Co-existing medical conditions
 Previous caesarean section
Pre-Op
 Informed consent and explanation of procedure
 Starve (in case GA is required)
 Brief Medical History and full examination

In Theatre
 IV Access (Venflon)
 BP at least 1 reading before procedure
 Pulse Oximetry, Sats monitoring

Sedation

 Pethidine 1mg/kg I.V. slowly – Max. 100mg/10 mins IMI before procedure OR
 Fentanyl (Sulimaze, Sufenta) 1-1.5ug/kg I.V. slowly. Max 100ug (Micrograms)
Plus Midozolam (Dormicum) 0.03mg/kg to max of 5mg (Wait 2 minutes for full effect
Local Anaesthetic to cervix (paracervical block) - Marcaine or Lignocaine if required.
Local anesthetic is injected into between two to six sites at a depth of 3–7 mm alongside the
vaginal portion of the cervix in the vaginal fornices.

Procedure

 Cleaned and draped in lithotomy position.

 Bladder emptied.
75
  Do a bimanual examination to assess the size of the uterus.
 NEVER use an uterine sound.(high risk of perforation)
 Visualise cervix with Auvard speculum if not available a cusco speculum will suffice.
 Inspect Cervix for any abnormalities, evidence of interference, lesions, and offensive
products?
 If suspect sepsis then proceed to colpopuncture. If pus aspirated, proceed to laparotomy, if
negative, proceed to evacuation.
 Visible retained products of conception in the cervix are removed with ovum forceps.
 Grasp the anterior lip of the cervix with a sponge holding forceps.
 The contents of the uterus are evacuated using wall suction via a Karmen Catheter of an
appropriate size in accordance with the dilatation of the cervix. Alternatively sharp curettage
with a Baum’s curette may be done.
 The largest size curette is used that can safely pass through the cervical os.
 Systematically proceed with evacuation until- gritty feeling, bubbles seen at introitus, no
further products are removed.
 A manual vacuum aspirator may be used if <12 weeks (MVA).
 Avoid overzealous curettage as this can result in synechiae formation.
 Assess need to send specimens for histology /MC&S.
 Clear documentation.

Post-Operative Care

 Monitor vitals and pad checks.

 Post-operative ward HB
 Correct anaemia appropriately( blood vs haematinics)
 Check rhesus status, administer anti D to Rh negative patients.
 Counsel patient.
 Family planning
 Follow up to be arranged as appropriate.

76
PROCEDURE FOR MANUAL VACUUM ASPIRATION:
.
 Informed written consent.
 Analgesia-Pethidine 100mg imi is administered 30 minutes before the procedure. OR
Morphine 10mg imi 30 minutes before the procedure OR para cervical block with 1%
lignocaine.
 Empty bladder.
 Confirm the size of the uterus,bimanual
 Give 10 IU of oxytocin IMI or 200mcg misoprostol po stat.
 Insert speculum, inspect cervix.
 Remove visible products in os with sponge-holding forceps or ovum forceps.
 Gently take hold of anterior lip of cervix with sponge holding forceps. Hold with the non-
dominant hand. Insert karman catheter into the cervix into the uterus (largest safe that can
pass through the os is selected). Do not touch the tip of catheter, push in to the fundus and
then pull back about 1-2 cm.
 Connect the prepared aspirator (depress two buttons at the most proximal end first, and
then pull back the plunger to create a vacuum. Attach aspirator to karman catheter, release
the buttons to activate vacuum. Evacuate contents, rotating and moving the cannula in a
systematic fashion.
 Evacuate till no more products can be removed, gritty feeling of the uterus, foamy bubbles
are seen.
 Remove the remove the cannula, forceps and speculum.
 Do a bimanual examination.
 Send off for histology, MC & S as appropriate.
 Documentation.
 Counsel patient.
 Analgesics x 48hrs –paracetomol 1g 6 hourly and ibuprofen 400mg 8hrly.
 Patients are observed for 3 hours post procedure in a day ward-Vital signs and pv loss are
checked every 30 minutes.
 Patients that are Rh negative- anti D immunoglobulin 100mcg imi as a single dose.
 Doxycycline 100mg BD x 7-10 days

Advice to patient:

 What to expect next few days.

 Take treatment as prescribed.
 Warning signs, return to hospital.
 Contraception.
 Check-up visit.
 When to resume coitus and safe sex practices.
 Next pregnancy.
 HIV test,CD4, lifelong Haart.

77
PROTOCOL FOR USE AT THE TERMINATION OF PREGNANCY (TOP) CLINIC

General
 All patients seeking this service should be treated with respect and dignity.
 Detailed appropriate history to be taken. This should include: Determining the reason for
requesting TOP, social circumstances, and socioeconomic circumstances, medical,
surgical, gynaecological and mental conditions.
 Appropriate involvement of the multidisciplinary team-social worker, psychologist,
physicians, etc.
 Evaluation of gestational age-history, bimanual examination, ultrasound.
 Comprehensive Pre -counselling, informed written consent and post counselling for all pts.
 Rh, VCT, RPR and family planning compulsory for all pts.
 Health care workers, who have a conscientious objection to perform TOPs, are still obliged
to carry out the pre- counselling, consent and emergency care and post counselling. For the
actual initiation they must personally arrange for another health care worker to perform the
initiation.
 After the evaluation the patient should be categorized according to Choice on Termination
of pregnancy Act. (92 of 1998) as amended in 2007.)

National Guidelines
All terminations of pregnancy are to be carried out in accordance with the regulatory requirements
of the Choice on Termination of Pregnancy Act, (92 of 1998).

 Where the pregnancy is less than or equal to 12 weeks gestation, TOP is performed by a
medical practitioner or a midwife who has completed the prescribed training course, -upon
request of the woman

 From the 13th and up to and including the 20th week of gestation, the medical practitioner
performs the TOP if one or more of the following criteria are fulfilled:

- Continuation of pregnancy would pose a risk to the physical or mental health of the patient;

- There is a risk of severe physical or mental abnormality to the foetus;

- The pregnancy resulted from rape or incest.

- The socio-economic situation of the woman would be significantly adversely affected.

 After the 20th week, TOP is carried out by a medical practitioner, after consulting with
another medical practitioner or registered midwife.

The TOP can only be carried out if:

- Continuation of the pregnancy would endanger the woman’s life;

- There is a severe foetal malformation

- Continuation of the pregnancy would pose a risk of injury to the foetus.

78
In a case of severe mental disability which precludes understanding and appreciation of the nature
or consequences of a TOP, or where the woman is in a state of continuous unconsciousness and
there is no reasonable prospect of her regaining consciousness in time to request and consent to
a TOP, the TOP may be effected upon the request and consent of the natural guardian, spouse,
legal guardian or curator personae. The requisite criteria for effecting the TOP would be the same
as for the mentally competent patient during the different gestation up to and including the 20th
week, the consent of two medical practitioners, or a medical practitioner together with a registered
midwife who has completed the prescribed TOP training course is also required. However, in the
situation where the patient is more than 20 weeks gestation; and the health professional is of the
opinion that the TOP is indicated; the health professional is required to consult with the natural
guardian, spouse, legal guardian or curator personae as the case may be. The TOP shall not be
denied if those individuals refuse to consent thereto.

Where the woman is a minor (under 18 years), she should be advised to consult with parents,
guardian, family members and friends before the TOP. However she cannot be denied a TOP
should she refuse to consult.

A “woman” means any female of any age.

 The patient is entitled to change her mind after counselling. Clear documentation should be
made to this effect.

 All patients will then have pre TOP counselling by sisters in TOP clinic or registrar/medical
officer in ward in cases that are done as an in-patient. Interns should counsel patients
under the direct guidance of medical officer or registrar or consultant.

 Written Informed consent for TOP is obtained after pre counselling.

 Where the patient is ≤ 12 weeks, she is given a booking for MVA, together with

5 x 200mcg misoprostol tablets with explicit directions for use as follows:

- 3 tablets to be inserted into the vagina between 20-21 h OO the night before the
appointment.

- 2 tablets to be ingested orally after 6 hrs if there is no response to (i) (i.e. no vaginal
bleeding or pregnancy loss).

- Perform MVA the next day if the patient has aborted or has pv bleeding with os open.

- Pethidine 100mg imi is administered 30 minutes before the procedure. OR Morphine

10mg imi 30 minutes before the procedure OR paracervical block with 1% lignocaine.

- Analgesics x 48hrs –paracetomol 1g 6 hourly and ibuprofen 400mg 8hrly.

- Patients are observed for 3 hours post procedure in a day ward-Vital signs and pv loss
are checked every 30 minutes.

- Patients that are Rh negative- anti D immunoglobulin 100mcg imi as a single dose.

- If no complications, post TOP counselling, family planning and all necessary

investigations, discharge patient.
79
 FAILED TOP

- In the event of a failed procedure- the midwife can repeat the procedure as stated x 2
further attempts. If failed x 3 attempts, the patient should be referred to be evaluated
by a medical officer.

- An ultrasound should be performed to exclude an advanced extra uterine pregnancy /

ectopic. If the pregnancy is confirmed to be intra-uterine the patient is admitted and
TOP shall be commenced by the registrar/ medical officer,, by insertion of vaginal
misoprostol, prior to admission. Should this fail, the method to effect the TOP should
be reviewed by the ward doctor (eg oral misoprostol/ lamicelle insertion, Foleys bulb).
The misoprostol regimen can be repeated X 2, but the doctor is required to insert
these personally to ensure compliance. Failure after the repeat misoprostol and Foleys
bulb induction, require- allow pregnancy to progress-(counsel on risks of fetal
exposure to misoprostol) or surgical evacuation-according to maternal preference.

Medical TOP- Mifeprostone oral as a single dose

Up to 9 weeks – 100-200mg

9-13 weeks -200mg

Followed 24-48 hours later by misoprostol 800mng, if expulsion has not occurred 4 hours after
misoprostol administration a second dose of 400mcg can be given pv/oral.

Review with ultrasound on day 7.

Bleeding may persist for 1 week.

Provide analgesiacs-paracetomol and ibuprofen

- Selected TOPS are done at Greys Hospital-these cases must be discussed with the
consultant before being accepted.

 Where the patient requests a TOP because of adverse social circumstances, and she is
between 13 and up to 20 weeks gestation, refer to the social workers for an opinion prior to
effecting the TOP.

 Where there is the possibility that the continuation of the pregnancy might impact adversely
on the mental health of the woman, confirm this by engaging the assistance of a
psychiatrist in the assessment of the patient.

 All patients> 14 weeks will require admission for misoprostol administration in the ward.

 No patient who warrants admission is to be denied admission based on the lack of

availability of beds in the hospital where this situation does arise, contact the consultant on
call.

 No patient is to be refused admission because the registrar /medical officer for the
gynaecology ward do not perform TOP because of religious or other conscientious reasons.
80
 Where this is the case, the registrar /medical officer has to find another doctor to effect the
TOP. The patient should not be left unattended or sent away.

 All patients that are admitted and are less than 12 weeks will have the MVA performed in
the TOP Clinic at both Northdale and Edendale by the doctors allocated to the gynaecology
ward. Careful patient selection is required to ensure that the patient qualifies for MVA,i.e.
low risk ,healthy patients with no sepsis and is haemodynamically stable. Please ensure
that adequate analgesia is administered 45 minutes — 1 hr prior to the procedure.

 All patients more than 14 weeks and those admitted to Greys Hospital, will have uterine
evacuation in theatre under anaesthesia.

81
RECURRENT MISCARRIAGE

DESCRIPTION:

Defined as the occurrence of three or more consecutive losses of clinically recognized

pregnancies prior to the 20th (some literature suggest 24 weeks as cut off) week of gestation
(ectopic and molar pregnancies are not included)

INVESTIGATIONS:

 Karyotyping Cytogenetic analysis should be performed on products of conception of the

third and subsequent consecutive miscarriage(s).
 Parental peripheral blood karyotyping of both partners should be performed in couples with
recurrent miscarriage where testing of products of conception reports an unbalanced
structural chromosomal abnormality.
 VCT
 RPR
 Anticardilolipin antibodies,dilute Russell viper venom test(lupus anticoagulant)
 pelvic ultrasound to assess uterine anatomy.
 Suspected uterine anomalies may require further investigations to confirm the diagnosis,
using hysteroscopy, laparoscopy
 second-trimester miscarriage should be screened for inherited
 thrombophilias including factor V Leiden, factor II (prothrombin) gene mutation and protein
S.
 Blood glucose, TFT and swabs are not of value.
 TORCH screen is of no value.

MANAGEMENT:
 Counselling, involve social worker and psychologist as appropriate.
 Women with recurrent miscarriage should be offered referral to a specialist clinic.
 Antiphospholipid syndrome - Pregnant women with antiphospholipid syndrome should be
considered for treatment with low-dose aspirin plus heparin to prevent further miscarriage.
 Finding of an abnormal parental karyotype should prompt referral to a clinical geneticist for
genetic counselling.
 Congenital uterine malformations
 There is insufficient evidence to assess the effect of uterine septum resection in
women with recurrent miscarriage and uterine septum to prevent further miscarriage.
If resection is required this can be done hysteroscopically.
 There are no published randomised trials assessing the benefits of surgical
correction of uterine abnormalities on pregnancy outcome.
 Cervical insufficiency.
 Women with a history of second-trimester miscarriage and suspected cervical
weakness who have not undergone a history-indicated cerclage may be offered
serial cervical sonographic surveillance.
 In women with a singleton pregnancy and a history of one second-trimester
miscarriage attributable to cervical factors, an ultrasound-indicated cerclage should
be offered if a cervical length of 25mm or less is detected by transvaginal scan
before 24 weeks of gestation.
 Treat any treatable cause eg Bicilllin for syphilis.
 Reassure and encourage patient to fall pregnant when ready.
 Ensure early ante natal booking, referral to regional or tertiary hospital, individualise cases.

82
PROTOCOL FOR MANAGEMENT OF RAPE VICTIMS

All rape victims who come to the Hospital need to be examined and treated.

Alleged rape victims are attended to at the crisis centre at Northdale Hospital or Edendale
Hospital. With the appropriate involvement of the police department. These cases are generally
attended to by the district surgeon. If no district surgeon is available, the onus is on the
registrar/medical officer in O&G to perform the examination, sexual assault kit and prescribe
treatment. Greys being a referral centre will attend to cases as per [Link], extensive injuries
requiring multidisciplinary surgery, etc.

THIS SHOULD BE DONE NO MATTER HOW LATE IT IS

PROCEDURE:
 The patient should be treated with respect and dignity and privacy respected.
 A female nurse should be present as a chaperone for the patient.
 History should be taken.
 Before starting the evidence collection, take the time to explain all the procedures to the
patient and why they are necessary.
 Take consent to perform examination and collect evidence, if patient less than 18 parent or
guardian to give consent.
 Record all findings on the outpatient’s card.

 Health Care Practitioners must establish whether the patient wishes to report the matter to
the SAPS. If the patient wishes to report the incident contact the police station IN THE
AREA in which the incident took place. If the patient is not injured in the attack the police
will take her to a CRISIS CENTRE.

 If the patient refuses to report the matter to the police the Doctor should still perform a full
forensic examination of the patient and record the findings. If the patient is under 14, the
child must be referred to the Paediatric Department at Grey’s Hospital or Edendale Hospital
according to drainage area. A patient who has sustained injuries must be assessed and
treated at the nearest Casualty/Trauma Centre. Once stabilized the Casualty Officer may
refer the patient to a Crisis Centre for Forensic Examination.

 Collection of forensic evidence- rationale is to link the suspect to the patient. There is only
one opportunity so collect as much as possible, as soon as possible.

 Maintain the chain of custody.

HISTORY AND EXAMINATION

 Take a history of what happened and of gynaecological relevant information.

 Date and time of assault, time of evidence collection
 Consensual coitus within the last week, yes when.
 Perpetrator known?
 One or more perpetrator
 Accurate description of sexual assault, including injuries sustained to self and to
perpetrator.
83
  Actions after incident,cleaning,brushing teeth, change of clothes
 Use of condoms, tampons,
 Last Menstrual Period
 Contraception
 Parity

 Look for and note any general body injuries viz. on the back and thighs – these are common
sites of injury.
 Full top to toe examination

VAGINAL EXAMINATION

 Injuries to the vulva and vagina

 Condition of the hymen
 the number of fingers possible to insert into the vagina
 State of the uterus and cervix in relation to pregnancy

SPECULUM EXAMINATION
Note the presence of

 Injuries
 Bleeding
 Discharge
 Semen

Take a pus swab from the posterior forensic and endocervix – from this make a Pap smear.

Note
Speculum examination should not be done in children and girls who have had no previous
intercourse.
Take a blind pus swab aimed at the posterior fornix.

SPECIMENS
 The pus swab and smear should be labelled and signed by you.

 Also consider fingernail scrapings if she has scratched the assailant and pubic hair combing
and plucking if foreign hair or clothing fibres are evident. If she has underpants that she was
wearing at the time of the rape these should be put into a paper bag labelled and submitted
as well.

FILL IN THE RAPE KIT

PLEASE FILL IN THE J88 IN DETAIL AND KEEP A COPY (the copy is usually kept at the
crisis centre and not the doctor personally).

84
TREATMENT

 Take blood for HIV/RPR screening, Hepatitis B (if no prior history of hep B immunization)

 If likely to become pregnant as determined by the history and patient is not pregnant at time
clinically, or, on urine testing - the following can be used.

 Levonogestrel 1, 5 mg po stat, preferably within 24 hours of event.

OR
 Ovral (50 mg Ethinyl Oestradiol + 500 mg norgestrel) two pills immediately and two after 12 hours.
The first dose must be given within 72 hours after exposure to conception. If patient vomits within 2
hrs a repeat dose is required.
 Emergency contraception can be given up to 5 days following unprotected sexual intercourse.

 If later than 72 hours, < 120 hours – an IUCD can be inserted.

 If refused, ask her to return in six weeks for a pregnancy test.

POST EXPOSURE PROPHYLAXIS FOR PENETRATIVE ANAL OR VAGINAL SEXUAL ASSAULT:

Adults
 Tenofovir, po, 300mg daily for 4 weeks
And
 Emtricitabine, po, 200mg daily for 4 weeks
Or
 Zidovudine, po, 300mg 12 hourly for 4 weeks
And
 Lamivudine, po, 150mg 12 hourly for 4 weeks
And
 Atazanavir / Ritonavir, po, 300/1000mg daily
Or
 Lopinavir / Ritonavir, po, 200/50, 2 tablets 12 hourly

Tenofovir is contra-indicated in renal disease or with concomitant use of nephrotoxic medicines e.g.
aminoglycosides (check baseline creatinine clearance). Where Tenofovir is contra-indicated, switch to
Zidovudine. If Zidovudine is not tolerated consult or refer for further management. Lopinavir / Ritonavir
often causes diarrhoeia. If Lopinavir / Ritonavir is not tolerated switch to Atazanavir / Ritonavir.

Prophylaxis against Sexually Transmitted Disease:

 Ceftriaxone (Rocephin®) 250mg imi stat or Cefixime 400mg po stat

PLUS
 Doxycycline 100 mg bd x 7 days (IF pregnant use Amoxil 500mg 8 hrly)
 Metronidazole(Flagyll®) 2g stat or 400mg 8hrly x 7 days per os

CRISIS CARE CENTRES

These are available at:

1. Doctors Quarters – Northdale Hospital. This is a 24-hour service.033 397 6420

2. Thuthuzela –Edendale Hospital –all ages. 033 395 4325/4352/4314
3. Grey’s Hospital – For children under 14 years old (Paediatric Department).

85
VAGINAL DISCHARGE:

Vaginal discharge may often be physiological, many women find excessive discharge distressing.
Therefore, identifiable causes for vaginal discharge must be sought where appropriate. A patient
can be reassured if no cause is found.

INVESTIGATIONS:

 Individualise according to each patient.

 Offer all patients Hiv testing,CD4,VL as appropriate.

 RPR

 If it is the first presentation of vaginal discharge, the pus swabs are not indicated.

 chlamydia, gonorrhoea and trichomonal infections can be diagnosed by means of high

vaginal and endocervical swabs in the appropriate culture media.

Bacterial vaginosis:

Treatment:

Metronidazole or clindamycin. Metronidazole 400 mg twice daily for 5 days or a stat dose of 2 g.

Vulvovaginal candidiasis:

Treatment:

 clotrimazole (500 mg) vaginal pessary PV STAT

 or oral fluconazole 150 mg

 a stat Dose will suffice to treat the vaginal infection. Topical anti-fungal

therapy is continued for seven days in severe cases.

Trichomoniasis

Treatment

metronidazole - a stat dose of 2 g orally will suffice. All patients and their partners should be
treated.

Chlamydia trachomatis

Treatment:

 doxycycline 100 mg twice daily for 14 days may be prescribed,

 Sexual activity must be avoided during treatment and for at least 1 week afterwards.

86
Gonorrhoea

Treatment

 ceftriaxone 250mg intramuscularly (stat dose) or a single oral dose of cefixime 400 mg.

NOTE:

Patients are generally not infected with a single organism but multiple co-infections at the same
time, hence the need for syndromic management of vaginal infection. Refer to chapter on PID.

• Cefixime 400mg p.o. stat or Ceftriaxone 250mg imi stat

• Doxycycline 100 mg orally 12 hourly x 10 days
• Metronidazole 400 mg x 8 hourly for 10 days
• Ibuprofen (in absence of renal dysfunction, asthma and peptic ulcer disease) 400mg x 8
hrly x 5 days po.
 Paracetamol 1 g x 6hrly po
• Advice to return if feeling worse or no improvement after 48 hours treatment
• Contact tracing

87
VULVODYNIA:

DESCRIPTION:Vulval discomfort (burning pain), occurring in the absence of relevant visible

findings, or a specific clinically identifiable neurologic disorder. When evaluating the patient it is
essential that all the secondary causes of pain are excluded before a diagnosis of vulvodynia is
made.

INVESTIGATIONS:

 As guided by the history and examination.

 HIV,CD4,VL
 Vaginal microbiological swabs can be helpful especially for patients with intermittent flare-ups
of symptoms to detect candida and streptococcus infections.

MANAGEMENT:

 Should focus on educating the patient about vulval anatomy, normal pain pathways, chronic
pain pathways and sexual response cycles.
 Regular use of emollients and avoidance of all scented products on the vulva.
 Reassurance is essential as many patients fear malignancy.
 Multi-disciplinary team approach sexual therapy, physiotherapy, cognitive behavioural therapy
and chronic pain management.
 Support groups

Provoked pain:

 Desensitization techniques e.g. massage, use of vaginal trainers

 Local anaesthetic gels and ointment prescription and instruction on use
 Local injection into the vulva (steroids, Botox etc)
 Surgery (vestibulectomy)
 Referral for physiotherapy for physical treatments e.g. biofeedback
 Referral for sexual therapy for advanced counselling/therapy

Unprovoked pain

 Drug treatment -Amitryptyline, the best studied tri-cyclic, is increased according to the patients
pain level starting at 10 mg/day increasing every week until the pain is controlled. The average
dosage is 60 mg/day although up to 100 mg/day can be used.
 Referral for Pain Management for advanced drug treatment ([Link]), nerve blocks
(e.g. pudendal block, regional anaesthetics)
 Referral for cognitive behavioural therapy.

88
ADNEXAL MASS:

An adnexal mass is a common clinical problem affecting the ovary, fallopian tube or surrounding
connective tissue, and can present in females of all ages. Mostly, they arise from the ovary. An
adnexal mass may be symptomatic or discovered incidentally during imaging performed for
another indication. Adnexal masses may be found in females of all ages, and there is a wide
variety of masses. The management of an adnexal mass depends upon the type of mass,
urgency of the presentation (eg, ectopic pregnancy or ovarian torsion require immediate
intervention), and degree of suspicion that the mass is malignant. Malignancies will not be covered
in detail in this text .Refer to oncology guidelines.

INVESTIGATION:

 Pregnancy test-rule out ectopic,GTD

 Ultrasound
 +- CT scan
 FBC, U&E,LFT
 Pap smear
 Ca125

MANAGEMENT:

 The management of an adnexal mass depends upon the location and etiology of the mass and
the characteristics of the patient.

 Suspected malignancy or uncertain etiology — excluding malignancy is a principal goal of the

evaluation of an adnexal mass. For women with a mass that is suspicious for malignancy after
an initial evaluation, surgical exploration is required.

In general, there are three options for managing an adnexal mass:

1. Surgery – Surgery is performed for the following indications: malignancy is suspected; there
are other risks associated with the mass (eg, torsion, infection), or the mass is symptomatic. For
ovarian masses, an oophorectomy or ovarian cystectomy may be performed. For other adnexal
masses, the mass may be biopsied or resected.

2. Continued surveillance – Continued surveillance is indicated if the suspicion of malignancy is

low, but it has not been completely excluded. Surveillance usually includes serial pelvic
ultrasounds and/or measurement of serum tumor markers.

3. Expectant management – If the apparent aetiology of the mass is benign and there are no
other indications for surgery or surveillance, no further follow-up is needed.

89
Ruptured or haemorrhagic ovarian cyst

 Ovarian masses may rupture or become haemorrhagic. This occurs most commonly in
physiologic cysts that are associated with the menstrual cycle (follicular cysts, corpus luteal
cysts).

 A ruptured or hemorrhagic ovarian cyst is occasionally accompanied by significant bleeding.

Women with uncomplicated cyst rupture (hemodynamically stable, no evidence of ongoing
blood loss on laboratory evaluation or pelvic imaging) can be managed expectantly.

 Women with complicated cyst rupture require hospital admission for close monitoring, with a
possible need for surgical intervention and/or blood product replacement.

Persistent pain or pressure:

 Ovarian cysts may cause pain or pressure symptoms. Since many cysts are transient and the
pain will resolve with the cyst, these symptoms are best managed with analgesics in the short
term while the patient is evaluated and it is determined whether surgery is needed for another
indication (eg, suspicion of malignancy, infertility).

Endometriomas

 May be associated with dysmenorrhea, pelvic pain, or dyspareunia. These masses are usually
recognized by their characteristic appearance on ultrasound. They are also often associated
with endometriosis at other sites within the pelvis. Surgical removal is the usual treatment of a
symptomatic endometrioma.

Ovarian mass indeterminate appearance on scan:

 Some women will have an ovarian mass with an indeterminate appearance on ultrasound, but
with no features of malignancy. In such cases, other sources of pelvic pain should be
investigated. However, if no other aetiology of the pain is identified and the pain is persistent
and not relieved by analgesics, an ovarian cystectomy or oophorectomy may be of benefit.

Recurrent physiologic cysts

 Patients with a history of recurrent painful ovarian cysts can be managed with hormonal
contraceptives to inhibit ovulation. This prevents the formation of new physiologic ovarian
cysts. Oral contraceptives (OCs) do not decrease the size of existing cysts.

Ectopic pregnancy

Ectopic pregnancy is a potentially life-threatening condition; the fallopian tube is the most
common site of an ectopic pregnancy, although ovarian or cervical pregnancy may also occur.
Refer to chapter on ectopic pregnancy.

Tuboovarian abscess:

 The classic presentation of a tuboovarian abscess includes acute lower abdominal pain, fever,
chills, vaginal discharge, and an adnexal mass. Pelvic imaging typically shows a complex
multilocular mass that obliterates normal adnexal architecture. Timely diagnosis and

90
 management are required to diagnose or avoid sepsis and to prevent further damage to the
ovary and fallopian tubes. Refer to chapter on PID.

Paratubal or paraovarian cyst:

 A paratubal or paraovarian cyst arises from the broad ligament in the area of the fallopian tube
or ovary. The most common findings in this area are simple cysts that originate from the
remnants of paramesonephric (Müllerian) or mesonephric (Wolffian) ducts that are present
during urogenital embryologic development.

 A simple, asymptomatic paratubal or paraovarian cyst can be managed expectantly without

further follow-up. Surgical removal is indicated for these lesions if they undergo torsion, cause
persistent pain or pressure symptoms, or appear neoplastic.

Hydrosalpinx

 A hydrosalpinx is an edematous fallopian tube, typically caused by an infection. A hydrosalpinx

may be asymptomatic or may result in chronic pelvic pain or infertility and sometimes be the
source of chronic pelvic pain. Other aetiologies of chronic pelvic pain should be excluded
before salpingectomy is performed. An asymptomatic hydrosalpinx does not generally need to
be removed or followed with imaging. The exception to this is women undergoing in vitro
fertilization.

Broad ligament fibroid

 A broad ligament fibroid may be located proximal to the ovary and fallopian tube. These are
usually diagnosed with pelvic ultrasound and are managed in the same manner as other
fibroid. Refer to chapter on fibroids.

Ovarian torsion

 Torsion of the ovary or fallopian tube requires urgent surgical treatment to avoid ischemic injury

91
PELVIC INFLAMMATORY DISEASE

DESCRIPTION:
Pelvic inflammatory disease refers to acute infection of the upper genital tract, involving any or the
entire uterus, fallopian tubes and ovaries. It is sexually transmitted and can be acute or chronic.

Stage 1 Early salpingitis – Local adnexal tenderness

Stage 2 Late salpingitis and pelvic peritonitis – (rebound and guarding)

Stage 3 Evidence of pyosalpinx or tuboovarian complex or tubal occlusion. ESR >60ml/hr

Stage 4 Rupture of tubo ovarian complex, generalized peritonitis, septicaemia.

Stage 5** Adult Respiratory Distress Syndrome. (ARDS)

** suggested addition to original classification.

INDICATIONS FOR HOSPITALISATION

 The diagnosis is uncertain.

 The possibility of surgical emergencies such as appendicitis or ectopic pregnancy cannot
be excluded.
 Severe pelvic inflammatory disease in the presence of an IUCD.
 Signs of peritonitis on examination.
 Temperature >38.3°C
 Nausea and vomiting.
 The presence of an adnexal mass on examination or ultrasonography.
 A pelvic abscess is suspected.
 The patient is pregnant.
 The patient is an adolescent.
 Severe illness precludes outpatient management.
 The patient is unable to tolerate oral therapy.
 The patient has not responded to outpatient therapy within 48 hours.
 Clinical follow up cannot be arranged within 72 hours of the initiation of antibiotic treatment.

MANAGEMENT

 Full history and clinical evaluation.

 Bloods FBC, U& E, RPR, HIV +- CD4 count
 Ultrasound if a mass is suspected or felt.

Outpatient management (Stage 1) mild to moderate disease.

 Cefixime 400mg p.o. stat or Ceftriaxone 250mg imi stat

 Doxycycline 100 mg orally 12 hourly x 10 days
 Metronidazole 400 mg x 8 hourly for 10 days
 Ibuprofen (in absence of renal dysfunction, asthma and peptic ulcer disease) 400mg *x 8
hrly x 5 days po.
92
 Paracetamol 1 g x 6hrly po
 Advice to return if feeling worse or no improvement after 48 hours treatment
 Contact tracing

Inpatient management (stage 2-4)

 Ceftriaxone 250mg imi stat, followed by

 Benzyl penicillin 2 million units 6 hourly +
 Gentamycin 6mg/kg dly(on average 240mg dly) +
 Metronidazole 500mg 8 hrly ivi
OR
 Ampicillin 1g 6 hrly ivi
 Gentamycin 6mg/kg dly(on average 240mg dly) ivi +
 Metronidazole 500 mg x 8 hourly ivi
 PLUS
 Ibuprofen( in absence of renal dysfunction, asthma and peptic ulcer disease) 400mg *x 8
hrly x 5 days po
 Paracetamol 1 g x 6hrly po
 If severe pain use morphine imi.

Non Responders-second line antibiotics

 Clindamycin 600mg 6 hrly ivi

 Ceftriaxone 1g 12hrly ivi
 Piperacillin /tazobactam loading dose 8g ivi then 4,5 g 12hrly ivi(reduce if renal failure).

Intravenous antibiotics are continued until definite clinical improvement.

Then change to oral antibiotics. Amoxicillin/clavulanic acid (Augmentin) 875/125mg 12 hrly to
complete 10 days therapy. PLUS Doxycycline 1oomg 12 hrly x 10 days (to treat chlamydia).

Penicillin Allergy:

 Ceftriaxone 250mg imi stat, followed by

 Clindamycin 600mg 8 hrly +
 Gentamycin 6mg/kg dly (on average 240mg dly)

Surgery
 Acute abdomen
 Tubo -ovarian abscess that does not respond to appropriate antibiotic therapy within 48 hrs
 Pelvic abscess pointing into the vagina, rectum or abdominal wall.
 Uncertainty about diagnosis.

The regimen is continued for at least 48 hours after the occurrence of substantial improvement
after which the change is made to oral therapy.
The patient should be counselled on condition and safe sex practices. Contact tracing card/s to be
given so partner/s can be treated.
Hiv testing and. family planning offered before discharge.

93
ECTOPIC PREGNANCY

INVESTIGATION:

 Urinary pregnancy test- will be positive

 Ward Hb stat
 Ultrasound- a ruptured ectopic remains a clinical diagnosis. In cases where the diagnosis is
doubtful, an ultrasound can be of assistance. Identification of an intra-uterine pregnancy
rules out an ectopic, except in the rare occasion of a heterotopic pregnancy(1%).empty
uterus + adnexal mass + free fluid in Pouch of Douglas = likely ectopic pregnancy.
 FBC, RH,RPR,U&E
 VCT as for all patients +- CD4
 Type and screen as appropriate
 Arterial blood gas(shocked)
 Uncertain cases Q BHCG –lowest level at which a viable pregnancy should be visible
(discriminatory zone). An intrauterine pregnancy is usually visible at trans vaginal ≥
1500IU/L transabdominal scan -≥ 6500IU/L.

MANAGEMENT:

 Call for assistance and inform senior-(junior doctors and interns)

 CAB’s
 Supplemental oxygen.
 Commence IVI line with wide bore cannula.
 Insert urinary catheter.
 Assessment made of patient- immediate laparotomy, laparoscopy or medical management
or expectant.
 Laparoscopy- unruptured ectopic, haemodynamically stable and surgeon with appropriate
skills or supervised.
 Counsel the patient.
 Informed written Consent
 Offer Tubal ligation for contralateral tube in patients whose family is complete.

Approach in theatre:

The ectopic can be addressed by open surgery or laparoscopically.

Open surgery: salpingectomy or salpingostomy

Laparoscopic approach:.

Principles are the same as for open surgery, salpingostomy or salpingectomy can be performed.
The surgeon needs to have the necessary skills or supervised by an experienced senior.

94
Medical management of ectopic pregnancy:

There is no role for medical management in the treatment of tubal pregnancy or suspected tubal
pregnancy when a patient shows signs of hypovolaemic shock.

Prerequisites for medical management:

 Specialist guidance and supervision of case

 Informed written consent.
 Patient should be well, sound mind, understands well, ambulant, amenable to regular follow
up and be able to return immediately if she feels unwell or has pain at any time during the
treatment process.
 Able to get to hospital speedily in the event of an emergency.
 Unruptured ectopic
 No fetal heart pulsation.( relative contraindication)
 Size of ectopic <3,5cm
 BHCG level < 3000. (Relative contraindication).
 Normal FBC, U& E and LFT.
 Counselling should include: abdominal pain following treatment, Occasional women will
also experience conjunctivitis, stomatitis and gastrointestinal upset.
 Women should also be advised to avoid sexual intercourse during treatment, to maintain
ample fluid intake and to use reliable contraception for three months after methotrexate has
been given, because of a possible teratogenic risk. Avoid sun exposure to limit
methotrexate dermatitis.
 Contraindications- active pulmonary disease, peptic ulcer disease, hypersensitivity to
methotrexate, coexistent viable intrauterine pregnancy(heterotrophic pregnancy) and
breastfeeding,

Procedure:

 Ensure that patient understands the treatment process, adverse effects including possibility
of failure and need for surgery.
 Baseline bloods-FBC, U&E, LFT, and Q-HCG.
 Methotrexate can be given ivi, imi, oral or direct local injection into the [Link] our centre
we prefer IMI.
 Intramuscular methotrexate is given as a single dose calculated from patient body surface
area (50 mg/m2) or 1mg/kg. For most women this will be between 75 mg and 90 mg.
 Calculate body surface area = square root ((height in cm X weight in kg)/3600) or a BSA
calculator
 Serum hCG levels are checked on days four and seven and a further dose is given if hCG
levels have failed to fall by more than 15% between day four and day seven
 Folic acid rescue on day [Link] 0.1mg/kg
 Follow up after 7 days -symptoms
-examination
- ultrasound
- blood for Q- BHCG
 After day & HCG levels are checked weekly. If the HCG level fails to fall by 15% from the
previous level, a repeat dose is given, followed by leucovorin administration on next day.
Repeat methotrexate x 3 doses only.
 Follow up until HCG is undetected.
 Advise to not fall pregnant at least 4 to 6 months to allow for washout of methotrexate.

95
Expectant management of pregnancy of unknown location

 Expectant management is an option for clinically stable women with minimal symptoms and
a pregnancy of unknown location.

 If women are managed expectantly, serial serum hCG measurements should be performed
until hCG levels are less than 20 iu/l. Do twice weekly serial hCG measurements and
weekly transvaginal examinations to ensure a rapidly decreasing hCG level (ideally less
than 50% of its initial level within seven days) and a reduction in the size of adnexal mass
by seven days. Thereafter, weekly hCG and transvaginal ultrasound examinations are until
serum hCG levels are less than 20 iu/l.

 Extensive counselling.

 Laparoscopic identification of ectopic pregnancy prior to expectant management can be

used.

Persistent trophoblast

 Patients that have had a salpingotomy for the management of tubal pregnancy should be
followed up to identify those women with persistent trophoblast.

 Persistent trophoblast is detected by the failure of serum hCG levels to fall as expected
after initial treatment.

 cases of delayed haemorrhage due to persistent trophoblast have been described and this
provides the rationale for following women with serial hCG measurements after treatment
and administering methotrexate if levels fail to fall as expected.

Anti-D immunoglobulin

 Nonsensitised women who are rhesus negative with a confirmed or suspected ectopic
pregnancy should receive anti-D immunoglobulin.

 Give anti-D immunoglobulin (rhogam®) 50 mcg imi.

96
HYPEREMESIS GRAVIDARUM

DESCRIPTION:

Nausea with or without vomiting is common in early pregnancy. Severe vomiting resulting in dehydration
and weight loss is termed hyperemesis gravidarum.

Diagnosis:

 Clinical diagnoses as there are usually no physical signs except possibly some dehydration and
mild tachycardia.

Investigations

 Urine dipstix- ketones, any evidence of UTI

 Urine MC&S if suspicion of UTI
 Blood for U&E , CMP-renal failure, hypokalaemia
 TFT
 Ultrasound- exclude molar pregnancy, multiple gestation.
 Make sure all baseline investigations have been done.

Management

Non pharmacological

 Advise the patient condition does not harm foetus, self-limiting, should settle by 16 weeks.
 Advice about diet-small frequent meals, figure out what foods they tolerate best and try to eat those
foods. Dietary manipulations that help some women include eliminating coffee and spicy, odorous,
high fat, acidic, and very sweet foods, and substituting snacks/meals that are protein dominant,
salty, low fat, bland, and/or dry (eg, nuts, pretzels, crackers, cereal, toast).
 Eat regular meals before feeling hungry.
 Antacids in patient who have heart burn, as heart burn can aggravate nausea and vomiting.
 Avoidance of triggers-odours, stuffy rooms, etc.
 Do not lie down immediately after a meal.
 Psychotherapy
 Use of ginger containing foods (eg, ginger lollipops, ginger tea) or ginger supplements.

Pharmacological therapy

 Metoclopramide (maxalon®) 10mg tds po when necessary. Or prochlorpherizine 12,5mg imi 8hourly
 Cyclizine 50mg tds po
 Pyridoxine is 25 mg tds po
 Mild cases can be managed as an outpatient. Moderate to severe cases should be admitted.
 Withhold meals for 1-2 days.
 Intravenous fluid therapy to rehydrate and main fluid status.
 Correct electrolyte abnormalities
 Consider thromboprophylaxis.

Vitamins and minerals — If the patient is experiencing persistent vomiting, it is important to replenish low
levels of vitamins (especially thiamine), electrolytes, and minerals (ie, magnesium, calcium, and
phosphorous)

Give 100mg Thiamine (vitamin B1) intravenously with the initial rehydration fluids and another 100 mg daily
for the next two or three days. Early administration of thiamine is important to prevent a rare maternal
complication, Wernicke's encephalopathy.

97
ABNORMAL VAGINAL BLEEDING IN A PREPUBERTAL CHILD

Differential diagnosis and management:

 Foreign body: removal under general anaesthetic

 Urethral caruncle: diathermy by experienced person, catheter X 24 hours

- refer to Greys specialist clinic

 Precocious puberty: refer to Greys specialist clinic

 Tumour: Biopsy under GA and refer to oncology specialist clinic

 Latrogenic- accidental ingestion of steroid hormones by children.

 Alleged sexual assault: appropriate referral to Greys Paediatric Abuse Unit or Edendale
Thuthuzela centre for continued management.

 Infection: rarely causes pv bleeding-syndromic management.

98
ABNORMAL UTERINE BLEEDING IN AN ADOLESCENT:

Uterine bleeding in the adolescent is almost always anovulatory.

MANAGEMENT:

 Exclude a pathological cause

 If mild bleeding- conservative management

 Reassurance

 Counselling

 Haematinics

 Menstrual diary

 If severe bleeding assess need for admission.

 Check FBC and exclude blood dyscrasias.

 Hormone therapy- low dose combined oral contraceptive pill or a cyclical

progestogen 20-30mg daily.

99
ABNORMAL UTERINE BLEEDING IN THE REPRODUCTIVE YEARS:

DESCRIPTION:

Abnormal Uterine Bleeding (AUB) is the new, internationally agreed, overarching term for any
deviation from the normal menstrual parameters detailed in the table below.

DEFINITIONS

 ACUTE AUB: is an episode of bleeding in a woman of reproductive age, who is not

pregnant,that is of sufficient quantity to require immediate intervention to prevent further
blood loss.,

 CHRONIC AUB is defined as bleeding from the uterus that is abnormal in frequency,
duration and/or volume and has been present for the majority of the previous six months.

 INTERMENSTRUAL BLEEDING (IMB) : is defined as bleeding between clearly defined

cyclic and predictable menses and includes random episodes as well as predictable
episodes occurring at the same time each month.

DO NOT USE old terminology such as Dysfunctional uterine bleeding/Functional uterine bleeding,
menorrhagia (including idiopathic menorrhagia, essential menorrhagia, ovulatory menorrhagia,
anovulatory menorrhagia,polymenorrhagia, epimenorrhagia), menorrhoea (including
epimenorrhea, hypermenorrhea, hypomenorrhoea, polymenorrhea) ,menometrorrhagia,
metorrhagia ,metropathia hemorrhagica, oligomenorrhea ,uterine haemorrhage.

CLASSIFY SYMPTOMS INTO THE FOLLOWING:

 disturbance of menstrual frequency - infrequent or frequent

 irregular menstrual bleeding - absent or irregular
 abnormal duration of flow - prolonged or shortened
 abnormal menstrual volume - heavy or light

INVESTIGATIONS -Guided by history and examination:

 Menstrual diary (helps to determine amount and timing)

 FBC
 TFT- if symptoms of thyroid disease
 Coagulation screen to exclude a clotting disorder where a positive family history or other
symptoms exist to suggest a coagulopathy. Incl Von Willebrand Factor, INR, Aptt.
 All patients-VCT +- CD4
 Pap smear
 Pregnancy test, if suspecting miscarriage, molar, or ectopic.
 Ultrasound pelvis-Trans vaginal or transabdominal, or saline infusion sonography
 Hysteroscopy- suspected intracavitatry polyps
 Endometrial sampling not usually indicated in reproductive age group, but if endometrial
hyperplasia or cancer is suspected or poor response to treatment then sampling of
endometrium should be done-pippelle.,Z aspirator,vabra
 Biopsy of cervical lesion.

100
Management:

 Counselling
 Haematinics in patients with anaemia. (ferrous sulphate)
 Symptomatic patients with haemoglobin < 7.5 need to be evaluated for a blood transfusion.
 If coagulopathy identified include physicians and haematologist in management.

Pharmacological Management:

Acute Haemorrhage:

 norethisterone acetate(Primolut N®) 5 mg 4 hourly for 24 -48 hours or tranexamic acid

(cyclokapron®) 1g 6 hourly

then:

1. Tranexamic acid (cyclokapron®), 500mg to 1g 8 hourly orally for up to 4 days during

menses

2. Ibuprofen 400mg tds orally after meals during menses, if dysmenorrhoea with heavy
bleeding. Or mefenamic acid 500mg tds when available.

Or

3. Combined oral contraceptives (COCs), taken daily for 21 days, followed by a 7 day break
for at least 6 months.

Or

4. Oral progestogen - norethisterone acetate ( Primolut N®) 5 mg, three times daily taken from
day 5 to day 26 of the menstrual cycle. Use for 3-6 cycles. Or medroxyprogesterone
acetate (Hexal®) 30mg daily day 5 to day 26. Use for 3-6 cycles

Or

5. Injected –medroxyprogesterone acetate –(depo provera®) 150mg imi every 3 [Link]

bleeding still irregular add 2 weeks of norethisterone(primolut®) 10mg po bd OR implanted
progestogen (Implanon®), implant for 3 years use.

Prolonged bleeding after use of Depo provera or oral contraceptives (thin endometrium)

 Conjugated oestrogen (premarin ®) 25mg ivi 4 hrly x 6 doses only.

 Maxalon® 10mg 8 hrly prn.

Or

 Conjugated oestrogen (premarin ®) 2.5mg 8hrly po

Once the acute haemorrhage has been arrested for 72 hours then Provera 10mg daily for 5 days.
This will induce a normal withdrawal bleed.

101
Regional or tertiary level-senior/consultant supervision

1. Levonorgestrel-releasing intrauterine system (LNG IUS-mirena®)

2. Gonadotrophin-releasing hormone analogue (GnRH-a), given as a monthly injection for

3-6 [Link] goserelin, leuprolide acetate.

SURGICAL MANAGEMENT:

Depends on cause;

OPTIONS

1. Polypectomy- endocervical polyps can be avulsed in the outpatient setting.

Endometrial polyps can be removed blindly under general anaesthetic, or by
hysteroscopic resection either under general anaesthetic, or in the outpatient setting.

2. Endometrial ablation /resection: endometrial ablation is targeted destruction of

endometrium. Endometrial ablation should be considered in women with HMB who have
a uterus no bigger than a 10-week pregnancy and also those with small uterine fibroids
(less than 3 cm in diameter) who do not wish to conceive. It includes laser ablation,
endometrial resection and various balloon techniques delivering heat, cold, or
microwaves to the endometrium.

3. Myomectomy: myomectomy is the surgical removal of intramural and subserosal

fibroids from the uterine walls with conservation of the uterus.

4. Uterine Artery Embolization: uterine artery embolization is carried out by interventional

radiologist, usually under local anaesthetic with or without sedation for fibroid related
bleeding.

5. Hysterectomy: hysterectomy should only be considered when a woman has completed

her family and when medical and less invasive surgical options have failed or are
inappropriate.

Management of post coital or intermenstrual bleeding:

1. Infection treated with appropriate antibiotics (see syndromic management PID), and
contact tracing and treatment of partners should be initiated.

2. Cervical polyps can be avulsed or resected hysteroscopically.

3. Cervical ectropions may resolve spontaneously if the OCP is stopped or after a

pregnancy. They can be treated conservatively or cauterized with silver nitrate,
diathermy or cryocautery.

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PERIMENOPAUSAL BLEEDING:

This refers to patients above the age of40.

INVESTIGATIONS:

 These are similar to the reproductive age group but he it becomes more pertinent to
take and endometrial sample to exclude malignancy.

MANAGEMENT:

 Manage according to the findings of the investigations.

 Simple hyperplasia without atypia- Provera® 10- 30mg X 6 months

 Repeat US and pipelle after 6 months

 If bleeding persists or recurs after progestogen therapy-hysterectomy.

 Complex hyperplasia or any hyperplasia with atypia- hysterectomy.

 If no cause can be identified and bleeding still a problem-low dose COC or refer to
Greys for Mirena®.

For the management of endometrial cancer refer to Oncology Guidelines.

In managing a patient with abnormal uterine bleeding, take into account the following:

 Aetiology and severity of bleeding (eg, anaemia, interference with daily activities)

 Associated symptoms (eg, pelvic pain, infertility)

 Contraceptive needs or plans for future pregnancy

 Contraindications to hormonal or other medications

 Medical comorbidities

 Patient preferences regarding medical versus surgical and short-term versus long-term
therapy

103
MENOPAUSE

DESCRIPTION:

Menopause is a biological process representing the permanent cessation of menses resulting from
loss of ovarian follicular function. It can occur spontaneously or be induced by medical intervention
(surgery, chemotherapy or pelvic radiation therapy.)

Contraindications:

 history of venous thromboembolic event or stroke, breast cancer, endometrial cancer

uncontrolled hypertension, undiagnosed abnormal uterine bleeding, coronary Heart Disease,
active liver disease, porphyria cutanea tarda,or those at high risk for these complications.
Women older than 60 years and those that are asymptomatic.

 Diabetes mellitus-relative contraindication (control may be affected)

Investigations:

 Mammogram

MANAGEMENT:

Hormone therapy (HT; oestrogen alone (ET) or combined with a progestin (EPT)) is currently
indicated for management of menopausal symptoms. Long-term use for prevention of disease is
no longer recommended. Oestrogen therapy ET (or EPT for women with an intact uterus) to be a
reasonable option for most women in their late 40s or 50s with moderate to severe vasomotor
symptoms,

General principles:

 Women with previous hysterectomy-unopposed oestrogen therapy only.

 Women with an intact uterus-sequentially opposed oestrogen therapy will result in cyclical
bleeding; continuously opposed oestrogen therapy will result in amenorrhoea.

 Treatment should be planned for 5 years but reviewed annually.

Oral unopposed oestrogen: (hysterectomized pts)

 Conjugated equine oestrogen (premarin®) - 0, 3; 0,625; 1,25mg daily. OR

 Estradiol valerate(Estro pause®) 1-2mg daily

Start with lower dose and increase as necessary to relieve symptoms.

Oral sequentially opposed oestrogen with progestogen)

 Estradiol valerate 2mg with cyproterone acetate 1mg and placebo in a 28 day pack
(Climen®)
104
  Conjugated oestrogen0,625mg or 1,25mg with medrogestone 5mg and placebo in a 28 day
pack (Prempak-N®) –where available

 Estradiol 1mg and 2mg with norethisterone acetate 1mg in a 28 day pack (Trisequens
,Kliogest) where available.

Oral continuously opposed oestrogen with progestogen:

Estradiol 2 mg with norethisterone acetate 1mg (Kliogest) taken continuously, no withdrawal

bleeds, not to be used first 2 years after menopause.

Vaginal Oestrogen

Conjugated equine oestrogen (Premarin®) 0,625mg- relief local vaginal symptoms

1-4g daily

Implants, gels, lotions, rings and transdermal patches are not available in public sector.

Follow up

 Review after 1 month and once settled on method after 6 months.

 Then review annually
 Remember to check BP
 Annual mammogram.
 Pap smear as appropriate

105
PRIMARY OVARIAN INSUFFICIENCY:

DESCRIPTION:

46,XX primary ovarian insufficiency is defined as the development of primary hypogonadism

before the age of 40 years in women who have a normal karyotype. The presenting symptoms are
similar to those of menopause.

INVESTIGATIONS:
 pregnancy test-patients with amenorrhoea
 prolactin concentration, exclude hyperprolactinemia
 oestradiol –(Low)
 follicle-stimulating hormone (FSH) -elevated.
 Pap smear
 HIV +- CD4 ,VL

Transvaginal ultrasound /transabdominal -the characteristic ultrasound appearance is enlarged

cystic ovaries.

MANAGEMENT:
 inform the patient of the diagnosis in a sensitive and caring manner, provide accurate
information, and offer referral to appropriate resources for emotional support

 Oestrogen therapy — unless there is an absolute contraindication to taking oestrogen therapy,

women with primary ovarian insufficiency should receive oestrogen therapy to prevent bone
loss (in almost all cases with a progestin, as most of these patients have an intact uterus).

 Lifestyle modification: including exercise, a healthy diet, adequate calcium and vitamin D
intake, and avoiding smoking.

 Treatment until the average age of natural menopause (age 50 to 51 years.)

Treatment:

 0,625mg to 1.25 mg of conjugated equine oestrogen or about 10 mcg of ethinyl oestradiol of 10

mg of medroxyprogesterone acetate per day for the first 12 calendar days of each month.
 Calcium 500mg daily po
 VIT D 800IU daily po.
Some patients may require higher dose of oestrogen to achieve symptom control. Some cases
may even benefit from COC.

After diagnosis made:

 Assess bone mineral density with DXA

 Karyotype
 TFT
 anti-21 hydroxylase antibodies and anti-adrenal antibodies

106
AMENORRHOEA:

There is overlap between primary and secondary amenorrhoea. Amenorrhoea can be considered
in 4 compartments.

OUTFLOW TRACT: imperforate hymen, absent uterus, Ashermans syndrome

OVARIES: Anovulation, Turners Syndrome, menopause

PITUATRY: hyperprolactinaemia, contraceptives, antipsychotic drugs.

HYPOTHALAMUS: anorexia nervosa, athletes, severe stress.

PRIMARY AMENORRHOEA:

DESCRIPTION:

Primary amenorrhea is defined as the absence of menses at age 15 years in the presence of
normal growth and secondary sexual characteristics. Due to this secular trend of an earlier onset
of menarche, some authorities recommend evaluating a girl for primary amenorrhea if her menses
have not occurred by age 15 years. At age 13 years, if no menses have occurred and there is an
absence of secondary sexual characteristics, such as breast development, evaluation for primary
amenorrhea should be begun

Investigations:

1. Pregnancy test

2. Pelvic ultrasound:

 To confirm the presence or absence of ovaries, uterus, and cervix.

 Also useful to look for vaginal or cervical outlet obstruction in patients with cyclic pain.

Uterus absent

 karyotype and measurement of serum testosterone

 These tests should then allow the clinician to distinguish between abnormal müllerian
development (46,XX karyotype with normal female serum testosterone concentrations) and
androgen insensitivity syndrome (46,XY karyotype and normal male serum testosterone
concentrations).

 Patients with 5-alpha-reductase deficiency also have a 46,XY karyotype and normal male
serum testosterone concentrations but, in contrast to the androgen insensitivity syndrome,
which is associated with a female phenotype, these patients undergo striking virilisation at
the time of puberty (normal development of secondary sexual hair, muscle mass, and
deepening of the voice).

107
Uterus present

For patients with normal müllerian structures and no evidence of an imperforate hymen, vaginal
septum, or congenital absence of the vagina, an endocrine evaluation should be performed.

 serum beta human chorionic gonadotropin to exclude pregnancy

 serum FSH

o A high serum FSH concentration is indicative of primary ovarian insufficiency. A

karyotype is then required and may demonstrate complete or partial deletion of the X
chromosome (Turner syndrome) or the presence of Y chromatin. The presence of a
Y chromosome (eg, vanishing testes syndrome, absent testis determining factor) is
associated with a higher risk of gonadal tumors and makes gonadectomy mandatory.

 In addition, evaluation for other diseases associated with the specific type of ovarian
insufficiency should be performed. As examples, congenital heart disease, hypertension,
and hearing loss are common in women with Turner syndrome, while evaluation for
autoimmune thyroid and adrenal disease should be done in all women with autoimmune
oophoritis.

 A low or normal serum FSH concentration suggests functional hypothalamic amenorrhea,

congenital gonadotropin-releasing hormone (GnRH) deficiency, or other disorders of the
hypothalamic-pituitary axis. Cranial magnetic resonance (MR) imaging is indicated in most
cases of hypogonadotropic hypogonadism to evaluate for hypothalamic or pituitary disease.
Cranial imaging is recommended in all women with primary hypogonadotropic
hypogonadism, visual field defects, headaches, or any other signs of hypothalamic-pituitary
dysfunction.

 Serum prolactin and thyrotropin should be measured if FSH is low or normal, especially if
galactorrhoea is present.

 If there are signs or symptoms of hyperandrogenism, serum testosterone and

dehydroepiandrosterone sulfate (DHEA-S) should be measured to assess for an androgen-
secreting tumour.

 Among women who are also hypertensive, blood tests should be drawn for evaluation for
17-alpha-hydroxylase (CYP17) deficiency. The characteristic findings are elevations in
serum progesterone (>3 ng/mL [9.5 nmol/L]) and deoxycorticosterone and low values for
serum 17-alpha-hydroxyprogesterone (<0.2 ng/mL [0.6 nmol/L.

MANAGEMENT:

TREATMENT — Treatment of primary amenorrhea is directed at correcting the underlying

pathology (if possible), helping the woman to achieve fertility (if desired), and prevention of
complications of the disease process (eg, oestrogen replacement to prevent osteoporosis.

 Once a diagnosis has been made, counsel the patient regarding its cause, treatment, and their
reproductive potential.
108
 Psychological counselling is particularly important in patients with absent müllerian structures
or a Y chromosome.

o Creation of a neovagina for patients with müllerian failure is usually delayed until the
women are emotionally mature and ready to participate in the postoperative care
required to maintain vaginal patency.

o In those patients in whom Y chromosome material is found, gonadectomy should be

performed to prevent the development of gonadal neoplasia. However, gonadectomy
should be delayed until after puberty in patients with complete androgen insensitivity
syndrome. These patients have a normal pubertal growth spurt and feminize at the time
of expected puberty; tumours do not usually develop until after this time.

 Women with primary ovarian insufficiency should be counselled (see section of primary ovarian
failure).

 In women with polycystic ovary syndrome (PCOS), treatment of hyperandrogenism is directed

toward achieving the woman's goal (eg, relief of hirsutism, resumption of menses, fertility) and
preventing the long-term consequences of PCOS (eg, endometrial hyperplasia, obesity, and
metabolic defects (refer to section on PCOS).

 Functional hypothalamic amenorrhea can be reversed by weight gain, reduction in the

intensity of exercise, or resolution of illness or emotional stress. For women who want to
continue to exercise, estrogen-progestin replacement therapy should be given to those not
seeking fertility to prevent osteoporosis and heart disease.

OUTLET OBSTRUCTION:

IMPERFORATE HYMEN:

DESCRIPTION:

Primary amenorrhoea with cyclical pain. There may be a pelvic [Link] hymen
appears as a bulging bluish membrane visible at the introitus.

MANAGEMENT:

 Counsel the patient and parent and guardian

 Book patient for incision and drainage under general anaesthetic. Dark viscous fluid will be
drained. Inform patient and caregiver that it is old menstrual blood and it will continue to drain
for about 3 days.

TRANSVERSE VAGINAL SEPTUM:

Presentation is similar to imperforate hymen. The septum however is paler, pinker and more solid
than an imperforate hymen. The septum maybe visible at the introitus or hidden within the vagina.
The patient should be investigated to exclude associated urinary tract abnormalities.

109
MANAGEMENT:

 Counsel patient and caregiver regarding findings and management plan

 Analgesics for pain
 Book patient for incision and drainage.
 The procedure may need to be repeated.

MULLERIAN AGENESIS:

In this condition there is no uterus or cervix. Phenotype appears as normal XX female. On

examination the vagina ends as a blind ending pouch. On investigation the pelvic ultrasound-no
uterus is seen, hormone profile and karyotype is normal. Urinary tract abnormalities may co-exist.

Differential diagnosis:

 Androgen insensitivity
 5 Alpha reductase deficiency
 Androgen synthesis or receptor errors.

MANAGEMENT:

 Counsel the patient on the finding. Particularly attention to infertility and coping with the
diagnosis.

SECONDARY AMENORRHOEA:

Description:

Absence of menses for more than three cycles or six months in women who previously had
menses.

Investigations

 Urinary BHCG-exclude pregnancy

 Serum prolactin -test for hyperprolactinemia),
 follicle-stimulating hormone (FSH) test for ovarian failure ,
 thyrotropin (TSH) to exclude thyroid disease
 If indicated can do androgens- DHEAS( to look for an adrenal source of androgens).If there
is clinical evidence of hyperandrogenism, serum total testosterone should be
measured,SHBG
 If suspected- measure early morning 17-hydroxyprogesterone at the initial visit to rule out
nonclassic 21-hydroxylase deficiency.
 Progestogen withdrawal- Medroxyprogestorone acetate (Provera®) 10mg daily for 5-10
days. About 5-10 days after stopping the medication the pt should have a withdrawal bleed
if the endometrium has been primed with oestrogen and if there is an intact outflow tract.
Positive test: demonstrates an oestrogenised and suggests anovulation as a cause.
Negative test- requires further evaluationof the hypothalamus and ovary
 Karyotype when indicated.
 Pelvic Ultrasound

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MANAGEMENT:

The management of patient is directed to the primary pathology.

Eating Disorders/stress/athletes

Multidisciplinary team approach –weight gain, dietician, psychiatrist, social worker

Mainly psychotherapy.

ASHERMAN SYNDROME: (Intrauterine adhesions)

Diagnosis:

 History of previous curettage after pregnancy or miscarriage.

 Examination and hormone profiles are normal.
 Negative progestogen challenge
 Diagnosis can be confirmed on hysteroscopy and hysterosalpingogram.

MANAGEMENT:

Hysteroscopic resection of adhesions, followed by insertion of an IUCD

High oestrogen oral contraceptive pill (Ovral®).

PCOS-refer to chapter on PCOS page

CHROMOSOME ABNORMALITIES

 Learn to recognise the cardinal features for each condition-Turners syndrome, androgen
insensitivity, ovarian dysgenesis etc

 Physical examination and blood test may be helpful too.

 Karyotyping is essential for accurate diagnosis.

MANAGEMENT

Refer patient to specialist endocrine clinic.

PRIMARY OVARIAN FAILURE:

Diagnosis:

 Menopause before the age of 40.

 FSH levels > 40IU/Lon 2 occasions 4 weeks apart.

 If LH > FSH, an FSH > 15 may be pre-ovulatory surge, therefore repeat after 1 week.

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MANAGEMENT:

Refer to section on primary ovarian failure.

PROLACTINOMA:

Diagnosis

 Patients may present with galactorrhoea or menstrual abnormalities

 Increased levels of prolactin may occur with pregnancy, hypothyroidism, and drugs.
 If due to tumour,-more than 90% are microadenomas(<1cm)
 Ask about pressure symptoms, headache and visual disturbances
 Arrange for CT scan of the brain (some cases may require MRI brain).
 Arrange for visual field testing.

MANAGEMENT:

 Counsel the patient

 Refer to endocrine clinic at Greys or Edendale Hospital according to referral pattern
 Individulaise management according to patient’s needs.-fertility, menstrual cycle control or
control of galactorrhoea.
 Bromocriptine(Parlodel®) –first line
 Start with 1,25mg nocte for 3 days then 2,5mg nocte for 3 days the 2,5mg twice
daily with meals.

 Follow up monthly, the prolactin levels should reduce.

 The dosage can slowly be increased up to 30mg daily-rare

 Watch for side effects-nausea,postural hypotension and dizziness.

 Second line-consultant prescribed Carbegoline (Dostinex®)

 Start with 0,5mg weekly, increase up to 1mg weekly-rarely to 4 mg weekly.

 Follow up monthly for prolactin levels.

 If patient on treatment for prolactinoma reports amenorrhoea-exclude pregnancy.

 Patients not desirous of fertility should be offered contaceptio(COC or injectable progestogen)

DELAYED PUBERTY:

 Reassurance and refer to endocrine clinic.

NEUROLOGICAL DISORDERS

Refer to neurologist.

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HIRSUTISM:

DESCRIPTION:

Hirsutism, defined as excessive male-pattern hair growth, affects between 5 and 10 percent of
women of reproductive age. It is a distressing endocrine and cosmetic condition associated with
significant psychological morbidity. Hyperandrogenism is the underlying disease in most cases
and polycystic ovarian syndrome is the commonest cause. About 90% of cases of hirsutism is
idiopathic and require no more than symptomatic treatment and reassurance. If the patient does
not have idiopathic hirsutism she has to be referred to the gynae endocrine clinic.

INVESTIGATIONS:

 Screening for serum total and free testosterone.

- Concentrations >5 nmol/l should prompt further tests of adrenal function
- a level of 2-5nmol/L suggests PCOS.
- a level >6nmol/L suggests an androgen secreting tumour.
 17 hydroxyprogesterone levels if congenital adrenal hyperplasia is suspected.
 CAH is diagnosed by the short synacten test in which 17-OHP and cortisol are measured
before and one hour after a single dose of 250 mg of synthetic ACTH.
 Estimation of 24 hours’ free urine cortisol or the low-dose dexamethasone suppression test
screens for Cushing’s syndrome.
 Women with irregular menses and hirsutism should be screened for thyroid dysfunction and
prolactin disorders.
 TSH screen for thyroid function is indicated if alopecia is present.
 Serum prolactin estimation is indicated galactorrhoea is present.
 Ultrasound of the pelvis diagnoses PCOS and ovarian masses.
 Ovulatory dysfunction should be excluded by estimation of luteal phase progesterone in
women with regular cycles.
 Take blood for DHEAS
- Slightly raised level suggests PCOS
- A markedly increased level suggests Cushings Syndrome.

MANAGEMENT:

Psychological therapy

 Counsel the patient on condition and combination management plan.

Lifestyle modification

 Obesity significantly exacerbates the severity of hirsutism. Women with a body mass index of
>30 kg/m2 should embark on a weight-loss programme as an adjunct to other therapies.

 Counselling regarding lifestyle changes should include healthy eating habits, moderate daily
exercise, and weight loss. The latter decreases serum insulin levels, ovarian androgen
production, and the conversion of androstenedione to testosterone. Obese women with PCOS
who lose >5% of their initial body weight have a significant improvement in biochemical profile,
including a reduction in free testosterone, an increase in SHBG, and an improvement in
Ferriman–Gallway scores.

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Non-medical measures –not provided by the hospital

 Mechanical and cosmetic control of hirsutism

Shaving, bleaching, plucking or chemical depilation may remove unwanted hair but should be
considered as complementary to other treatments. Shaving does not lead to a worsening of
hirsutism, but shaving (and other cosmetic measures) may result in folliculities, pseudofolliculities
and ingrown hair.

 A combination of electrolysis and thermolysis (‘blend technique’)

May produce good results. Efficacy is 15–50% permanent hair loss with repeated treatment.

 Laser hair removal

Laser hair removal is safe and effective, but a course of treatment is necessary and the best
results are in fair-skinned patients with dark hair. Alternative approaches are needed for non-
pigmented hair. The side effects of Nd:YAG laser therapy are uncommon and include blistering,
(usually short-lived), pigmentary disturbances (2.4% of patients) and scarring (0.2%).

Refer to level 2 or 3 individualise each case.

MEDICAL MANAGEMENT:

The goal of medical therapy is to reduce the time spent mechanically removing unwanted hair.
This goal must be clearly discussed with the patient to prevent unrealistic expectations.

1. The combined oestrogen-progestin (OCP) contraceptive pills

2. Medroxyprogesterone acetate can produce good results if OCP is contraindicated. Regimens

include a three-monthly dose of 150 mg (i.m.) or a dose of 10–20 mg (p.o.) per day.
Observable decrease in hair growth may not be obvious for ≤6 months because this depends
on the hair growth [Link], previously established hair growth will not disappear with
hormone treatment alone. Hair can be removed using mechanical and cosmetic methods. The
effect of hormone treatment (prevention of new hair growth) may not be apparent unless the
previously established hair is removed.

3. Long-term use of insulin-lowering agents such as metformin at a dose of 850 mg b.d. control
hirsutism in overweight hyperandrogenic women with PCOS.

4. Consultant driven- Gonadotropin-releasing hormone (GnRH) agonists-Up to three months’

of treatment may be required for the full suppressive effects of the agonists to occur; therapy is
usually combined with OCP or an androgen receptor-blocking agent.

5. Cyproterone acetate (CPA) -androgen receptor-blocking agents

6. Spironolactone

- Initially 200 mg daily X 6 months then 25-50mg daily as maintenance

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7. Flutamide.
- 250 mg daily X 6 months (Monitoring of liver function at regular intervals is essential)
8. Finasteride
- 5 mg daily po treats hirsutism. (Women of childbearing age using finasteride should use
contraception due to the potential risk of feminization of a male fetus.)
9. Efflornithine
-Local application of efflornithine hydrochloride 13.9% cream to facial hair slows overall growth
and makes hair softer. Twice daily application produces marked improvement.

CONDITIONS CAUSING HIRSUTISM:

TESTOSTERONE SECRETING TUMOURS:

DIAGNOSIS

 These are rare but serious

 Include- androblastomas, arrhenoblastomas, lipid cell tumours, thecomas and luteomas.
 Onset of hirsutism is sudden and marked and virilism is frequent.
 Serum testosterone level will be >7nmol/L
 Ultrasound scan may show tumour (not always)-then a CT or MRI will be beneficial.

MANAGEMENT:
-Surgery

CUSHINGS SYNDROME/DISEASE

DIAGNOSIS
 Cushings Syndrome is caused by an adrenal adenoma or other cortisol producing tumour.
 Cushings disease is caused by pituitary ACTH –producing tumour.
 Cushingoid features, hirsutism and hypertension are frequent
 .Early morning cortisol (>620nmol/L) is diagnostic.

MANAGEMENT:

Refer to medical endocrine clinic to specialist physician.

CONGENITAL ADRENAL HYPERPLASIA:

DIAGNOSIS:
 Atypical maturity onset variant presents with hirsutism,primary or secondary amenorrhoea.
 May also have virilism or ambiguous genitalia.
 A 17-hydroxyprogesterone level >20nmol/L may be found.
 17-hydroxyprogesterone may rise only in response to ACTH stimulation.

MANAGEMENT:
Refer to endocrine clinic
Low dosse oral dexamethasone is the mainstay of medical treatment.

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5 ALPHA REDUCTASE DEFICIENCY

DIAGNOSIS
 Rare condition
 Presents with amenorrhoea, hirsutism or virilism.
 There is mullerian agenesis.
 Testosterone level >6nmol/L, with an XY karyotype.

MANAGEMENT:
 Refer to gynae endocrine clinic.
 Will require gonadectomy.

PRECOCIOUS PUBERTY:

Description:

Menstruation before the age of 10myearsor development of secondary sexual characteristics

before the age of 8 years. Most cases are idiopathic (constitutional). Other causes are hormone
secreting tumours,cerebral tumours,McCune Albright Syndrome,pevious head injury,meningitis
amd accidental ingestion of hormone preparations.

INVESTIGATIONS:

 Radiography of the left hand and wrist enables determination of the bone age.
 Basic hormone profile, ultrasound, skull X-ray.
 Abdominal and pelvic ultrasonography, though operator dependent, can provide useful
information on uterine maturation, adrenal and ovarian tumours or ovarian cysts.
 Abdominal CT is warranted when the presentation is suggestive of an adrenal
tumour.
 MRI assessment of the pituitary gland and brain
 Sex steroids including serum testosterone and oestradiol concentrations should be measured
depending on the presentation.
 If there are signs of virilization, blood samples should be taken for unstimulated
 17-hydroxyprogestone, androstenedione and DHEAS assessment, and a urinary steroid profile
obtained.
 Thyroid function tests and serum prolactin levels.
Note: Children with GnRH-dependen causes have pubertal levels of FSH, LH, and sex hormones
and have a pubertal LH response to the GnRH stimulation test. Children with

GnRH-independent precocious puberty has elevated estradiol levels despite low or prepubertal
levels of FSH and LH; there is usually no LH response to GnRH stimulation.

These initial laboratory tests can therefore indicate a central versus a

peripheral aetiology.

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MANAGEMENT:
 Refer to endocrine clinic
 Treatment is directed at cause.
 GnRh analogues. Treatment should be stopped when the child reaches an age at which
puberty is acceptable.
 Careful counselling, involve social worker for further counselling.
 Hypothyroidism is treated with a gradual introduction of thyroxine
 Non-classical CAH with hydrocortisone and, if indicated, fludrocortisone.
 Aromatase antagonists such as letrozole and anastrozole have been used in
girls with conditions such as McCune–Albright syndrome.

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POLYCYSTIC OVARIAN SYNDROME:

DESCRIPTION:

Polycystic ovary syndrome (PCOS) is one of the most common complex and heterogeneous
endocrine disorder in women with uncertain aetiology. The syndrome is associated with a wide
range of symptoms and the diagnosis is based on the Rotterdam criteria.

INVESTIGATION:

 FSH
 LH
 Testosterone
 Sex hormone binding globulin
 Free androgen index(FAI)
 Fasting insulin
 Prolactin
 Diabetes screen
 Screen for dyslipidaemia.

Possible findings in PCOS:

 Elevated serum concentration of LH, LH: FSH ratio 2 and hyperinsulinaemia. Increased
Testosterone >2.5 nmol/l (~70%), increased Free androgen index (FAI) >5 (~75%) and
decreased sex hormone binding globulin (SHBG) (~50%) may be seen in women with
[Link] features of increased insulin (>20 mU/ml) and increased blood prolactin.

The FAI is a simple method of estimating the circulating free testosterone and is calculated as:
FAI ¼ [total testosterone] divided by [SHBG] x 100.

 Ultrasound- The criteria fulfilling sufficient specificity and sensitivity to define PCO are the
following: ‘presence of 12 or more follicles in each ovary measuring 2- 9 mm in diameter,
and/or increased ovarian volume (>10 cm3)’. Only one ovary fitting this definition is sufficient to
define PCOS’

MANAGEMENT:

Refer patient to regional or tertiary hospital for further management.

 Life style interventions: lifestyle management (single or combined approaches of diet,

exercise and/or behavioural interventions) for weight loss, prevention of weight gain or for
general health benefits should be recommended in women with PCOS.

 Lifestyle management targeting weight loss (in women with a body mass index (BMI) >25
kg/m2 (overweight/obese)) and prevention of weight gain (in women with a BMI 18.5-24.9
kg/m2 (lean)) should include both reduced dietary energy (caloric) intake and exercise
should be first line therapy for all women with PCOS.

 Involve dietician and physiotherapy to assist in weight loss and exercise programme.

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  Identify what the current needs of the patient are? What is the most pressing problem? Eg
irregular menses or hirsutism, or depression, not desirous of fertility and desirous of fertility.

 Address the most pressing problem.

DESIRE FOR FERTILITY:

 Patients must be encouraged to lose weight. Weight loss of just 5-10% has been shown to
reverse the deleterious effects of obesity on ovarian function and can restore reproductive
function in a majority of women within 6 months of weight reduction.

 Pharmacological ovulation induction should not beoffered as first line therapy in women with
PCOS who are morbidly obese (BMI 35 kg/m2) until they lose weight.

 Clomifene citrate (CC) should be the first-line pharmacological therapy.

 CC 50mg from day 2 of cycle x 5 tablet daily po , increase by 50 mg increments

in subsequent cycles until ovulation is achieved.

 The treatment with doses up to 150 mg is reasonable before considering

alternatives.

 Alternative to CC – tamoxifen citrate

 As for CC start on day 2 of cycle x 5 days starting dose of 20 mg that can be

increased to 40 mg and then 80 mg in subsequent cycles if ovulation is not
achieved.

SECOND LINE:

 In women with PCOS who are CC resistant, metformin can be combined with CC to improve
fertility outcomes. Target dose of 1500-2550 mg per day in divided doses.

 Letrozole for 5 days from day 2 of menstrual cycle at doses of 2.5- 7.5 mg per day with 2.5 mg
increments.

SURGICAL MANAGEMENT OF INFERTILITY IN PCOS:

Laparoscopic ovarian drilling (LOD)

Indication: LOD is a second line of therapy for women with PCOS, who are either CC resistant or
do not conceive.

Assisted reproduction techniques: IVF –are not offered in the Pietermaritzburg complex.

PATIENTS NOT DESIROUS OF FERTILITY

 Can be placed on COC to regulate menses, treat acne and hirsutism.

 REFER TO CHAPTER ON HIRSUTISM.

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 Counselling for these patients is very important as they often have much psychological
morbidity relating to body habitus, obesity, hirsutism, etc. Refer to social worker /psychologist
for support as necessary.

 They should receive appropriate counselling with regard to the long term sequelae of the
condition-diabetes mellitus, dyslipidaemia, and cardiovascular risk. Life style changes therefore
should be a lifelong endeavour and not just while trying to conceive.

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INFERTILITY:

DESCRIPTION:

Infertility is defined as failure by a couple to conceive after a year of regular unprotected sexual
[Link] affects approximately 10% of the population with variable
[Link] it is not an identifiable physical disease, its psychological impact on the
affected couple can be severe and can lead to social disability. The doctor needs to be tactful and
sensitive in his/her investigation of

INVESTIGATIONS:

The decision to investigate the patient will depend on the suitability and prognosis. In general
patients UNDER 35 with no obvious gynaecological pathology may be investigated.

Baseline tests

 pap smear
 screening for STIS
 Tests of ovulation- day 21 progesterone. Irregular menstrual cycles, it can be difficult or
impossible to time a mid-luteal progesterone assay. For this group, anovulation should be
suspected therefore, assays of follicle stimulating hormone (FSH) and luteinizing hormone (LH)
should be obtained. Serum progesterone levels >30 nmol/L are considered as diagnostic of
ovulation and the chance of a luteinised unruptured follicle in this situation is unlikely.
 tubal patency- tests for tubal patency are hysterosalpingogram and laparoscopy and dye test (
the preferred choice)
 Endocrine tests for PCOS as appropriate.
 Assays of prolactin, or thyroid function tests are not routine part of basic subfertility.
 In the presence of oligo/amenorrhoea, careful history taking and other hormonal investigations
should be carried out, including the measurement of serum levels of prolactin, androgens, sex
hormone-binding globulin and gonadotrophins, and thyroid function tests.
 All patients should have an HIV test ,+- CD4 /VL as indicated according to national guidelines
.
MALE FACTOR ASSESSMENT:

 The partners of an infertile couple should be investigated together, and it is sensible to start
with semen analysis

 At least two semen analysis tests should be carried out to minimise the effect of the
confounding variables on the semen analysis results. If an abnormal smear is obtained another
semen analysis should be repeated after 3 months.

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MANAGEMENT

 Refer to Greys or Edendale hospital according to referral patterns.

 Care is individualised according to problem identified
 General lifestyle advice should be offered on the effects of obesity, cigarette smoking,
occupational hazards, and alcohol or recreational drug misuse on fertility.
 Well selected patients with fibroids which distort the uterine cavity may benefit from
myomectomy.
 The body mass index (BMI) of the female partner is important as being over- or under-weight
can influence fertility. Weight normalisation prior to embarking on a pregnancy is important to
avoid the obstetric and foetal complications inherent in obesity
 Most professional bodies advise against offering treatment to obese women with a BMI >30.
 Women, who are planning a pregnancy, including fertile women, should take folic acid due to
its proven value in reducing neural tube defects.
 Advise on coital technique and timing around ovulation.
 Currently assisted reproduction or In-vitro fertilization is not offered in any KZN public hospital.
Patients that can afford this service can be referred to the private sector.
 Patients should be carefully counselled, be honest and empathetic.
 Mention alternatives such as adoption.
 Refer to social worker for further counselling.
 Do not bring patients back repeatedly if nothing can be done for them.

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FIBROIDS

A fibroid is a benign tumour of composed of smooth muscle interlaced with fibrous strands. Also
referred to as leiomyomata, fibromyoma or myoma. Uterine fibroids are the commonest tumour of
the female reproductive tract and occur in approximately 25% of women of reproductive age.

INVESTIGATIONS:

 VCT as for all patients, +- CD4/VL as indicated as per guidelines.

 FBC,U&E
 Pelvi-abdominal ultrasound.
 Pap smear.

MANAGEMENT

 Counsel the patient on findings.

 Patients with small fibroids that are asymptomatic can be managed expectantly.

Medical management:

 Treatment of heavy bleeding –refer to chapter on Abnormal uterine bleeding. Optimise

haemoglobin-individualise according to clinical situation; haematinics vs blood transfusion.

 Pain control-consider Paracetomol + ibuprofen combination. Carefully assess if pain not

occurring in the background of PID or torsion of a pedunculated fibroid.

 GNRHa-these can reduce the size of fibroids by as much as 50% , reduce menstrual flow,
pelvic pain and dysmenorrhoea. This is not for routine use and should not be prescribed at a
district level.

 Goserelin (Zoladex®) 3,6mg imi monthly X 3.

Surgical management:

Consider hysterectomy:

 Request from patient

 Patients with heavy bleeding that require blood transfusion.
 Patients that fail medical management.
 Symptomatic patients-pain and pressure symptoms
 Very large fibroids-particular fibroids larger the uterus.>14 weeks.
 Completed families.
 When there is doubt regarding the nature of the fibroid ie malignancy suspected.
 Sudden enlargement of fibroid.

 Carefully selected patients still desirous of fertility may be considered for myomectomy. These
patients should be counselled well as there remains a risk for hysterectomy.

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ENDOMETRIOSIS:

DESCRIPTION:

Endometriosis is defined as the presence of endometrial-like tissue outside the [Link] some
women with endometriosis experience painful symptoms and/or infertility, others have no
symptoms at all.

Diagnosis is based on history, symptoms and signs; and is corroborated by physical examination
and imaging techniques, and finally proven by histology of either a directly biopsied vaginal lesion,
from a scar, or of tissue collected during laparoscopy

INVESTIGATIONS:

Individualise according to history and examination findings.

 HIV-CD4,VL

 Pap smear according to national guidelines.

 FBC

 US pelvis

MANAGEMENT:

MEDICAL:

 Analgesics-NSAIDS

 Oestrogen progestogen combined –cyclic or continuous

 Progestogen-injectable or oral.

 Counselling and support

At regional or teriary hospital-antiprogestins, danazol,GnRHa with add back.

SURGICAL:

Laparoscopy biopsy remains gold standard in identification, histological confirmation and

treatment of endometriosis.

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URINARY INCONTINENCE:

Urinary incontinence (UI) can affect women of all ages, with a wide range of severity and nature.
UI may seriously influence the physical, psychological and social wellbeing of affected individuals.

DEFINITIONS:

URINARY INCONTINENCE (UI):

UI is defined by the International Continence Society as 'the complaint of any involuntary leakage
of urine'.

STRESS UI :

Is involuntary urine leakage on effort or exertion or on sneezing or coughing.

URGENCY UI:

Is involuntary urine leakage accompanied or immediately preceded by urgency (a sudden

compelling desire to urinate that is difficult to delay).

MIXED UI :

Is involuntary urine leakage associated with both urgency and exertion, effort, sneezing or
coughing.

OVERACTIVE BLADDER (OAB)

Is defined as urgency that occurs with or without urgency UI and usually with frequency and
nocturia. OAB that occurs with incontinence is known as 'OAB wet'. OAB that occurs without
incontinence is known as 'OAB dry'.

INVESTIGATIONS:

 Urine dipstix
 U MC&S
 Glucose reading
 bladder diary x 3 days
 intravenous pyelogram/ VCU-if suspect fistula

MANAGEMENT:

Indications for immediate referral:

 presence of: associated abdominal or pelvic pain

 haematuria in the absence or urinary tract infection
 new neurological symptoms in addition to incontinence
 complex neurologic conditions (eg, Parkinson disease)
 suspected vesicovaginal fistula
 severe pelvic organ prolapse
 urinary retention
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  Encourage women to complete a minimum of 3 days of the diary covering variations in their
usual activities, such as both working and leisure days.
 Undertake a urine dipstick test in all women presenting with UI to detect the presence of
blood, glucose, protein, leucocytes and nitrites in the urine.
 Prescribe an appropriate course of antibiotic treatment pending culture results
 Contributory factors such as medical conditions and medications should be addressed
before proceeding with the treatment approach described here
 Dietary changes — some foods and beverages are thought to contribute to bladder
leakage, it is reasonable to see if eliminating one or all of these items is helpful.
●Alcoholic beverages
●Carbonated beverages (with or without caffeine)
●Coffee or tea (with or without caffeine)
 Women with urinary incontinence need to be advised about fluid management, including not
drinking too much before bedtime.
 Adequate, but not excessive fluid intake during the day (up to two liters), is advised. Older
individuals with incontinence should not be severely fluid restricted, given the potential for
adverse events, such as dehydration and hypotension.
 Advise women with UI or OAB who have a BMI greater than 30 to lose weight.
 Behavioural treatments (bladder training and pelvic muscle exercises [PME]) are effective for
urgency, stress, and mixed urinary incontinence, and may help patients with overactive bladder
symptoms, with or without incontinence.

Bladder Training for urgency:

 Offer bladder training lasting for a minimum of 6 weeks as first-line treatment to women with
urgency or mixed UI.

Patients are instructed to stand still or sit down when urgency occurs and to concentrate on
making urgency decrease by taking a deep breath and letting it out slowly, contracting their pelvic
muscles and/or visualizing the urge as a "wave" that peaks and then falls. Once they feel in control
of the urgency, they should walk to a bathroom and void. When the patient can go two days
without leakage, the time between scheduled voids is increased by 30 to 60 minutes, and this
process is continued until the patient is voiding every three to four hours without urinary
incontinence or frequent urgency. Successful bladder training takes several weeks. Patients often
need reassurance to proceed despite initial lack of response.

Pelvic muscle exercises

Offer a trial of supervised pelvic floor muscle training of at least 3 months duration as first-line
treatment to women with stress or mixed UI. Pelvic muscle (Kegel) exercises strengthen the
muscular urethral closure mechanism, and they are effective for urgency, stress, and mixed
incontinence, as well as for pregnancy-related urinary incontinence. The basic recommended
pelvic muscle exercises regimen consists of three sets of 8 to 12 slow velocity contractions
sustained for six to eight seconds each, performed three or four times a week and continued for at
least 15 to 20 weeks.

Pessaries

Continence pessaries may be used for women with stress incontinence as an adjunct or
substitute for pelvic muscle exercises. Treatment of stress urinary incontinence with a vaginal
pessary is inexpensive, effective, and safe
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SUBSEQUENT TREATMENT —

 Treat initially with lifestyle changes and behavioural therapy for three months before
considering pharmacologic therapy. If initial treatment of urgency, urgency-predominant mixed
urinary incontinence, or overactive bladder symptoms is ineffective, a trial of pharmacologic
therapy can be commenced. Most antimuscarinics are similarly effective. The choice of
antimuscarinic is based upon patient comorbidities, drug-drug interactions and availability in
your centre.

 Antimuscarinics do not have a role in women with stress urinary incontinence. For women with
stress urinary incontinence who have not achieved their continence goals with initial therapy,
intensify modification of lifestyle factors and behavioural therapy, or refer for consideration of
surgical treatment. Antimuscarinics can take up to four weeks to reach their full efficacy. Offer
one of the following choices first to women with OAB or mixed UI:

 oxybutynin (immediate release) (ditropan®) 2,5 bd ,increase to 5mg 2-3 x daily

maximum 5mg 4 x day. or

 tolterodine(detrusitol®) 2/4mg daily (immediate release), or

 darifenacin (enablex®)(once daily preparation).7,5mg daily-increase after 2

weeks to 15mg daily if response inadequate

 Use vaginal estrogen to treat urinary incontinence only if the patient has concurrent symptoms
of vaginal atrophy. Premarin cream® 0,625mg -1g daily local application

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URINARY FISTULA:

Most common-Vesico vaginal fistula. Fistulae present with continuous urine leakage.

In history taking, establish the events that preceded and caused the fistula.

Causes:

• Obstetric fistulae; Obstructed labour

• Post-surgical-caesarean section, hysterectomy

• Malignancy-cancer of cervix

• Radiation therapy

EXAMINATION:

General, abdominal and vaginal examination

Speculum- identify leakage

Dye test/ three swab test

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PELVIC ORGAN PROLAPSE:

DESCRIPTION:

Pelvic organ prolapse (POP), the herniation of the pelvic organs to or beyond the vaginal walls, in
women is diagnosed using pelvic examination.

Investigations

 Guided by history.
 Urine dipsticks +- U MC&S
 HIV,+- CD4 and VL
 Pap smear

The Baden-Walker Halfway Scoring System is the next most commonly used POP staging
system. The degree, or grade, of each prolapsed structure is described individually (eg, grade 1
anterior vaginal wall prolapse or grade 3 uterine prolapse). The grade/degree is defined as the
extent of prolapse for each structure noted on examination while the patient is straining.

The system has five degrees/grades [For the urethra, posterior descent is graded, for other
anatomic sites, the lowest part is graded:

 0 – Normal position for each respective site

 1 – Descent halfway to the hymen

 2 – Descent to the hymen

 3 – Descent halfway past the hymen

 4 – Maximum possible descent for each site

MANAGEMENT:

 Refer to Regional( Edendale) or tertiary hospital(Greys Hospital) according to your referral

pattern

Management includes conservative treatments and surgery. Treatment is based on symptoms,

severity of prolapse and the general condition of the patient.

CONSERVATIVE:

 Many patients present with mild symptoms that are not bothersome and only require
reassurance.

 Occasionally patients can present with stage 3 or 4 prolapse and remain relatively
asymptomatic. These patients are at increased risk of voiding difficulties, decubitus ulcer
formation and rarely evisceration. Treatment is recommended in these cases to avoid these
complications.

 General measures-weight loss, stop smoking, treatment of constipation, avoid high impact
exercise.

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Pessaries:

 Short term-while awaiting definitive management.

 Long term-elderly patients or patients that are too high risk for a surgical procedure and/or
anaesthetic.

 Patients who decline surgical intervention.

 Minor complications from pessary use include bleeding, discomfort and discharge, which may
be offensive. Major complications such as incarceration and vaginal fistulae are rare and are
often due to neglected pessaries. It is important, therefore, that pessaries are changed
regularly.

SURGICAL

 Surgery is indicated in patients who desire sexual function, patients with posterior prolapse or
patients with stress incontinence.

 Support pessaries such as a ring pessary, and the space filling shelf pessary can be used.

 Shelf pessaries are useful for severe degrees of prolapse and in post-hysterectomy prolapse.
Pessaries may not suit everyone and several trials may be needed to get the right size.

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GYNAE- ONCOLOGY

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GYNAE-ONCOLOGY PROTOCOLS – REFERRAL TO GREY'S HOSPITAL

GENERAL

1. Strictly on booking-only basis · [Clinic contact details (033) 8973353/4]

2. If for emergency, please speak to Registrar covering Gynae-Oncology
3. If workup incomplete, patients will be sent back to complete the workup with a letter
explaining what the problem is, and when the next appointment has been set.
4. All patients referred back will be given a letter from Grey's Hospital explaining the plan of
treatment for the patient.
5. Escorts are NOT to leave patients in clinic. Escorts to inform Sisters at relevant stations
where they will be going and how they can be contacted. All escorts have to check on
patients intermittently.
6. NO TRANSPORT TO LEAVE ANY PATIENT UNLESS ESCORT INFORMED BY THE
CLINIC STAFF OF ADMISSION
7. If any concerns regarding instructions please contact one of the Gynaecology Consultants.

ALL PERIPHERAL HOSPITALS WORKUP OF PATIENT

1. Cancer of Cervix

A. Histological confirmation (formal print-out). NOT Pap smear report

B. BLOOD TEST
o FBC, U&E, RPR, LFT
o HIV and CD4 count if positive
C. RADIOLOGICAL EXAMINATION
o Abdominal Ultrasound [Bladder, Ureters, Kidneys & Liver] and
o Pelvic Ultrasound
o Chest-X-ray
D. 24 hour urine creatinine clearance

NB All macroscopic lesions must be biopsied Once above results obtained patient to be booked
with Grey's Gynae-oncology Clinic on (033) 8973353/4

2. Cancer of Vulva

A. Histology Confirmation
B. Pap smear
C. FBC, U&E, LFT
D. HIV and CD4 count if positive
E. Chest-X-ray
F. Ultrasound Abdomen, if available
G. FNAB of palpable inguinal lymph nodes

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3. Suspected Ca Endometrium

A. Do pipelle [endometrial sampling]

B. Histology Confirmation
C. FBC, U&E, LFT, Chest-X-ray, U/S abdomen & Pelvis
D. HIV and CD4 if positive

4. Suspected Ca Ovary

A. FBC, U&E, LFT, CA 125, Chest-X-ray, U/S abdomen & Pelvis

B. HIV and CD4 if positive

Discuss with Gynae-oncology Registrar for prompt consultation & admission

5. Gestational Trophoblastic Dx

A. If suspected/confirmed
B. FBC, U&E, LFT, BHCG, TFT,
C. HIV and CD4 if positive
D. Chest-X-ray, US of Pelvis and Abdomen

Discuss with Greys Gynae Registrar or MO for prompt consultation and admission

SUGGESTED PROTOCOL FOR MANAGEMENT OF GYNAECOLOGICAL PRENEOPLASIA

AND MALIGNANCIES IN REGIONAL/TERTIARY CENTER

1. MANAGEMENT OF VIN LESIONS

a. Colposcopy of the lesion with biopsy
b. Surgical excision if lesion is focal
c. Excision and laser therapy is lesion is multi-focal and/or involving the clitoral area
d. Cautery for smaller lesions or if laser not available

2. MANAGEMENT OF VAIN LESIONS

a. Colposcopy and biopsy to confirm diagnosis
b. Lesions maybe situated at the apex of the vagina, posterior,anterior or lateral walls
of the vagina
c. Excision of the vaginal cuff for apical lesions
d. Excision using the LLETZ loop for focal lesions with cautery or laser of the edges

3. MANAGEMENT OF CIN LESIONS

a. Colposcopy of the cervix
b. Local ablative therapy for lesions satisfactorily seen with the colposcope
i. LLETZ
ii. Cautery
iii. Laser
iv. Cold coagulation
v. Liquid Nitrogen therapy
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 c. Cone biopsy for unsatisfactory lesions
d. Pregnancy:
i. Colposcopy initially at diagnosis to exclude invasive lesions
ii. If no invasive lesions are present, colposcopy/cytology every 3 months for the
duration f the pregnancy
iii. Biopsy in theatre only if an invasive lesion is seen
iv. Colposcopy and definitive therapy as in 3b) above 2 months post delivery
v. Caesarean section only for obstetrical reasons
vi. Unsatisfactory lesions at colposcopy needs cone biopsy or wedge biopsy in
theatre with a cerclage if the cone biopsy is performed between 14 and 28
weeks of pregnancy

4. VULVAL CANCER
a. WORKUP
i. Blood: FBC, UE, LFT, HIV/CD4/VL
ii. CXR
iii. US Abdomen
iv. GFR for advanced lesions needing chemotherapy
v. Stage I/II FIGO lesions:
1. Wide local excision of the vulval lesion
2. Inguinal lymph node dissection (bilateral if primary lesion is central)
3. Chemo-XRT for positive margins or if nodal metastases
vi. Stage III/IV lesions
1. Individualised treatment depending on performance status
2. Chemo-XRT
3. Palliative XRT or symptomatic treatment for patients with poor
performance status
b. VAGINAL CANCERS
i. Workup as in 4a) above
ii. Stage 1 lesions excision with chemo-XRT
iii. Stage 11-1v lesion chemotherapy
c. CERVICAL CANCER
i. Workup
ii. Stage1-11a lesions-
1. Simple hysterectomy or cone biopsy if pregnancy desired for Stage
1a1 lesions
2. Wertheims hysterectomy and pelvic lymph node dissection for Stage
1a2 lesions
3. Meigs Radical hysterectomy with pelvic lymph node dissection
iii. Chemo-XRT if lymph nodes are positive
iv. Stage 11b-Iva: Chemo-XRT
v. Stage IV: Palliative XRT or symptomatic treatment if performance status is
poor
vi. Radical Trachelectomy with pelvic lymph node dissection if the lesion is 2cm
in size or less and if pregnancy is desired
vii.

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5. ENDOMETRIAL CANCERS

a. ADENOCARCINOMAS
i. Workup
ii. Vaginal hysterectomy for patients with morbid obesity
iii. TAH BSO for patients with high-risk for prolonged anaesthesia due to medical
conditions
iv. Primary XRT if surgery is contra-indicated on the grounds of medical reasons
or age
v. TAH BSO with pelvic/par-aortic lymph node dissection if high-risk factors are
present in the tumour
vi. Cheo-XRT if the lymph nodes are positive
vii. Adjuvant XRT alone if the nodes are negative but high-risk factors in the
tumour
viii. Adjuvant chemotherapy for all Serous Papillary/Clear cell histology

b. CARCINOSARCOMAS
i. Workup including CT scan Chest/Abdomen and pelvis
ii. TAH BSO is there are no nodal spread followed by pelvic radical XRT

6. OVARIAN CANCERS

a. Epithelial Ovarian Cancers

i. Work-up
ii. Staging laparotomy: TAH BSO, Appendectomy and omentectomy if the
patient is assessed as having resectable disease
iii. Neoadjuvant chemotherapy for irresectable disease followed by definitive
surgery
iv. Chemotherapy for all patients with Stage ≥ 1aG3
b. GERM-CELL TUMOURS
c. Usually occurs in infancy, childhood, adolescence and young adults
d. Preferably unilateral salpingecto-oophrectomy for unilateral lesions for most GCTs
e. Adjuvant chemotherapy for all advanced GCTs
f. XRT for treatment failures

7. GESTATIONAL TROPHOBLASTIC DISEASE

a. MOLAR PREGNANCY
i. Work-up including TFTs, HCG, Rhesus and coagulation screen
ii. Ultrasound of pelvis to exclude myometrial invasion
iii. Suction evacuation of the uterus for non-invasive lesions
1. Check histology results to exclude incidental choriocarcinoma
2. Serial HCG levels to ensure resolution of molar tissue
3. Chemotherapy for patients if HCG levels plateau, rise or fail to become
negative by 6 months post suction evacuation
iv. Primary chemotherapy for invasive molar pregnancies or choriocarcinomas

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b. CHORIOCARCINOMA
i. CT Brain if chest metastases are present
ii. Primary chemotherapy (Regime depends on scoring and FIGO stage)
iii. Surgery for isolated resistant lesions to chemotherapy or complications such
as infection, bowel obstruction etc
iv. Angiographic embolisation of theanterior division of the internal iliac arteries
for pelvic haemorrhage
v. Ligation of the anterior divison of the internal iliac arteries if embolisation fails
or is not available
vi. Hysterectomy for patients where there is NO parametrial and vaginal
metastases

c. PLACENTAL SITE TROPHOBLASTIC DISEASE

i. Usually an incidental diagnosis following endometrial sampling
ii. TAH (?BSO) as lesion is usually not responsive to chemotherapy
iii. Chemotherapy is indicated for metastatic disease in addition to TAH

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