OBSTETRICS & GYNAECOLOGY GUIDELINES

OBSTETRICS & GYNAECOLOGY
OBSTETRICS AND GYNAECOLOGY

TOPICS/CONDTIONS FOR STGs: The subgroup has prepared the following guidelines in the first phase as per specific template approved by the Ministry:
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Adenexal Mass Anaemia in Pregnancy Antepartum Haemorrhage Caesarean section Carcinoma cervix, Adnexal mass, Prolapseuterus, Pre -eclampsia, Elampsia
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Cardiac disease in pregnancy Diabetes & Pregnancy Dysfunctional uterine bleeding Ectopic pregnancy, Fibroid uterus
COMPOSITION: The following sub group was notified by Ministry of Health and Family welfare, Government of India for this purpose. GROUP HEAD: Dr Ashley Cruz, Director and Senior Paediatric Surgeon, Narayana Hrudayalaya, Bangalore GROUP MEMBERS 1 2 3 4 Dr.Sheela H.S Hospital, Tamil Nadu Dr.Garima Arora Gandhi Dr.Lavanya Dr.Kiran Mayi 5 6 7 8 Dr. Tamil Selvi, State Government Hospital Dr.Annamma Thomas, Medical College hospital (SJMCH), Bangalore Dr.Basavaraj, Rural PHC, Tumkur Dr.Sameena
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REVIEW OF STGs The draft guidelines were forwarded to many experts for critical review, suggestions and amendments. The following experts have reviewed these draft guidelines. The sub group would like to place on record their useful contribution and acknowledges their efforts.
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Dr.Almas Banu, Railway Hospital, Bangalore Dr.Loyd-Nephrologist Dr.Shalini Rajesh-Diabetologist Dr.Mahala-Cardiologyst Dr Krishna, Semi Urban/Rural, Kuppam, Andhra Pradesh
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Dr.Anil Kamath-Surgical Oncologist Dr.Rajiv Aggarwal-Neonatology'st Dr.Sharath-Haemotologist Dr.Shakuntala Baliga
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NAME OF THE CONDITION: ADENEXAL MASS

I. INTRODUCTION:
The finding of an adnexal mass is a common gynaecological problem. Adnexal mass has presented a diagnostic as well as therapeutic challenge. It may occur in all age groups. 5-10% of all women attending gynaec OPD will undergo evaluation for adnexal mass. The management of adnexal mass starts with differential diagnosis.
II. DIFFERENTIAL DIAGNOSIS:

Adnexal mass maybe from the following, Ovary, fallopian tube, Uterus, Broadligament, bowel, Urinary system & Retroperitonium
Ovarian Ovarian neoplasms Ovarian cyst Tuboovarian abscesses Hyperstimulated ovaries after ovulation induction Tubal Ectopic pregnancy Hydrosalpinx Tubal neoplasms Paratubal cyst Tuberculosis salpingitis Uterine myoma Gastrointestinal Appendiceal abscess Appendiceal tumor Diverticular abscess Colonic tumor
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Genitourinary Pelvic kidney Retroperitoneal Hematoma Lymphocyst Lymphoma Sarcoma Distribution based on age: In premenopausal women, the risk of a neoplasm being malignant is 7% - 13% while it is 3040% in post menopausal woman. Young women - Functional cyst, tubal abnormalities, ectopic pregnancy, hydrosalphinx, endometriomas, dermoid cyst, fibroid, germ cell tumours. Reproductive age - Functional cyst, endometriomas, myomas, dermoid cyst, serouscystadenoma. Oldage - Ovarian cancers. Review of adnexal pathology: Ectopic pregnancy Reproductive age group Amenorrhoea Irregular bleeding Urine HCG positive Abdominal pain USG - Empty Uterus, adenexal mass. Tubal Infections: Fever, pain abdomen, unhealthy discharge Nonneoplastic cysts: Functional cysts 6-8cm size. Endometriotic cyst - bilateral in 50% of cases, adhesions. Ovarian Neoplasms: Serous - 50-70% of ovarian neoplasms.
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Benign - average age 40yrs but can occur at any age, 20% bilateral. Malignant - 50% of ovarian cancers, menopausal age. Mucinous Benign - 25% of ovarian neoplasms, occur at younger age, rarely bilateral - 3%, tend to be verylarge multiloculated Malignant - 15% of ovarian cancers. Endometriod Largely malignant, 25% of ovarian cancers, size moderate 20cms, bilateral in 30% of cases Clearcell 10% of ovarian cancers. Germcell tumours Benign - Dermoid cyst, 25% of ovarian neoplasms, reproductive age, prone of torsion. Malignant - 6% of ovarian cancers. Stromal tumours Benign - Fibroma 10% of ovarian tumours. Malignant - 5% of malignant ovarian tumours. Metastatic 3-5% of ovarian cancers, origin from Breast & GI Tract. Situation 1: At Secondary Hospital / Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited a) Clinical Diagnosis: Symptoms: Abdominal pain, pelvic pain, dyspareunia Menstrual irregularities Abdominal swelling (sometimes it is the first symptom) Acute pain, vomiting and low grade fever (torsion, rupture & ectopic) Pressure symptoms - retention of urine, frequency of micturition Dyspnoea, Palpitation (very large tumours) GIT symptoms - indigestion, loss of weight, loss of appetite
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Signs: Per abdomen Abdominal swelling, symmetrical, upper & lateral borders felt, lower border not felt, smooth surface, mobility (according to the size), on percussion dull in the centre & resonant in the flanks due to displacement of bowel, Ascites should be elicited. Per Vagina: Uterus felt separately, displaces the uterus to the opposite side, sometimes difficult to palpate the uterus if the cyst is large, lower pole felt, nodules in the POD (malignant) Examination of neck nodes & breast is important: b) Investigations: Hb, PCV CBC RFT LFT Serum Electrolytes Urine HCG X-ray Chest X-ray abdomen IVP Barium meal, enema Upper GI endoscopy, colonoscopy USG - abdomen & pelvis with colour Doppler Site Unilateral Bilateral, Size, internal characteristics, septal Thickness, nodularity, free fluid in abdomen Doppler - low resistance ovarian arterial flow Tumour markers CA125 - epithilial ovarian tumour, cutoff 35 U/ml CEA - GI tract tumour HCG - Chrio carcinoma Inhibin - Granulosa cell tumour LDH - Dysgerminoma
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CT, MRI PET Ascitic fluid cytology, FNAC of solid tumour - Questionable role because of the risk of spread in case of malignancy. c) Treatment: Ectopic pregnancy: Laparotomy / Laparoscopy Salphingotomy Salphingectomy T.O. mass: Hydrosalphinx - removal Abscess - pus drained, antibiotics Ovarian Masses: Prediction of malignancy by Age, menopausal status, clinical findings, radiological appearance Staging laparotomy: 1. Incision, pfannensteil, cherney's, maylard - these are transverse incision used for benign conditions.Midline, Paramedian in malignancies 2. Peritoneal washings to be obtained, NS is preferable (cell lysis is less) 3. Thorough exploration of both upper & lower abdomen, entire surface of the diaphragm, liver surface, parenchyma, porta hepatis region, gall bladder fossa, kidneys & peritoneum overlying them, stomach, spleen tip, pancreas, mesentry traced to aortic pulsations, lymphatics evaluated on either side of aorta, omentum, small bowel, large bowel, mesentry, appendix 4. Finally the adnexal mass of interest in examined 5. Overian cyst - Frozen section (90% correlation) 6. Benign - Cystectomy, oopherectomy 7. Malignant - TAH with BSO, peritoneal washings, peritoneal biopsces from suscipicion areas, paracolic gutters, pelvic side walls, culdesac, anterior vertical surface 8. Scrapings of diaphragm - cytology
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9. Pelvic and para aortic node dissection 10. Omentectomy 11. Heamostasis obtained 12. Sponge & instruments counts verified 13. Abdomen closed. Laparoscopic Removal of Benign Ovarian Mass is done d) Referral Criteria: ACOG AND SGO GUIDELINES FOR REFERRAL OR CONSULTATION WITH A GYNECOLOGIC ONCOLOGIST Premenopausal or < 50 years old with one or more of the following:
l Very elevated CA-125 (>200U/mL) l Ascites l Evidence of abdominal or distant metastases l Family history of breast or ovarian cancer in a first-degree relative Postmenopausal
or > 50 years old with one or more of the following

l Elevated CA-125 (>35U/mL) l Ascites l Nodular or fixed pelvic mass l Evidence of abdominal or distant metastases l Family history of breast or ovarian cancer in a first-degree relative
ACOG, American College of Obstetricians and Gynecologists; SGO, Society of Gynecologist Oncology. * Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available A) Clinical Diagnosis B) Investigations & Treatment as in situation I Gynaec Oncology workup will be done in situation 2
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COMPLETE STAGING FOR OVARIAN CANCER

l Abdominopelvic exploration l Peritoneal
washings from pelvis, bilateral paracolic gutters, and infradiaphragmatic
areas
l If desirous of fertility: Unilateral salpingo-oophorectomy l Biopsy of the contralateral ovary if it appears suspicious l If postmenopausal or does not desire fertility: l Bilateral salpingo-oophorectomy l Total hysterectomy l Pelvic node dissection l Paraaortic node dissection l Omentectomy l Peritoneal
biopsies (cul-de-sac, vesical peritoneum, bilateral pelvic sidewalls, bilateral paracolic gutters, biopsy or scraping of right diaphragm)
l Biopsy of any additional suspicious findings
CRITERIA FOR LAPAROSCOPIC REMOVAL OF THE ADNEXAL MASS

l Surgical expertise skills appropriate for performing cystectomy or adnexectomy l Prompt and accurate frozen section services l Personnel and facilities available for timely surgical staging
Special Situations: 1. Premenopausal woman 2 issues 1. reproductive function 2. Hormonal function Remove the cyst, frozen section If malignant - oopherectomy Look opposite ovary If normal leave it Uterus if normal - Left as such for eggdonation and IVF 2. Mass with borderline histology Tumours of low malignant potential (LMP), no stomal invasion, multilayered, mild nuclear atypia, serous or mucinous, 16% of ovarian tumours are borderline tumours, 1/3rd of borderline tumours are bilateral In post menopausal woman - TAH with BSO ? enough. If fertility to be preserved cystectomy 3. Young women - Germ cell tumours Do unilateral adnexectomy and staging Radical surgery after finishing childbirth 4. Adnexal masses in pregnancy Mostly cystic, resolve There is a risk of torsion and rupture 16-18wks - ideal time for surgery Risk of malignancy 5%
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NAME OF THE CONDITION: ANEMIA IN PREGNANCY

Anemia is defined as decrease in the oxygen carrying capacity of the blood due to decrease in amount of RBCs or hemoglobin or both
I. WHEN TO SUSPECT/ RECOGNIZE?

l WHO - Hemoglobin -11gm/dl or less
n
Mild
8-11 gm/dl
Moderate 5-7 gm/dl below 5 gm/dl
Severe
l RBC<3.2million l PCV<30%
Introduction: Anemia in pregnancy is a condition with effects that may be deleterious to mothers and fetuses. Indeed, it is a known risk factor for many maternal and fetal complications. Over one third of the world's population suffers from anemia, mostly iron deficiency anemia. India continues to be one of the countries with very high prevalence. National Family Health Survey (NFHS-3) reveals the prevalence of anemia to be 70-80% in children, 70% in pregnant women and 24% in adult men. Prevalence of anemia in India is nearly two thirds of the pregnant women, because of low dietary intake, poor availability of iron and chronic blood loss due to hook worm infestation and malaria. Iron deficiency anemia is responsible for 95% of the anemias during pregnancy. In order to tackle this public health problem, a multi-pronged 12 x 12 initiative has been launched in the country. The initiative is targeted at all adolescents across the country with the aim for achieving hemoglobin level of 12 gm% by the age of 12 years by 2012. In India, anaemia is directly or indirectly responsible for 40 percent of maternal deaths. India contributes to about 80 per cent of the maternal deaths due to anaemia in South Asia.There is 8 to 10-fold increase in MMR when the Hb falls below 5 g/dl. Maternal anemia is associated with poor intrauterine growth and increased risk of preterm births and low birth weight rates. This in turn results in higher perinatal morbidity and mortality, and higher infant mortality rate. A doubling of low birth weight rate and 2 to 3 fold increase in
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the perinatal mortality rates is seen when the Hb is <8 g/dl. Intrauterine growth retardation and low birth weight inevitably lead to poor growth trajectory in infancy, childhood and adolescence and contribute to low adult height. India was the first developing country to take up a National Programme to prevent anaemia among pregnant women and children. The National Anaemia Prophylaxis Programme of iron and folic acid distribution to all pregnant women in India through the primary health care system was evolved and implemented from 1972.
II. INCIDENCE OF THE CONDITION IN OUR COUNTRY

l Incidence- About one third of the global population(over 2 billion) are anaemic l CDC-Up to 56% of all women in India are anaemic (Hb < 11 g/dl) l NNMB,
DLHS and ICMR surveys showed that over 70 percent of pregnant women are anaemic
The World Health Organization (WHO) estimates that 42% of all women, and 65-75% of pregnant women in our country are anemic. In India, the second National Family Health Survey in 1998-1999 (NFHS-II) showed that 54% of rural women of childbearing age were anemic compared with 46% of women in urban areas. Kerala has only a 23% prevalence of anemia compared with 62% in many northeastern states of India.
l National Family Health Survey (NFHS) l District Level Household Survey
(DLHS)
l National Nutrition Monitoring Bureau (NNMB) l Indian Council of Medical Research (ICMR) Micronutrient Survey
III. DIFFERENTIAL DIAGNOSIS

l Hemoglobinopathies l Hemorrhagic l Nutritional l Bone marrow disorder l HIV
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l Drug induced l Tuberculosis l Inherited disorders l Anemia caused by inflammation/ malignancy.
IV. OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT & REFERRAL CRITERIA

Complete medical history and Physical examination is very important. *Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited a) Clinical Diagnosis: Symptoms: 1. Dyspnea 2. Fatigue 3. Dizziness or vertigo especially when standing. 4. Headache. 5. Irritability. 6. Generalized Swelling. 7. Yellowing of skin, eyes and mouth. Signs 1. Pallor 2. Icterus 3. Koilonychia 4. Oedema. 5. Glossitis 6. Tachycardia, systolic murmurs, bounding pulse 7. Palpitation 8. Splenomegaly 9. Hepatomegaly.
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b) Investigations:
l Hb% l PCV l Peripheral smear for immature cells, type of anemia and MP. l Urine routine and microscopy, Urine C/S if required l Stool for Routine and microscopy l USG
c) Treatment: Although there are over 400 different forms of anemia, this health profile will only address the three most common: iron-deficiency anemia, vitamin B12 anemia and folic acid deficiency. Non-drug treatment
l Diet rich in Vit C, Protein and Iron to be recommended l Food Fortification l Awareness/ Education l Good Hygiene for eradication of helminthiasis l Routine screening for anaemia for adolescent girls form school days l Providing iron supplementation from school days l Annual screening for those with risk factors
Iron rich foods: Pulses, cereals, jaggery, Beet root, Green leafy vegetables, nuts, meat, liver, poultry, Egg, fish, legumes, dry beans, and iron enriched white breads, dry fruits viz: dates, figs, apricots etc . Drug treatment: Prophylaxis
l Tab. Ferrous sulphate (60 mg elemental iron) once daily and l Tab. Folic acid 0.5 mg daily l To be given for minimum 100 days.
Ferrous sulphate is least expensive and best absorbed form of iron. It also allows more elemental iron absorbed per gram administered. If for some reasons this is not tolerated, then ferrous gluconate, fumarate are the next choice for iron therapy.
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Treatment of Iron deficiency has included:

l Oral iron l Intramuscular iron l Iron dextran l Iron Sucrose Complex l 200mg FeSo4 (60mg elemental iron) 3 times daily till HB level becomes normal, after
three months of pregnancy, repeat Haemoglobin. Then maintenance dose of 1 tab for 100 days following delivery. If < 11 gm%
l Tab. Ferrous Sulphate (60 mg elemental iron) once daily till lactation is complete. l Tab. Folic Acid 0.5 mg, 1 tablet once daily till lactation is complete. l If patient is non-compliant to oral therapy or if there is gastritis then reduce doses &
give it after meals Or

l To change over to Ascorbic Acid/ Carbonyl Iron
Or Parenteral Therapy: Indicated:

l If Hb less than 7g/dl and >36 weeks or l Malabsorption Syndrome or l Developing incapacitating side effects with oral iron.
Formula: For Iron Sucrose Complex Amount of iron deficit (mg) = Body wt. (Kg) Hb deficit 0.3 Or [Hb deficit = Hb target - Hb initial] Or Amount of iron to replenish (mg) = Body wt (Kg) 10 Total iron deficit (mg) = Amount of iron deficit + amount of iron to replenish Stores (Iron Sucrose Complex is considered to show a significant improvement of Hb and iron stores in pregnant women).
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Formula: For Dextran and Sorbitrate [(Normal Hb-Patient's Hb) x weight (kg) x2.21]+1000=mgs of iron needed. Total dose of infusion of iron: To calculate TDI: (15- patient's Hb %) x body weight in Kg x3 =Mg.
l Deworming necessary : l Albendazole 400 mg single dose l Mebendazole 500 mg single dose or 100 mg twice daily for 3 days l Levamisole
2.5 mg/kg single dose, best if a second dose is repeated on next 2 consecutive days
l Pyrantel 10 mg/kg single dose, best if dose is repeated on next 2 consecutive days l To prevent
recurrence, patients should be advised to use footwear, improve sanitation, and personal hygiene.
l Malaria prophylaxis in endemic area to be treated.
Treatment of Folic Acid/ Vitamin B12 deficiency

l Tab. Folic acid 5 mg daily
Prophylactic - all woman of reproductive age should be given 400mcg of folic acid daily Preventive daily or intermittent iron or iron+folic acid supplementation taken by women during pregnancy reduces anaemia in mothers. There is evidence that taking iron or iron and folic acid daily or intermittently has a similar effect in reducing anaemia at term and improving haemoglobin concentrations in the mother.
l Vitamin B12 deficiency:
Oral preparation of Vitamin B12 (not very effective) In Moderate cases- 1000mcg of Parenteral Cynocobalamine every month In Severe cases 1000mcg/day for 1 week, following by weekly for 1 month d) Referral criteria:
l Hb less than 5 gm in all trimester, less than 7gm if >36weeks l Cases not responding to treatment l Associated with medical disorders eg:leukaemias/ other obstetric complications
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l Haemolysis or evidence of bone marrow suppression l Other types of anemia(Sickle cell anemia, Thalasemia) l Level II USG to rule out fetal complication/ compromise by CVS/ Amniocentesis l If any of the below suspected, as the below are common in pregnancy:
n
Maternal risk during Antenatal period: poor weight gain. Pre term labours, PIH, placenta previa, accidental Hg, eclampsia, premature rupture of membrane (PROM), cardiac failure etc.
Maternal risk during intranatal period: Dysfunctional labour, intranatal hemorrhage, shock, anesthesia risk, cardiac failure, if signs of respiratory Distress
Maternal risk during postnatal period: Postnatal sepsis, sub involution, embolism, PPH (primary, secondary).
Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available A) Clinical Diagnosis: Same as situation 1 B) Investigations:
l Same as situation 1, in addition l CBC l Reticulocyte count l LFT, RFT, LDH l Coombs Test l Iron studies
n n n
serum iron serum iron binding capacity
serum Ferritin
l Hb electrophoresis l Bone marrow aspiration/ Biopsy
C) Treatment: Same as situation 1

l Confirm iron deficiency anaemia
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Treatment of IDA has included : l

n n n n n n
Oral iron Intramuscular iron Iron dextran
Iron Sucrose Complex
Recombinant erythropoietin and
Blood transfusion
Inj. Iron Dextran (50 mg / ml elemental iron) 2 cc IM on alternate day after test dose l x 10 injections Transfusion if Hb < 5 gm & in last trimester to be done by Packed cells and we have to l watch for signs of fluid overload. Diagnosis l Manage l & management of sickle cell disease, Haemoglobinopathies, Pancytopenia in cases not responsive to iron.
congestive cardiac failure/ PIH / Placenta Previa if associated/ where indicated.
Megaloblastic Anemia VitB 12 or Folic Acid Supplementation. l Blood Transfusion preferably Packed cell if HB% < 5 gm & if < 7gm in last trimester. l LABOUR MANAGEMENT: Oxygen and other measures to deal with heart failure and PPH to be kept ready To cut short second stage by Outlet forceps l To routinely use Oxytocin with Prostaglandins at the time of delivery of the head if l not contraindicated. LSCS only for Obstetric Indications under strict asepsis l
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RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (PATIENT WEIGHT 60 KGS) (Units to be specified for human resources, investigations, drugs, and consumables and equipment. Quantity to also be specified)
Situation 1. At Secondary Hospital/ Non-Metro situation Optimal Standards of Treatment in Situations where technology and resources are limited Human resources Obstetrician Physician Pathologist Lab technician House keeping Investigations Hb% PCV RBC Peripheral smear Urine routine and microscopy Stool for Routine and Microscopy Drugs and consumables Gloves x 10 pairs Drapes for delivery/Caesarean Suture materials Foleys catheter Urobag Venflons Drip sets IVFluids Antiseptics, Compatible blood/packed cells Equipment Stethoscope BP apparatus Pulse oximeter USG machine ECG monitors Lab equipment Labour room, CTG Labour couch Delivery/Caesarean tray Vacuum apparatus Boyles appar OT table Light source Oxygen Suction Baby warmer
2. At Super Specialty Facility in Metro location where higher-end technology is available
Obstetrician Pathologist Anaesthetist Neonatologist Intensivist Nurses x 5 OT technician Lab technician Porters House keeping
CBC Peripheral blood smear Reticulocyte count Urine routine and microscopy Stool for Routine and Microscopy Iron studies LFT,RFT,LDH Coombs Test Hb electrophoresis Bone marrow aspiration/ Biopsy
Gloves x 15 pairs Drapes for delivery/Caesarean Suture materials Foleys catheter Urobag CVP line Arterial line Venflons Drip sets IVFluids Epidural anaesthesia kit General anaesthesia kit Drugs to manage cardiac failure , PPH
Stethoscope BP apparatus Pulse oximeter USG machine ECG Lab equipment Automated cell counter Biochemistry analyser Labour room, CTG Labour couch Delivery tray Caesarean tray Vacuum apparatus Boyles apparatus OT table Light source Oxygen Suction ICU bed Syringe pumps Baby warmer
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. FURTHER READING / REFERENCES

Cochrane Database of Systematic Reviews 2007 l Medscape J Med. 2008; 10(12): 283. l DeMayer EM, Tegman A. Prevalence of anaemia in the World.World Health Organ Qlty l 1998; 38 : 302-16. WHO. 2004. Micronutrient deficiency: Battling iron deficiency anaemia: the challenge. l Available from: http://www.who.int/nut/ida.htm, accessed on April 24, 2008. Ezzati l IIPS l IIPS. l M, Lopus AD, Dogers A, Vander HS, Murray C. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360 : 1347-60.
National Family Health Survey 1998-99 (NFHS-2): Available from: http://www.nfhsindia.org/india2.html;accessed on September 24, 2008.
National Family Health Survey 2005-06 (NFHS-3): Available from: http://mohfw.nic.in/nfhsfactsheet.htmb accessed on September 24, 2008.
DLHS on RCH. Nutritional status of children and prevalence of anaemia among children, l adolescent grils and pregnant women 2002-2004. Available from: http://www.rchindia.org/nr_india.htm 2006, accessed on September 24, 2008. Toteja GS, Singh P. Micronutrient profile of Indian population.New Delhi: Indian Council l of Medical Research; 2004. National l Nutrition Monitoring Bureau (NNMB). 2002.NNMB Micronutrient survey. Hyderabad: National Institute of Nutrition.
Maternal l
Mortality in India 1997-2003, Registrar General of India. Available from: http://www.censusindia.net/, accessed on December 15, 2008.
Breymann l
C. Iron deficiency and anemia in pregnancy: Modern aspects of diagnosis and therapy. Blood Cells Mol Dis 2002; 29: 506-16.
Practical guide to High Risk Pregnancy and Delivery; Fernando Arias, 2nd edition; chapl 3, pg245-262. Williams Obstetrics, Eds Cunningham FG, Gant NF, Leveno KJ et al. 22nd Edn. 2005. l
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NAME OF THE CONDITION: ANTE PARTUM HAEMORRHAGE

Definition: Bleeding from genital tract after the period of viability of the foetus (28 weeks) till the delivery of baby. Major causes are a) Placenta praevia b) Abruptio placenta Minor causes are
n n n n n
Exaggerated show,
Trauma to cervix or vagina
Cervical ectropion,
Carcinoma of cervix or polyps
Vasa previa
a) PLACENTA PRAEVIA
1 Definition: Placenta praevia is implantation of placenta in the lower uterine segment Incidence: 1 in 300 pregnancies. Perinatal morbidity and mortality are primarily related to the complications of prematurity, because the haemorrhage is maternal. Predisposing factors:
n n n n n
Advancing maternal age
Multiparity Multifetal gestations
Prior cesarean delivery
Prior placenta previa
Differential Diagnosis : abruptio placentae, other minor causes.
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Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited. a) Clinical Diagnosis: Obtained from history, physical examination and investigations. Nature l of bleeding: Painless, recurrent, bright red. Initial bleeding is not usually profuse enough to cause death; it spontaneously ceases, only to recur later.
Patient might be in shock l Abdominal examination: Height of uterus proportionate to gestational age, l Feel is soft. Some l degree of uterine irritability is present in about 20% of the cases. malpositions usually present
Malpresentations , l
Foetal heart sound usually present. l If you l suspect placenta previa, do not perform a vaginal examination unless preparations have been made for immediate caesarean section.
b) Investigations Blood investigations (Full blood count , blood group and type) l Ultrasound examination : Rules out four types of placenta praevia ; fetal anomalies l fetal parameters , presentation and position. Transabdominal ultrasonography l A simple, n precise, and safe method to visualize the placenta, this ultrasonography has an accuracy of 93-98%.
False-positive n
results can occur secondary to focal uterine contractions or bladder distention.
Transvaginal ultrasonography l Recent n studies have shown that the transvaginal method is safer and more accurate than the transabdominal method. Transvaginal ultrasonography is also considered more accurate than transabdominal ultrasonography.
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c) Treatment : Assess the blood loss Resuscitate: Monitor BP Start IV Line Restore blood volume by infusing normal saline Explain the need of blood transfusion Arrangements made to shift to higher centres. d) Referral Criteria: Shift to hospitals where blood bank, neonatal and emergency caesarean section facilities are available. Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available a) Clinical diagnosis: Diagnosis reached by history ,physical examination and sonographic examination After initial assessment further investigations need to be performed to ascertain cause , degree of bleeding, plan the on-going care and to decide mode and time of delivery. b) Investigations : As above .
l Blood investigations (Full blood count, blood group and type) l Ultrasound examination : Rules out Four types of placenta praevia
Type I- Dips in to lower segment Type II - Reaches lower border of uterus up to cervical os but not covering completely. Type III- covers the internal os Type IV - Covers the internal os, even on full dilatation of the cervix.
l At 18 weeks, 5-10% of placentas are low lying. Most 'migrate' with
development of
the lower uterine segment.

l MRI: MRI has been suggested as a safe and alternate method and may be useful in
determining the presence of placenta accreta.
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c) Treatment:
l No Vaginal Examination l Resuscitate:
Monitor BP Assess the amount of bleeding. Start IV Restore blood volume by blood products The definitive treatment depends upon the duration of pregnancy,fetal and maternal status and extent of haemorrhage Investigations .
l Type I and Type II anterior - vaginal delivery can be expected.
Type II -b, III & IV - Elective/emergency caesarean section has to be done at the earliest. Mode of delivery determined by
l severity of bleeding l fetal maturity l degree of fetal distress. l In every case of placenta previa , be prepared for postpartum haemorrhage.
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b) ABRUPTIO PLACENTA
1) Definition: Abruptio placenta is the detachment of a normally located placenta from the uterus before the fetus is delivered. It is an obstetric emergency. 2) Case definition: can be classified as Revealed (separation of placenta with blood visible outside) Concealed(blood collects behind the separated placenta. Not visible outside) Mixed, (common type). According to Sher clinical grading for placental separation 1. Grade 1: (Herald bleed) diagnosed retrospectively 1. Less than 100cc -150cc of uterine bleeding 2. Uterus non-tender 3. No Fetal Distress 2. Grade 2 ; Classical features of abruption 1. Uterus tender 2. Fetal Distress 3. Concealed hemorrhage 3. Grade 3 1. Fetal death 2. Maternal shock 3. Extensive concealed hemorrhage 4. Coagulopathy 1. Absent: 3A (66% of patients) 2. Present: 3B (33% of patients 3) Incidence : 1-2% Perinatal mortality rate associated with placental abruption was 119 per 1000 births compared with 8.2 per 1000 for all others.
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Cause is unknown .But risk factors are

l Increased age and parity l Preeclampsia l Chronic hypertension l Preterm ruptured membranes l Multifetal gestation l Hydramnios l Cigarette smoking l Thrombophilias l Prior abruption l Uterine leiomyoma l External trauma (Sudden jerk or assault over abdomen) l Anaemia l Short cord.
Complications: Complications include the following:

l Maternal
blood loss (possibly with shock, disseminated intravascular coagulation [DIC], or both), multiorgan failure.
l Fetal distress or death I; IUGR if chronic and mild. l Sometimes fetomaternal transfusion and Rh sensitization. l Prematurity
4) Differential Diagnosis: Placenta previa, other minor causes 5) Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria:
Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited a) Clinical Diagnosis: Placental Abruption is a clinical diagnosis. Severity of symptoms and signs depends on degree of separation and blood loss.
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Symptoms: Vaginal Bleeding ,Uterine tenderness, , frequent uterine contractions, l Signs: Vital signs suggestive of cardiovascular compromise l 1. Tachycardia 2. Orthostatic changes in Blood Pressure and pulse Abdominal l examination: Uterus may be larger than gestational age. , uterine hypertonus, fetal demise(depending on severity)
Haemorrhagic shock,disseminated intravascular coagulation. l Diagnosis is clinical and sometimes by ultrasonography; Done only for knowing the GA, presentation. Treatment: Bed rest for mild symptoms and prompt delivery for severe or persistent symptoms b) Investigations: Full blood count, Blood grouping and typing, cross match, DIC screen l Fetal heart monitoring l Transabdominal l ultrasonography done for evaluation of foetal presentation, size, foetal well-being and placental localization detect a nonreaasuring pattern or fetal death
Fetal heart monitoring may l c) Treatment :-
Usually prompt delivery and aggressive supportive measures. l Prompt delivery is usually indicated if any of the following is present: l a) Maternal hemodynamic instability b) Nonreassuring fetal heart rate pattern c) Near-term pregnancy Resuscitate l Start IV Line with normal saline and refer to higher centre. l Explain l the need of blood transfusion and send the relatives along with patient for donating blood .
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l Management :
a) Stable patient (Grade I) management :

n Trial of
hospitalization and bed rest if the pregnancy is not near term and if mother and fetus are stable
n Hospitalization and bed rest are advised if all of the following are present:
a) Bleeding does not threaten the life of the mother or fetus. b) The fetal heart rate pattern is reassuring. c) The pregnancy is not near term . This approach ensures that mother and fetus can be closely monitored and, if needed, rapidly treated. Corticosteroids should be considered (to accelerate fetal lung maturity) if gestational age is < 34 wk. If bleeding resolves and maternal and fetal status remains stable, ambulation and usually hospital discharge are allowed. If bleeding continues or if status deteriorates, prompt delivery is indicated. Complications : Maternal complications
n Hypovolemic shock n Renal Cortical necrosis n Coagulopathy n Amniotic Fluid Embolism n Maternal Death n Uteroplacental apoplexy (Couvelaire uterus)
a) Bleeding into myometrium results in hypotonic wall b) Risk of Postpartum Hemorrhage

n Fetal complications n Intrauterine Growth Retardation n Preterm Labor n Intrauterine Fetal Demise
d) Referral Criteria: Shift to hospital where blood bank, neonatal and emergency caesarean section facilities are available; where facitilies are available for management of multiorgan failure, DIC 661
Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available a) Clinical Diagnosis: Detailed history, physical examination and investigations ,will aid in the diagnosis of this condition b) Investigations:
l Full blood count, Blood grouping and typing, cross match, DIC screen. l Ultrasound:
Evaluation of foetal presentation, size, foetal well-being and placental
localization. c) Treatment:
l Admit l History & examination l Assess blood loss .Nearly always more than revealed. l Treatment
for placental abruption varies depending on gestational age and the status of the mother and foetus.
l Begin
continuous external fetal monitoring for both the fetal heart rate and contractions.
l Obtain intravenous access using 2 large-bore intravenous lines. l Institute crystalloid fluid resuscitation for the patient. l Type and crossmatch blood. l Begin
a transfusion if the patient is hemodynamically unstable after fluid resuscitation.
l Correct coagulopathy, if present. l Administer Rh immune globulin if the patient is Rh-negative. l Management of coagulopathy l Indicators for prompt delivery
a) Foetal distress (Nonreassuring fetal heart rate pattern). b) Maternal hemodynamic stability. c) DIC
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d) Labor e) Term
l Vaginal delivery is acceptable (and generally preferred with DIC). l If bleeding is heavy (evident or hidden) deliver as soon as possible. l Patient
has to be delivered within 8 hours by Artificial rupture of membrane and Oxytocin 2.5units (not more than 5 units) in 500 cc of Dextrose.
l If cervix is fully dilated deliver by forceps or vaccum extractor. l If vaginal delivery is not imminent or foetus is alive deliver by caesarean section. l In every case of abruptio placentae, be prepared for postpartum haemorrhage.
FURTHER READING / REFERENCES

Williams Obstetrics : 23rd edition Practical guide to High Risk Pregnancy and Delivary by Fernando arias RCOG Greentop guideline No: 27
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Situation Human resources 1 Obstetrician Physician Anaesthetist Paediatrician Nurses x 2 Ot technician Lab technician House keeping Investigations CBC RBS Urine r/e, c/s Blood Gp Rh TSH Serology VDRL APTT,PT,INR USG ECHO ECG X Ray Drugs and consumables Gloves x 10 pairs Drapes for delivery/Caesarean Suture materials Foleys catheter Urobag CVP line Arterial line Venflons Drip sets IVFluids TED Stockings Equipment Stethoscope BP appar Pulse oximeter USG machine ECGmonitors Xray Lab equipment Labour room Labour couch Delivery/Caesarean tray Vacuum apparatus Boyles appar OT table Light source Oxygen Suction Baby warmer Stethoscope BP appar Pulse oximeter USG machine ECG,Xray Lab equipment Cath lab Labour room Labour couch Delivery tray Caesarean tray Vacuum appar Boyles appar OT table Light source Oxygen Suction ICU bed Syringe pumps Baby warmer
Obstetrician Interventional Cardiologist Paediatric Cardiologist Cardiac Anaesthetist Neonatologist Intensivist Nurses x 5 Ot technician Lab technician Porters House keeping
CBC RBS Urine r/e, c/s Blood Gp Rh TSH Serology VDRL APTT,PT,INR USG ECHO ECG X Ray Cardiac catheterization ABG studies
Gloves x 15 pairs Drapes for delivery/Caesarean Suture materials Foleys catheter Urobag CVP line Arterial line Venflons Drip sets IVFluids Epidural anaesthesia kit General anaesthesia kit
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NAME OF THE CONDITION: CAESAREAN SECTION

I. WHEN TO SUSPECT OR RECOGNIZE?
Introduction and case definition: Caesarean section is a form of childbirth in which a surgical incision is made through a mother's abdomen and uterus to deliver one or more babies. The commonest uterine incision is the lower segment inscision. It may be done electively or as an emergency procedure. Some of the common indications recognizable during the antenatal period are malpresentations, antepartum haemorrhage, post caesarean pregnancy, previous surgery on the uterus, bad obstetric history, fetal macrosomia, cephalopelvic disproportion, IUGR, conditions where induction of labour may be necessary as in pre eclampsia, gestational diabetes, postdatism, premature rupture of membranes. Some intrapartum indications include fetal distress, dysfunctional or prolonged labour assessed through partograms, malpresentations leading to relative CPD, Obstructed labour and cord prolapse.

Ranges from 10 to 50% depending on the level of care - whether a primary or tertiary referral center.
III. OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT AND REFERRAL CRITERIA:

Situation 1: At Secondary Hospital/ Non-metro situation: Optimal Standards of treatment in situations where technology and resources are limited. a) Clinical Diagnosis: Indications mentioned above should be looked for during the antenatal period and during labour. b) Investigations: Clinical diagnosis should be supported with blood investigations like Hb%, BT, CT, blood grouping crossmatching, reservation of blood and urine routine as a minimum to facilitate safe operative delivery.
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c) Treatment: IV line and Oxygen inhalation, Regional or general anaesthesia Operative details- Informed Consent, prepare abdomen, perineum and back, catherisation, start IV line. As premedication give a parenteral H2 blocker, antiemetic, and IV antibiotic. Abdominal incision could be transverse, suprapubic or vertical. The uterine incision usually transverse in the lower segment, midline vertical (Classical ) may be rarely indicated. Baby is extracted, cord clamped cut and baby handed over to the paediatrician. Cord blood may be collected if necessary. Placenta with entire membranes removed. Oxytocics administered to contract the uterus and prevent post patum haemorrhage. Uterus sutured with absorbable sutures to secure haemostasis. Tubes, ovaries, mops and instument count checked. Abdominal wall closed in layers. Post operatively, vitals, urine output, and bleeding are monitored. IV fluids, antibiotics and pain medication given, dvt prophylaxis advised, oral feeds encouraged with return of bowel sounds after 8 hours. Early breast feeding and ambulation encouraged. d) Referral criteria: Cases warranting immediate delivery to save the life of baby or mother should be dealt with. In those situations where skilled manpower and technology is not available institutional delivery should be encouraged. Situation 2: At superspeciality facility in metro location where higher end technology is available. a) Clinical Diagnosis: As in situation 1 based initially on history and clinical findings, supported by investigations. b) Investigations: Ultrasound for presentation, estimated fetal weight, placental position, profile, Doppler studies in IUGR biophysical
In labour partogram, cardiotocography or electronic fetal monitoring if necessary. Complete blood count, urine routine, TSH, LFT, RFT, Coagulation profile needs of the patient. Blood grouping and crossmatching with reservation. tailored to the
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c) Treatment: As in situation 1. d) Referral criteria: Situations warranting neonatal intensive care management facilities, need for blood and blood component therapy, special anaesthesia services like epidual analgesia; For the management of post operative complications of caesarean section like sepsis, secondary haemorhage, wound dehiscence, acute renal failure etc where multidisciplinary input is warranted need referral.
IV. FURTHER READING/ REFERENCES:

RCOG Guidelines Williams text book of Obstetrics Resources required for one patient/procedure
Situation 1
Human resources Investigations Obstetrician Anaesthetist Nurse Floor nurse House keeping
Senior obstet Junior doctor Anaesthetist Nurses x3 Ot technician
Drugs and consumables Equipment Boyles Ot table Light Section tray Suction apparatus BabyWarmer electrocautery Boyles Ot table Light Section tray Suction apparatus BabyWarmer electrocautery
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NAME OF THE CONDITION: CARCINOMA CERVIX

I. INTRODUCTION AND CASE DEFINITION:
Carcinoma cervix is the cancer affecting the cervix, which is the lowermost part of the uterus. Cancer of cervix is a leading cause of mortality worldwide and especially in developing countries Worldwide cancer cervix is the second most common cancer among women, next only to breast cancer. But among Indian women, cancer cervix is the commonest cancer. Invasive cancer of cervix is considered to be a preventable cancer as it is associated with a long pre-invasive state, which is detectable and treatable to a large extent. Various risk factors for carcinoma cervix are young age at first intercourse, multiple sexual partners, cigarette smoking, high parity and low socio-economic status. Human papillomavirus infection has been postulated to be the etiological factor for inducing dysplasia in the cervical epithelium. About 85% to 90% of cervical cancers are squamous cell carcinomas, and the rest 10-15% are adenocarcinomas.
II. INCIDENCE IN INDIA:

Based on the data of the population based cancer registries, the estimated number of new cancers during 2007 in India was 90,708.1 As per the same data, the age adjusted incidence rate of cervical cancer in India per 100,000 persons varies from 12.3 - 25.4 in various parts of the country.2
III. PREVENTION:
Detection of pre-malignant lesions by Pap smear testing and HPV-DNA testing followed by appropriate management of the detected lesions forms the mainstay of prevention of occurrence of invasive cervical cancer.
IV. DIFFERENTIAL DIAGNOSIS

Fibroid polyp (especially when infected/ulcerated) l Tuberculosis of cervix l Cervical erosion l OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT & REFERRAL CRITERIA Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited
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a) Clinical Diagnosis: History:

l Asymptomatic in early stages l Vaginal bleeding (postcoital/irregular/postmenopausal) l Foul smelling, blood stained vaginal discharge l Loss of weight/ appetite l Difficulty in micturition (advanced stages)
Examination:
l Malnourished, emaciated appearance (advanced stages) l Supraclavicular/groin lymphadenopathy (advanced stages) l Per speculum
examination: Ulcero-proliferative friable growth on cervix with or without vaginal involvement. Cervix may bleed on touch. examination: Nodularity of parametria (parametrial extension of
l Per vaginal examination: Expanded firm/friable irregular cervix l Recto-vaginal
disease) b) Investigations:
l CBC l Blood grouping l Cervical
biopsy on out-patient basis at the time of speculum examination for confirmation of diagnosis where obvious growth is visualized
l In cases
where no obvious lesion is found on the cervix at the time of visual examination, apply 3% acetic acid on cervix and take biopsy from dense white areas, if seen.
l Colposcope guided biopsy to be done in cases where there is abnormality detected
on Pap's smear and no obvious lesion on cervix. If facility of colposcopy is not available due to lack of equipment or expertise, patient should be referred to a centre with these facilities are available.
l Endocervical curettage if there is suspicion of endocervical cancer. l Cone biopsy may be done if required, but only after colposcopy. l USG l Contrast CT scan if required.
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c) Treatment:
l Treatment
of local infection with Tab. Ciprofloxacin 500mg BD X 5days & Tab. Metronidazole 400 mg TDS X 5days.
l Oral iron and other nutritional supplements for malnourished and anemic patients.
d) Referral criteria: All patients with carcinoma cervix should be referred to multi-specialty hospital that is adequately resourced and equipped with facilities for oncological surgeries, radiotherapy, chemotherapy and blood transfusion. (* If a gynae-onco-surgeon is available along with anesthetist and blood bank facility, inoma cervix stage Ia & Ib1 may be done in situation1. In such situations, if need for postoperative radiotherapy arises, patient should be referred to situation 2 along with all records including surgical records) Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available a) Clinical Diagnosis: Same as situation 1 b) Investigations:
l CBC l Blood grouping l Cervical
biopsy on out-patient basis at the time of speculum examination for confirmation of diagnosis where obvious growth is visualized. examination and guided biopsy: in cases with abnormal Pap test results and no obvious lesion on the cervix.
l Colposcopic
l Endocervical curettage during colposcopy to rule out endocervical carcinoma l Cervical conization in indicated cases.
When carcinoma cervix is confirmed, further investigations required are:

l KFT l LFT l Urine analysis l Chest X-Ray l IVP l Other investigations: Ultrasonography, MRI or contrast CT scan Abdomen and pelvis
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may be useful in select cases for planning therapy.

l Cystoscopy
/ Barium enema / sigmoidoscopy- if bladder or rectal involvement is
suspected. c) Treatment: Treatment modality depends on the stage of disease, age of the patient, patient's desire, need for preservation of ovarian function, presence of co-morbidities, associated gynecological conditions requiring surgery and availability of facilities and expertise. Various modalities available are:
l Surgery: For stages I & II a l Radiotherapy: For all stages l Chemo-radiation:
For patients with high-risk cervical carcinoma after radical hysterectomy and in patients with locally advanced cervical carcinoma.
Surgery
l Advantages:
n Conservation of ovaries n Surgical
injuries to bladder/ bowel are easier to treat compared to chronic bladder and bowel problems resulting from radiation induced fibrosis and decreased vascularity.
l Disadvantages:
n Not curative in advanced stages of carcinoma cervix n Requires expertise
Surgical management depends on the stage, depth of invasion and lymph-vascular space invasion. Types of hysterectomies for carcinoma cervix:
l Type II:
Also called as modified radical/ Wertheim's hysterectomy. Medial half of cardinal and uterosacral ligaments are removed.
l Type III: Also called as radical/ Meig's hysterectomy. Most of the utersacral and cardinal
ligaments along with upper third of vagina are removed.

l Type IV: Extended radical hysterectomy. The periureteral tissue, superior vesical artery
and up to three-fourths of vagina are also removed.

l Type V: Portions of distal ureters and bladder are also resected.
These days, type IV & type V hysterectomies are mostly not performed as patients with
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advanced malignancy are usually given radiotherapy. Complications of radical hysterectomy:

l Acute complications:
n Blood loss n Uretero-vaginal fistula (1% to 2%) n Vesico-vaginal fistula (1%) n Pulmonary embolus (1% to 2%) n Small bowel obstruction (1%) n Febrile morbidity (25 to 50%)
l Sub acute complications:

n Bladder dysfunction n Lypmhocyst formation (<5%)
l Chronic complications:
n Hypotonic bladder n Ureteral strictures n Recurrent cancer n Lymphocyst formation
Radiotherapy:
l Advantages:
n Can be given in all the stages n Cure rates equivalent to surgery in early stages n Avoids surgical and anesthetic complications
l Disadvantages:
n Induces radiation fibrosis of bowel and bladder in 6%-8% n May result in intestinal and urinary strictures (1.4%-5.3%) n Induces vaginal fibrosis and stenosis n Premature menopause due to the affects of radiotherapy on ovaries.
Clinical staging (FIGO) and stage-wise treatment recommendations Stage I: Carcinoma confined to cervix Stage Ia: Preclinical carcinomas of cervix, diagnosed only on microscopy Stage Ia1: >3 mm invasion and <7mm width horizontally
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No lymph-vascular space invasion -Conization/ Type I hysterectomy With lymph-vascular space invasion-Type I or II hysterectomy with (?) pelvic lymph node dissection Stage Ia2: >3-5mm invasion- Type II hysterectomy with pelvic lymphadenectomy Stage Ib : >5mm invasion-Type III hysterectomy with pelvic lymphadenectomy and paraaortic lymph node evaluation. Stage II: Carcinoma extending beyond the cervix but not up to lateral pelvic wall. The carcinoma involves the vagina, but not the lower one-third. Stage IIa: No obvious parametrial involvement- Type III hysterectomy with pelvic lymphadenectomy and para-aortic lymph node evaluation. Concurrent chemo-radiation therapy may be offered as an alternative to radical surgeryfor stages Ib and IIa, especially when the lesion size is more than 4cm, as this has been shown to be associated with improved survival rates. Indications of post-operative radiotherapy: - Positive surgical margins - Positive lymph nodes Stages IIb to IVb: Concurrent Chemo-radiation (Cisplatin based chemotherapy) is the main stay of treatment. Palliative treatment may be offered in advanced stage carcinoma cervix. Stage IIb: Obvious parametrial involvement Stage III: Carcinoma extending up to the lateral pelvic wall. Carcinoma involves the lower one-third of vagina. Hydronephrosis or non-functioning kidney. Stage IIIa: No extension to the pelvic wall Stage IIIb: Extension up to the pelvic wall and/or hydronephrosis or non-functioning kidney. Stage IV: Carcinoma extended beyond the true pelvis or involved mucosa of the bladder or rectum. Stage IVa: Spread of the growth to adjacent organs Stage IV b: Spread to distal organs Recurrent Cervical cancer: For patients, who were primarily treated with surgery, should be considered for radiotherapy and vice-versa.
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d) Referral criteria: In case of carcinoma cervix stage IIb or higher, it may be required to refer the patient to a cancer centre having facility for radiotherapy, as the same may not be available in all super-specialty hospitals.
V. REFERENCES:
1. National Cancer Registry Programme (NCRP, ICMR). Time trends in cancer incidence rates: 1982-2005. Bangalore: NCRP; 2009. 2. A. Nandakumar, T. Ramnath & Meesha Chaturvedi. The magnitude of cancer cervix in India.National Cancer Registry Programme (ICMR), Bangalore, India. Indian J Med Res 130, September 2009, pp 219-221
VI. SUGGESTED READING:

1. Novak's Gynaecology. Ed Berek JS. Fourteenth edition. 2006 2. Te Linde's Operative Gynaecology. Eds Rock J A, Jones III H W. Ninth edition 2003
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NAME OF THE CONDITION: CARDIAC DISEASE IN PREGNANCY

I. WHEN TO SUSPECT / RECOGNISE ?
Heart disease should be suspected or diagnosed at booking for antenatal women. When a pregnant lady presents with symptoms of progressive dyspnoea or orthopnoea, nocturnal cough, haemoptysis, syncope or chest pain. When there are clinical findings like cyanosis, clubbing, distended neck veins, systolic murmur of grade 3/6 or greater, diastolic murmur, cardiomegaly, persistent arrhythmias, persistent split second sound, or pulmonary hypertension. a) Introduction: Heart disease is the third leading cause of death in women of reproductive age group. It is observed in 1% of pregnant women world wide. Risk of maternal mortality ranges from 0 to 50% depending on the cardiac condition. b) Case definition: For both situations of care (mentioned below*) Rheumatic heart disease(RHD) remains an important cause of heart disease especially in developing countries like India. A large number of women undergoing valve replacement surgeries on oral anticoagulants warrant specialized care during pregnancy and childbirth. With advances in paediatric cardiac surgery that have pioneered since the mid 1960s more women with congenital heart disease(CHD) are now surviving and reaching child bearing age. Maternal mortality is most likely in conditions that restrict an increase in pulmonary blood flow, typically pulmonary hypertention and mitral stenosis. The situation is at its worst in Eisenmengers syndrome, where there is refractory hypoxaemia when the mortality is 25 to 50 %. Other cardiac complications associated with pregnancy include infective endocarditis, cardiac arrhythmias, development of cardiomyopathy. Fetal outcome in pregnancies complicated by maternal RHD is usually good although there is an increased incidence of growth restriction and preterm birth. The effects of maternal anticoagulant therapy with warfarin could lead to abortions, stillbirths in 15%, warfarin embryopathy in 15%of live born infants. Warfarin exposure in the 2nd and 3rd trimesters could lead to deformation and scarring and dysharmonic
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growth of organs due to haemorrhage in the fetus, leading to corpus callosum agenesis, Dandy Walker malformation, cerebellar atrophy, optic atrophy, microphthalmia, mental retardation and blindness. Fetal growth restriction and preterm birth are more common in pregnancies complicated by CHD with restricted maternal cardiac output, especially poor in cyanotic varieties when the fetal wastage rates may be as high as 40%. The etiology of CHD is multifactorial and incidence is 0.8 %. Incidence of CHD in the offsprings of parents with CHD ranges from 5 10%.

Nearly 1 % of all pregnant women have cardiac disease
III. PREVENTION AND COUNSELING

l Women may be aware of their cardiac condition before falling pregnant. l In more than 50% of women it is first diagnosed during pregnancy. l A Cardiologist should be involved in initial assessment and follow-up. l Women with conditions like pulmonary hypertension, aortic coarctation with valvular
involvement and Marfans syndrome with aortic involvement should be counseled for early termination of pregnancy to avoid maternal mortality.
l Concurrent medical problems like infections, anaemia should be aggressively treated. l Pneumococcal and influenza vaccines are recommended to avoid respiratory infections
precipitating cardiac failure.

l Cigarette smoking and illicit drug abuse is prohibited to prevent cardio respiratory side
effects and infective endocarditis.

l If the condition warrants surgical correction it should be undertaken before pregnancy.
Women with cardiac disease should be counseled regarding the risk of maternal death, possible reduction in maternal life expectancy, fetal issues, need for timely switch over of anticoagulant therapy, need for frequent hospital attendance and possible admission, intense feto-maternal monitoring during labour.
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IV. DIFFERENTIAL DIAGNOSIS

a) Normal physiological changes of pregnancy b) Anaemia
V. OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT & REFERRAL CRITERIA .

*Situation 1: At Secondary Hospital/Non-Metro situation: Optimal Standards of treatment in situations where technology and resources are limited a) Clinical Diagnosis A clinical suspicion or recognition of cardiac disease based on history, clinical symptoms and signs as explained above is made b) Investigations Basic work up like complete blood counts, urine routine, blood grouping Rhtyping, serology,VDRL, APTT, PT INR, scans for dating, aneuploidy screening, anomalies. Nonivasive studies like electrocardiography, echocardiography and chest radiography with abdominal shielding can be conducted during pregnancy to support the diagnosis. c) Treatment Clinical Classification Schemes commonly used are that of NYHA and ACOG These classification systems are useful to clinicians to evaluate the functional capacity and to aid in counseling the woman regarding advisability of conception or continuation of pregnancy. New York Heart Association (NYHA) Classification Scheme Class 1 Class II Uncompromised. No limitation of physical activity. Slightly compromised. Slight limitation of physical activity.
Class III Markedly compromised. Marked limitation of physical activity. ClassIV Severely compromised. Inability to perform any physical activity without discomfort
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Risk of Maternal mortality Caused by Various Types of Heart Disease (ACOG 1992a) Cardiac disorder Mortality % Group 1 - Minimal Risk ...............................................0-1 Atrial septal defect Ventricular septal defect Patent ductus arteriosus Pulmonic or tricuspid disease Corrected Tetrology of Fallot Bioprosthetic Valve Mitral stenosis (NYHA Classes 1and II) Group 2- Moderate Risk ....................................... 5-15 2A Mitral stenosis (NYHA Classes III and IV) Aortic stenosis Aortic coarctation without valvar involvement Uncorrected Fallot tetrology Previous myocardial infarction Marfans syndrome, normal aorta 2B Mitral stenosis with atrial fibrillation Artificial valve Group 3- Major risk ...........................................25-50% Pulmonary hypertension Aortic coarctation with valvar involvement Marfan syndrome with aortic involvement The management in most instances is by a multidisciplinary team involving
l Obstetrician l Physician /Cardiologist
Anaesthetist l Paediatrician l
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Most women in Classes 1 and 2 go through pregnancy without morbidity. However, special attention should be directed toward both prevention and early recognition of heart failure. Indicators being cough, edema, tachycardia, haemoptysis and basal rales. Empirical therapy with diuretics and betablockers could be hazardous unless the underlying pathophysiology is understood and the cause of decompensation is clear. Labour and Delivery: Vaginal delivery is recommended unless there is an obstetric indication for caesarean section. Await spontaneous onset of labour. Avoid induction of labour intervention thereby haemorrhage and infections. Careful fluid balance necessary. Avoid supine position. A semirecumbent position with lateral tilt preferred. Monitor vitals - pulse, respiration, BP, Oxygen saturation and intake output. Epidural analgesia by a skilled senior anaesthetist considering its hypotensive effect. Cut short 2nd stage of labour with outlet forceps or vacuum extractor to reduce maternal effort. Infective endocarditis prophylaxis is given Avoid methyl ergometrine which causes intense vasoconstriction, hypertension and heart failure. Instead use syntocinon for delivery of placenta. Caesarean section is preferred for obstetrical indications, the principles of intraoperative management are similar. d) Referral Criteria All patients with moderate and major risk of maternal mortality should be referred to a higher centre where a) superspecialists in cardiology and anaesthesia with indepth understanding of each cardiac condition are available. b) facilities should be available for obstetric care with intensive monitoring of mother and fetus under the supervision of a high risk pregnancy specialist(Obstetrician) to minimize risk of
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c) neonatologist with a well equipped NICU is available. Referral may be necessary for fetal echocardiography to plan neonatal care in advance. *Situation 2: At superspeciality Facility in Metro location where higher -end technology is available a) Clinical diagnosis A clinical suspicion or recognition of cardiac disease based on history, clinical symptoms and signs as explained above is made. b) Investigations Basic work up as in any pregnancy like complete blood counts, urine routine, blood grouping Rhtyping, VDRL, serology, APTT, PT, INR, ultrasound for dating, aneuploidy screening, anomaly scan. Fetal echocardiography when indicated. Nonivasive studies like electrocardiography, echocardiography and chest radiography with abdominal shielding can be conducted during pregnancy to support the diagnosis. If indicated, cardiac catheterization can be performed with limited x-ray fluoroscopy by an interventional cardiologist. c) Treatment Clinical Classification Schemes commonly used are that of NYHA and ACOG These classification systems are useful to clinicians to evaluate the functional capacity and to aid in counseling the woman regarding advisability of conception or continuation of pregnancy. The management in most instances is by a multidisciplinary team involving
l Obstetrician l Cardiologist l Cardiac Anaesthetist
Neonatologist l Intensivists l
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During the antenatal period Severe mitral stenosis is associated with a higher risk of pulmonary edema. Both beta blockers and balloon mitral valvotomy are safe in pregnancy. Pulmonary edema should be treated in the usual way with oxygen and diuretics. Women with prosthetic heart valves on oral anticoagulants will need replacement with heparin in early pregnancy between 6 to 12 weeks, to prevent embryopathy. Again warfarin should be discontinued and replaced with heparin 10 days prior to delivery to allow clearance of warfarin from the circulation. Warfarin and heparin are restarted 6 hrs after vaginal delivery and 24 hours after a caesarean section. In an emergency situation VitK or fresh frozen plasma can be used to reverse warfarin anticoagulation and protamine sulfate for heparin anticoagulation. Labour and Delivery;
l Vaginal
delivery is recommended unless there is an obstetric indication for caesarean section.
l Await
spontaneous onset of labour and induction of labour should be very judiciously attempted to minimize risk of intervention thereby haemorrhage and infections.
l Careful fluid balance with central venous pressure monitoring may be necessary to
manage conditions like mitral stenosis and aortic stenosis optimally.

l Such monitoring
is rarely indicated in women who have remained in functional A semirecumbent position with lateral tilt is preferred.
class1& 2
l Avoid supine position.
l Monitor vitals - pulse, respiration, BP, Oxygen saturation and intake output. l Epidural analgesia is administered by cardiac anaesthetist
judiciously based on the
cardiac haemodynamics, as it causes hypotension.

l Cut short
2nd stage of labour with outlet foreps or vacuum extractor to reduce maternal effort.
l Infective endocarditis prophylaxis to be given. l Avoid
methyl ergometrine which causes intense vasoconstriction, hypertension and heart failure. Instead use syntocinon for delivery of placenta. 681
l Caesarean
section is preferred for obstetrical indications when the principles of management remain similar.
l Epidural anesthesia is preferred by most clinicians. l Hypotension
can be very hazardous with pulmonary hypertension or aortic stenosis, when narcotic conduction analgesia or general anaesthesia may be preferable.
Peripartum Cardiomyopathy Risk factors include multiparity, multiple pregnancy, hypertension ,increased age, and Afrocarribean race. Diagnostic criteria 1. Development of cardiac failure in the last month of pregnancy or within 5 months after delivery. 2. Absence of an identifiable cause for the cardiac failure. 3. Absence of recognizable heart disease prior to the last month of pregnancy 4. LV systolic dysfunction shown on echo as ejection fraction <45%, and LV end -diastolic dimension >2.7cm/sqm Recommended treatment Fluid and salt restriction, treatment of hypertension, routine exercise postpartum if stable Drugs like digoxin, betablockers, diuretics, vasodilators may be used. In selected patients aldosterone antagonists, inotropes, anticoagulation, implantable defibrillators, biventricular pacing, cardiac transplantation may be the last resort. Prognosis and recurrence depends on the normalization of left ventricular size within 6 months of delivery. d) Referral Criteria Even in a metro situation a multidisciplinary specialist team with skill and facilities may not always be available under one roof. In such instances referral may be required to an optimal setup under one roof for best feto maternal outcome.
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V. FURTHER READING / REFERENCES

Williams Obstetrics 22nd edition 2008 l Obstetrics and gynaecology Clinics Update on Medical disorders in Pregnancy, volume l 37, No 2, June 2010 American l College of Obstetricians and Gynaecologists -Cardiac disease in pregnancy. Technical Bulletin No 168, June 1992a
Situation 1 Human resources Obstetrician Physician Anaesthetist Paediatrician Nurses x 2 Ot technician Lab technician House keeping Investigations CBC RBS Urine r/e, c/s Blood Gp Rh TSH Serology VDRL APTT,PT,INR USG ECHO ECG X Ray Drugs and consumables Gloves x 10 pairs Drapes for delivery/Caesarean Suture materials Foleys catheter Urobag CVP line Arterial line Venflons Drip sets IVFluids TED Stockings Equipment Stethoscope BP appar Pulse oximeter USG machine ECGmonitors Xray Lab equipment Labour room Labour couch Delivery/Caesarean tray Vacuum apparatus Boyles appar OT table Light source Oxygen Suction Baby warmer Stethoscope BP appar Pulse oximeter USG machine ECG,Xray Lab equipment Cath lab Labour room Labour couch Delivery tray Caesarean tray Vacuum appar Boyles appar OT table Light source Oxygen Suction ICU bed Syringe pumps Baby warmer
Obstetrician Interventional Cardiologist Paediatric Cardiologist Cardiac Anaesthetist Neonatologist Intensivist Nurses x 5 Ot technician Lab technician Porters House keeping
CBC RBS Urine r/e, c/s Blood Gp Rh TSH Serology VDRL APTT,PT,INR USG ECHO ECG X Ray Cardiac catheterization ABG studies
Gloves x 15 pairs Drapes for delivery/Caesarean Suture materials Foleys catheter Urobag CVP line Arterial line Venflons Drip sets IVFluids Epidural anaesthesia kit General anaesthesia kit
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NAME OF THE CONDITION: DIABETES AND PREGNANCY

I. WHEN TO SUSPECT OR RECOGNIZE?
a) Introduction: The prevalence of pre existing diabetes in pregnancy is increasing largely. As rates of obesity increase there is also increase in the incidence of gestational diabetes. Outcomes of diabetic pregnancies have improved for the mother and the newborn due to understanding of the disease process, improved education, and new treatment modalities delivered in a team approach. Nausea and vomiting from pregnancy and associated insulin resistance can make glycaemic control a challenge. Care of women with preexisting diabetes demands careful monitoring in the preconception, prenatal, and preipartum periods. Pregestational diabetics should plan conception only when their glycosylated haemoglobin levels are <6.5 to avoid congenital anomalies in their offsprings. Controversies still exist in screening, management, and treatment of gestational diabetes. b) Case definition: For both situations of care (mentioned below) Pre gestational diabetes: Women who present with keto acidosis or random plasma glucose levels greater than 200mg/dl plus classical signs and symptoms such as polyuria or polydipsia. American Diabetes Association (2004) also recommends that pregnant women with fasting glucose levels of 126mg/dl or greater be considered to have overt diabetes. Gestational diabetes mellitus: Current practice is a 2 step testing, screening and diagnosis. Universal screening is recommended in India as Asians are a high risk group for diabetes. O'Sullivan 50 g glucose, 1 hour screening test cutoff ranges from 130mg/dl to 140 mg/dl. The next step, diagnostic 3 hour 100gm GTT has atleast 2 different algorithms for diagnosis of GDM.
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Diagnostic parameters for the 3 hour, 100g GTT NDDGC time FBS 1hr 2hr 3hr CCC mg/dl 105 190 165 145 mg/dl 95 180 155 140
NDDGC-National diabetes data group criteria CCC -Carpenter-Coustan Criteria
Clinicians outside USA use 1 step 75 g glucose tolerance test. Here a fasting glucose level is obtained, after a 75 g glucose load a 1hr and 2 hr plasma glucose levels are measured.
II. INCIDENCE OF THE CONDITION IN OUR COUNTRY:

1-2% of mothers
III. DIFFERENTIAL DIAGNOSIS:

Glycosuria of pregnancy
IV. OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT AND REFERRAL CRITERIA:

Situation1: At Secondary Hospital/Non-Metro situation:Optimal standards of situation where technology and resources are limited a) Clinical diagnosis: As described in case definition. Women with risk factors for GDM should be carefully screened like the obese, prior GDM, prior macrosomic infant, elderly mothers, multiple pregnancy, south east Asians, Hispanics, African Americans, polycystic ovarian syndrome, family history of diabetes, periodontal disease, low maternal birth weight. Such women at very high risk may benefit from early screening in the first trimester. If early screening is normal, screening is repeated at 24 to 26 weeks.
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b) Investigations:
l Close monitoring of blood glucose and baseline and interval glycosylated haemoglobin
levels are helpful throughout pregnancy.

l Diet therapy- Capillary blood glucose levels 4 times a day( FBS and PPBS thrice) l On pharmaceutical therapy- will in addition need preprandial values. l Other
investigations required specially include ultrasound for dating, aneuploidy screening , anomaly scanning, growth profile monitoring for fetal weight, AFI and biophysical profile is necessary in poorly controlled diabetics.
l Non stress
test if necessary by 32 to 34 weeks especially in the poorly controlled diabetics. Lack of USG and NST facilities warrant referral to higher centers.
c) Treatment: Diet and exercise instituted first. Generally a 1900 to 2400 k cal/d with CHO restriction to 35-40% preferably complex high fiber carbohydrates with the help of a dietician is prescribed. 1 to 2 miles walk atleast 3 times a week recommended. Pharmacotherapy with insulin instituted when diet and exercise therapy fail as evidenced by an abnormality in more than half the self monitored glucose values or an abnormal value in those women tested weekly. Recommended initial dose of Insulin is, 0.7-0.8 U/kg body wt in the 1st trimester 1.0 U/kg body wt in the 2nd trimester 1.2U/kg body wt in the 3rd trimester Dose is adjusted according to the response of hyperglycaemia to initial therapy Of the calculated daily dose, 2/3rds is given before breakfast, divided as 2/3rd NPH insulin and 1/3rd regular insulin, and the remaining 1/3rd of the daily dose is given as 1/2 regular insulin before dinner and 1/2 NPH insulin at bed time. Antenatal care- twice weekly visits required. Well controlled diabetics can deliver at 40 weeks Poorly controlled non compliant patients on pharmacotherapy need antenatal testing for monitoring macrosomia or growth restriction and timely planning of delivery when fetus is optimally mature with lung maturity. Women with pregestational diabetes with nephropathy, retinopathy may worsen and warrant earlier delivery. Preeclampsia, and IUGR may set in. Good glycaemic control during pregnancy can avoid ketosis and sepsis.
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Diabetic ketoacidosis should be suspected when a pregnant diabetic mother presents with sugars 200mg/dl, vomiting and dehydration with low serum bicarbonate and presence of acetone as it could lead to fetal loss if not intensively managed. Labor and delivery- Women with presestational diabetes and GDM requiring pharmacotherapy are best managed with IV insulin drips and glucose monitoring protocols during labor. Women with very mild GDM may not require insulin therapy but should have blood glucose assessment during labor. When estimated fetal weight is above 4.5 kg elective caesarean is planned to avoid shoulder dystocia and birth trauma. In those where the EFW ranges between 4 to 4.5 kg other obstetric factors should be considered in decision making for caesarean section. Preparedness for the management of neonatal problems is a must. Post partum management: A 75 g GTT should be performed at the time of the routine post partum visit for GDM mothers. Subequently testing can be done annually or trianually(ADA recommendation) d) Referral criteria: When careful monitoring facilities are not available. For expert opinion regarding anomalies and paediatric surgery, for fetal echocardiography. When there are comorbidities warranting multidisciplinary input especially in pregestational diabetics and poorly controlled gestational diabetics. When there is need for intensive neonatal care unit to manage problems in the newborn. Situation 2: At Superspeciality Facility in Metro location where higher end technology is available. a) Clinical diagnosis: As described in situation1. b) Investigations: As described in situation I. c) Treatment: As described in situation 1. A multidisciplinary team is involved early in care and planned delivery is carried out in the presence of anomalies to facilitate optimal care in a tertiary center with good nicu and paediatric surgeons. d) Referral Criteria: Even in a metro situation not all centers will be equipped with the multiple specialists, skilled hands and facilities. The decision to refer to a better facility should be taken if it warrants to give the best care to the mother and the newborn.
V. FURTHER READING AND REFERENCES:

Williams Obstetrics Obstetrics and Gynaecology clinics of North America, June 2010, Vol 37, No 2
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NAME OF THE CONDITION: DYSFUNCTIONAL UTERINE BLEEDING

A) INTRODUCTION
DUB affects 22 to 30% of women and accounts for 12% of gynecological referrals. Within 5 yrs of referral, 60% of the women will have undergone hysterectomy, making it the commonest major gynecological operation. DUB is not one condition one etiology - it is a group of disorders characterized by dysfunction of any part of the reproductive system - uterus, ovary, pituitary, hypothalamus, higher centers. In clinical practice the precise nature of the dysfunction is often not determined and the diagnosis of DUB is usually made by exclusion of organic disease of the genital tract or systemic organic disease.
B) DEFINITION
It is defined as abnormal uterine bleeding without any clinically detectable organic pathology. DUB is also defined as abnormal bleeding from the uterus for which an organic causes, either of the genital tract or systemic cannot be found.
I) WHEN TO SUSPECT/RECOGNISE
History: H/o Abnormal Uterine Bleeding l Excessive menses-duration of menstrual flow > 7 days or menstrual blood loss > n 80 ml Frequent menses-duration of menstrual cycle < 21 days n Irregular / acyclical uterine bleeding. n H/o Symptoms Suggestive Of l Pregnancy n Dysmenorrhoea/ n dyspareunia/ infertility may suggest endometriosis and PID, fibroids, adenomyosis
H/o contraceptive practice, HRT n
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n Symptoms
suggestive of hypothyroidism, bleeding disorders, other systemic
illness
n Ingestion of drugs, like antiplatelet drugs (aspirin, clopedrogel)
Examination:
l A general examination for signs of anemia, thyroid disease or bleeding disorders. l Abdominal examination for masses. l All women with abnormal genital tract bleeding must have a speculum examination
to visualize the cervix, vagina and exclude any local cause.

l Per vaginal examination - look for uterine enlargement (fibroids), tenderness/fixity
(PID, endometriosis), any adnexal mass.
II) INCIDENCE: 22 to 30% of women

1. Pubertal or adolescent DUB - usually women less than 20 yrs, incidence - 4% 2. Reproductive DUB - seen in women from 20 to 40 yrs, incidence - 57% 3. Perimenopausal DUB - women aged above 40 yrs, incidence - 39% 4. Postmenopausal DUB - incidence around 10%
III) DIFFERENTIAL DIAGNOSIS

l Pregnancy related bleeding
n Abortions n Ectopic pregnancy n Guestational trophoblastic disease
l Fibroid uterus l Endometrial cancer l Thyroid abnormalities l PID, Endometriosis. l Endometrial TB l PCOS
SITUATION 1 Diagnostic Criteria, Investigation, Treatment & Referral Criteria Diagnosis

a) Clinical Diagnosis made by history and examination as explained above. Final diagnosis is done after investigation.
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b) Investigation
CBC l Thyroid profile l Platelet l count, BT, CT, PT, PTT especially in puberty menorrhagia not responding to treatment
Urine pregnancy test l LFT & RFT only in strongly suspected cases l USG - TAS/TVS. l Pap smear l Sonohysterography l D & Cl mandatory in perimenopausal age group (>40 years) and is contraindicated in unmarried girls, puberty menorrhagia. biopsy - by Novac curette - By Pipelle aspirator
Endometrial l
Hysteroscopy - with hysteroscopic guided biopsy sensitivity is 98%. l Laparoscopy l - to exclude unsuspected pelvic pathology such as endometriosis, PID/Ovarian tumor. The indication is urgent is associated with pelvic pain.
c) Treatment
General 1. Rest during bleeding phase of menstrual cycle 2. Resume activities between periods to prevent pelvic congestion 3. Assurance and sympathetic handling of physiological or emotional problems 4. Correction of anemia by diet, haematinic and even by blood transfusion 5. Clinically evident systemic/endocrine abnormalities should be investigated and treated accordingly
d) Medical Management:
Non hormonal methods: Anti fibrinolytic l agents - tranexemicacid - 500 mg twice or thrice daily oral/IV. Effective in ovulatory DUB, iatrogenic menorrhagia secondary to insertion of IUCD, Von Wilibrand's disease 690
l Prostaglandin synthetase inhibitors (NSAIDS) - Mefenamic acid - 250 mg - 500 mg -
twice or thrice daily, effective in ovular DUB

l Ethamsylate - 250 - 500 mg TDS oral/IV l Antitubercular treatment when disease is confirmed
Hormonal Methods: To stop acute episodes of bleeding and to regulate the cycles
l Progestins
Tab nonethisterone 20 - 30 mg/day in divided doses Arrest bleeding in 24 - 48 hrs later dose is tapered and continued in cyclical fashion from 5th day of withdrawal flow. Similarly Medroxy progesterone acetate (MPA) can also be used.
l Cyclical therapy:
In ovular bleeding: OCP is given from 5th to 25th day of cycle for 3 consecutive cycles.In ovular bleeding where patients wants pregnancy or in case of irregular shedding or ripening dydrogesterone 10 mg per day from 16th to 25th day. In anovular bleeding: MPA 10mg 5th to 25th day, NE 5mg 5th day to 25th day for 3 consecutive cycles
l DMPA
- 150 mg I.m every three months useful in maintenance therapy in woman who have difficulty with or cannot take OCPs.
l Ormeloxifene (Sevista) - 2 tab of 60 mg/week that is on Sunday and Wednesday for
12 weeks, 1 tab of 60 mg on following Sunday or Wednesday for 12 weeks

l Levonorgestrol - Releasing IUD(Mirena)
Surgical Management
l Hysterectomy - TAH/vaginal hysterectomy/laparoscopic hysterectomy.
e) Referral Criteria
l Puberty
menorrhagia where bleeding disorders are suspected and further investigation are to be done.
l Young
women who wants to preserve the uterus and facilities for endometrial destruction and ablation are not available.
l Associated comorbid medical conditions in which surgery is required.
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SITUATION 2 Diagnostic Criteria, Investigation And Treatment a) Diagnosis As in situation 1 b) Investigation In addition to investigations as in situation 1, certain specific tests like Specific tests for bleeding disorders c) Treatment Along with the general and medical treatment as mentioned in situation 1. l Conservative surgeries like l Endometrial destruction or ablation - hysteroscopic and non hysteroscopic methods are available (TCRE, uterine thermal balloon ablation, radio frequency induced endometrial ablation, etc.) Criteria to be filled for undergoing these procedures: To exclude atypical endometrium n CIN, Ca cervix, Ca endometrium has to be ruled out n Not expecting 100% amenorrhea n Uterus size less than 12 weeks n No pelvic inflammatory disease n Completed family n If necessary patient should be ready to undergo hysterectomy n Ready for regular follow up n Surgically fit n Patient should know that its not effective contraception n These criteria hold good for all types of ablation and destructive methods. Associated comorbid medical conditions in which surgery (Hysterectomy, Endometrial l destruction or ablation) is required.
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NAME OF THE CONDITION: ECTOPIC PREGNANCY

I. WHEN TO SUSPECT/ RECOGNIZE?
a) Introduction: Implantation of the embryo outside the uterine cavity commonly the fallopian tube.The risk of death from an unrecognised ectopic pregnancy is greater than that of an induced abortion or delivery. Prognosis for a successful subsequent pregnancy is reduced in these women. With earlier diagnosis, both maternal survival and conservation of the reproductive capacity are enhanced. Risk factors for ectopic pregnancy are PID, endometriosis, IUCD use, progesterone only contraceptive pill use, pregnancy after tubal ligation, tubal surgery, ovulation induction and assisted reproduction techniques, b) Case definition: For both situations of care (mentioned below) Implantation of the embryo anywhere else other than the endometrial lining of the uterine cavity is an ectopic pregnancy.
II. INCIDENCE OF THE CONDITION IN OUR COUNTRY:

1 to 3% of all pregnancies.
III. DIFFERENTIAL DIAGNOSIS:

Very early intrauterine pregnancy Heterotopic pregnancy
IV. OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT AND REFERRAL CRITERIA

Situation1. At Secondary Hospital/ Non Metro situation: Optimal Standards of treatment in Situations where technology and resources are limited. a) Clinical Diagnosis: Presentation could be diverse depends on whether rupture has occurred. The reproductive age group woman may present with amenorrhoea, bleeding pv, pain abdomen, sometimes with shock due to rupture.
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b) Investigations: A urine pregnancy test should be positive Ultrasound -abdominal/ vaginal- thickened echogenic endometrium, absent intrauterine gestational sac, sometimes a pseudosac, fluid in the culde sac, occasionally haematosalpinx, adnexal mass or a tubal ring representing the gestational sac. Culdocentesis if ultrasound facility is not available Blood grouping crossmatching and reservation Histopathological examination of the operative specimen to confirm diagnosis. c) Treatment: The standard aim of care is to control the bleeding and remove the ectopic pregnancy Start an IV line, arrange for blood transfusion, rush patient to the operating room. General anaesthesia, IV antibiotic prophylaxis given and catherised. Abdomen entered through a transverse suprapubic inscision. The affected tube is brought out and salpingectomy is performed. Strict haemostatsis secured. Peritoneal cavity cleared of blood and blood products. Mops and instruments counted and abdomen closed in layers. Blood transfused depending on the amount of loss and post op haemoglobin. Inj Anti D immunoglobulin given if the lady is Rh negative and husband Rh positive Patient should be advised to report immediately in future pregnancies d) Referral Criteria: When an unruptured ectopic pregnancy is diagnosed and facilities are lacking for timely monitoring of serum beta hcg titres and medical management. When patient is stable and facilities or skill to offer laparoscopic surgery are not available When heterotopic pregnancy is diagnosed and patient is desirous of continuing with the intrauterine conception. After a life saving laparotomy, for need of blood transfusion.
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Situation2.: At Superspeciality Facility in Metro location where higher end technology is available. a) Clinical diagnosis; Similar to situation 1 b) Investigations:As in situation 1. Special investigations like Serum Beta HCG titres need estimation serially to facilitate expectant management or medical manangement with Methotrexate. When Methotrexate is used, CBC, LFT, RFT will be needed. c) Treatment: When ruptured ectopic is diagnosed laparotomy may be done as in situation 1. When laparoscopy is chosen- Salpingostomy or salpingectomy is peformed. Expectant management: Proportion of all ectopics will not progress to tubal rupture, but will regress spontaneously and be slowly absorbed. Level of hCG must fall and the woman becomes clinically well. On hcg monitoring if the level increases active medical management is resorted to. Medical management with Methotrexate- A single dose of 1mg/kg body weight or 50mg/square metre body surface area of methotrexate given intramuscularly in addition to leukovorum(folic acid antagonist) 0.1mg/kg IM. Methotrexate should not exeed 4 doses There is 70-95% efficiency in the treated cases. It takes 4-6 weeks for the complete resolution of ectopic pregnancy with methotrexate. Methotrexate is also useful in the management of persistent ectopic which is a complication of conservative surgical treatment and incomplete removal of trophoblastic tissue. d) Referral criteria; Patients with comorbidities requiring multidisciplinary input. When skilled manpower and facilities are not available. When it is a heterotopic pregnancy usually a consequence of assisted reproductive techniques, referral to an ART center for further care is necessary.
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V. FURTHER READING AND REFERENCES:

l RCOG Guidelines l Williams Obstetrics l Te Linde's Operative Gynaecology l Novaks Text book for Gyanecology l Novaks Text book for Gyanecology Resources required for one patient/procedure
Situation 1. Human resources Gynaecologist Anaesthetist Nurses 2
Gynaecologist Assistant doctor Anaesthetist Nurses x 3 Sonologist Technicians x2 House keeping Blood bank officer
Investigations Blood tests
Drugs and consumables
Equipment Boyles OT Laparotomy set
2.
Blood tests HCG quantitative
Methotrexate
Boyles OT Laparotomy set Laboratory Ultrasound machine
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NAME OF THE CONDITION: LEIOMYOMA UTERUS /FIBROMYOMA / FIBROID UTERUS

I. INTRODUCTION AND CASE DEFINITION:
Leiomyoma of uterus also called as fibromyoma or fibroid uterus is a benign tumor of uterus, essentially composed of smooth muscle tissue and a variable amount of fibrous connective tissue. It is the most common tumor of uterus and female pelvis, and is found in 20% of women in reproductive age group. 1 Leiomyomas are the reason behind one-third of all hospital admissions to gynecology services and one of the commonest indications for hysterectomy. 2 This tumor is more common among older nulliparous and obese women, particularly the ones with family history of this disease. Based on the location of tumor in the uterus, the various types of myoma are-subserous, intramural and submucous fibroids.
II. INCIDENCE OF FIBROID IN INDIA

Nearly 20-30% women in reproductive age group have fibroid uterus. At any given time, nearly 15-25 million Indian women have fibroid uterus.
III. DIFFERENTIAL DIAGNOSIS

Adenomyosis l Bicornuate uterus l Ovarian tumor l Retroperitoneal connective tissue tumor l Calcified tuberous pyosalpinx l Complications: Torsion of pedunculated subserous fibroid l Infection of submucous myoma l Ascites may be caused rarely by pedunculated subserous fibroid l Intraperitoneal l (rare) hemorrhage from rupture of a large vein on the surface of myoma
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l Malignant change in 0.2% of uterine fibroids l Degeneration (Hyaline/Cystic/Fatty/Red degeneration) l Pregnancy
complications like spontaneous abortion, preterm delivery, abruption-
placentae
l Labor complications: Inertia, Dystocia, PPH
Pelvic pathologies commonly co-existant with fibroid uterus

l Endometrial hyperplasia and endometrial polyps l Endometriosis l Anovulation and dysfunctional uterine bleeding l Pelvic inflammatory disease l Tubal pregnancy

Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited a) Clinical diagnosis: History
l Most leiomyomas are asymptomatic and are diagnosed incidentally l Bleeding-Menorrhagia, Meno-metrorrhagia
n Continuous/irregular
bleeding and blood-tinged discharge per vaginum may occur in cases of surface ulceration of submucosal fibroid polyp.
l Pressure symptoms-Pelvic discomfort or feeling of heaviness in pelvis

n Acute urinary retention n Urgency or frequency of micturition n Rarely dyspepsia or constipation
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Pain -Dysmenorrhoea l Lower n abdominal and pelvic pain: Not a common symptom but may occur in cases of fibroid polyp/ torsion of pedicle of subserous pedunculated fibroid/ degeneration of fibroid/ sarcomatous change in fibroid
Infertility l Pregnancy complications-Abortions, preterm labor, Malpresentations l Labor complications-Inertia, Dystocia, PPH l Examination General l physical examination-Pallor may be present in cases of anemia due to menorrhagia.
Abdominal l
examination may reveal a firm, non-tender, rounded/lobulated mass with side to side mobility and which is dull to percuss. (Only in cases of huge fibroids)
Bimanual pelvic examination reveals an enlarged irregular firm uterus, but it may be l symmetrically enlarged in cases of submucous fibroid. Subserous fibroid may be felt attached to the uterus or it may be felt as an adnexal mass in case it is pedunculated. Submucosal fibroid polyp may be seen/ felt coming out of the cervix into the vagina. b) Investigations CBC l Blood grouping l Urine routine and microscopy l Ultrasonography l Pap smear l Endometrial biopsy when required. l c) Treatment Treatment modality should be individualized to each patient after considering patient's age, severity of symptoms, need for fertility preservation, presence of other gynecological diseases and any other co-morbidity.
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Leiomyomas l
discovered incidentally and not associated with any complications usually do not require any treatment. Such patients should be explained, reassured and called for examination at periodic intervals.
Asymptomatic fibroid may warrant treatment in following situations: The size of fibroid uterus is more than 12-14 weeks pregnant uterus n Rapidly growing fibroid n Evidence n of hydroureter / hydronephrosis resulting because of compression of ureters by the tumor.
Subserous n General l
pedunculated fibroids are liable to undergo torsion of pedicle and hence may be treated even if asymptomatic.
measures: Correction of anemia with hematemenics (iron & folic acid). Severe anemics with ongoing blood loss may require packed cell transfusion.
Medical l
management: Gonadotropin- releasing hormone agonists may be given pre-operatively in order to reduce blood loss and operating time prior to hysterectomy, myomectomy or myolysis.
Indications of GnRH agonists adminstration: Correction of anemia in these patients prior to planned surgery. n Short term alternative to surgery in perimenopausal females. n Disadvantages of giving GnRH agonists High cost n Side effects like hot flashes & vaginal dryness n Risk of development of osteoporosis if given for more than 6 months. n Higher n risk of recurrence of fibroids after myomectomy if GnRH analogues have been given pre-operatively.
Surgical treatment l Hysterectomy is the surgical removal of uterus which may be done abdominally/ n vaginally or laparoscopically based on the size of uterus, mobility and descend of uterus, patient's desire and presence of other gynecological diseases and other co-morbidities. In women who don't wish to preserve uterus/ fertility, hysterectomy is a definitive treatment. Disadvantages of hysterectomy are the surgical and anaesthetic risks involved in the same.
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n Myomectomy is the surgical removal of myomas while uterus is being preserved.
This may be done abdominally/ vaginally/laparoscopically or hysteroscopically, depending on the site and size of myomas. The merit of myomectomy lies in preservation of fertility but the disadvantage is risk of recurrence of fibroids, which may require a repeat surgery. Myomectomy is usually preferred in patients less than 40 years of age, who wish to preserve their menstrual and reproductive functions. Vaginal myomectomy is suitable for patients with submucous pedunculated fibroid projecting into vagina. d) Referral criteria
l Patients
desirous of fertility who can be managed by laparoscopic / hysteroscopic myomectomy should be referred to a super specialty hospital, in case facilities for the same are not available in situation1.
l In case laparoscopic hysterectomy is planned and adequate facilities / equipment /
skilled laparoscopic surgeon / anaesthetist are not available, patient should be referred to a super specialty hospital in a metro location.
l Patients suitable for uterine artery embolization procedure/myolysis l Presence of co-morbidities like cardiac diseases, pulmonary diseases etc.
Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available a) Clinical diagnosis- Same as situation1 b) Investigations
l CBC l Blood grouping l Urine routine and microscopy l Ultrasonography (Transabdominal & transvaginal) l Sonohysterography /Hysteroscopy l Pap smear l Endometrial biopsy where indicated. l Magnetic resonance imaging (if needed)
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c) Treatment Treatment modality should be individualized to each patient after considering patient's age, severity of symptoms, need for fertility preservation, presence of other gynecological diseases and any other co-morbidity. Management of asymptomatic fibroids, general measures and medical management as already mentioned in situation1.
l Surgical
treatment options are as already mentioned in situation1.Laparoscopic hysterectomy or laparoscopic myomectomy can be offered in case where patient does not have any cardiac or respiratory disorders which contradict the same. Very large tumors may limit the suitability of the case for laparoscopic management. Subserous pedunculated fibroids are usually good candidates for laparoscopic myomectomy. Hysteroscopic myomectomy can be done for symptomatic submucosal fibroids. Laparoscopic Myolysis or myoma coagulation is usually done with Nd:YAG lasers or bipolar needles. This results in necrosis and shrinkage of myoma. It may be combined with endometrial ablation to reduce bleeding.
l Non-surgical treatment:
n
Uterine artery embolization is an interventional radiologic procedure to occlude uterine arteries and hence relieves menorrhagia in more than 90% of patients. In this procedure, a micro-catheter is introduced into the uterine artery via femoral approach and usually polyvinyl alcohol foam particles are used to occlude uterine arteries. This results in infarction of myomas. It has the advantage of being a minimally invasive procedure, avoids surgery and entails a shorter duration of hospital stay. Its role in preservation of fertility is yet undetermined pending long term studies. The disadvantage is risk of symptom recurrence in nearly 17% cases.
V. REFERENCES
1. Pratap Kumar , Narenda Malhotra. Jeffcoate's principles of gynecology. 7th ed. Jaypee publishing; 2008 2. Rock, John A.; Jones, Howard W. III. Te Linde's Operative Gynecology. 10th ed. Lippincott Williams & Wilkins (LWW); 2008
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NAME OF THE CONDITION: PRE ECLAMPSIA

I. WHEN TO SUSPECT OR RECOGNIZE:
Definition: A disorder associated with pregnancy consisting of hypertension, proteinuria and new onset edema after 20 weeks of gestation.
II. INCIDENCE:
Pre-eclampsia : 6-8% of pregnancies Eclampsia: 0.05-0.2%
III. PREVENTION AND COUNSELLING:

Not standardized. l IF APLA - early onset PIH & IUGR in the previous pregnancy Low dose aspirin maybe l started from the time of documentation of fetal heart by ultrasonogram.

*Situation 1: Optimal Standards of Treatment in Situations where technology and resources are limited (PHC) a) Clinical Diagnosis: Absolute rise of B.P. equal to or more than 140/90 mm Hg. The rise shouldbe evident l on at least two occasions 6 hours apart or a single reading of B.P. of 160/110 mm Hg or more. Urinary proteinuria l Symptoms: Headache, Edema, Visual disturbance, Epigastric pain, Decreased urine output. Signs: Bp>140/90 mm Hg Tachycardia Tachypnea Generalised edema
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b) Investigations: Mother: Hb CBC (Plateletcount) Pheriperalsmear Liver Function Test Renal Function Test Serum Uricacid Coagulation profile 24hrs Urinary protein Baby: CTG USG- BPP (NST & AFI) Fetal growth charts Doppler of velocimetry of umbilical artery and MCA (If IUGR) Treatment: Clinical monitoring of mother & fetus Deliver at GA at which the newborn is salvaged in that place
No drugs: - If BP 140/90 is maintaining - Fetal growth is satisfactory - Rest, left lateral position - Lifestyle adjustment - No added salts in diet. Antihypertensives: If diastolic BP ? 100 mmHg. Tab. Methyldopa Tab. Nifedepin Tab. Labetelol
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Clinical Monitoring: Mother: Daily weight gain. Check BP twice a day Edema to be checked daily Monitor urine output - I/O Chart Fundus examination Imminent S/S - headache, blurring of vision & epigastric pain to be asked daily. Urine albumin daily Baseline RFT & repeat everyweek Baby: DFMC FH - record daily Fundal height assessment every week NST & AFI weekly twice Doppler study if necessary Seizure Prophylaxis: Incase of severe preeclampsia prophylactic MgSO4 maybe given as seizure prophylaxis. Criteria for Delivery: Severe IUGR with absent diastolic flow Severe IUGR - GA ? 34 wks. Persistent proteinuria - Urine Alb - 2 + & more. BP 160/110 mm Hg despite treatment Urine output < 400ml in 24hrs. Imminent symptoms. FHR repetitive decelerations with poor variability
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Management During Labour: FHR monitoring Avoid fluid overload Uterine contractions monitoring Ergot containing drugs are contraindicated in hypertensive. Inj. PGF2 250 IM, Inj. Pitocin 10U IM can be given. Keep all emergency drugs ready. c) Referral Criteria: Complicated preeclampsia - organ failure - fetal complications - DIC - HELLP Syndrome. To be refer to higher centres. Situation II: - Clinical diagnosis - Maternal monitoring - Fetal monitoring - Delivery Same as in situation I Complicated preeclampsia is managed with multiple specialists (Nephrologist, Respiratory Physician, Anaesthetist, Heamotologist, Obstetrician) in ICU. CVP monitoring plays a vital role.
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ECLAMPSIA I) DEFINITION :
Preeclampsia when complicated with convulsion & coma is called eclampsia.
II) INVESTIGATION:
HB CBC Blood Group & Rh RFT LFT Coagulation profile Peripheral Smear Serum uricacid Serum electrolytes Urine - routine USG with Fetal Doppler
III) TREATMENT:
A) General & Fluid Management: Receive in a cot with side railing Mouth gag Suctioning of mouth O2 - Nasal Record vitals Temp, Pulse & BP Fundus examination IV line. Fluid RL 100ml / hr Give anticonvulsant (MgSO4 as given below) Bladder catheterization (I/O chart) Do PA & PV examination. Keep emergency drugs, CVP line, Ventilator ready.
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B) Anticonvulsant Management: 1. MgSo4 Loading Dose - MgSO4 4 gm in 20 ml of Dextrose 5 % as 20% solution IV over 5 minutes. And MgSO4 10gm as 50% solution (5gm IM on each buttock) preferably with 2% lidocaine - If convulsion recur, after 15 minutes, give 2gm MgSO4 IV over 2 minutes. Maintenance Dose MgSO4 5gms (50% solution) + 1 ml lidocaine 2% IM every 4hrs into alternate buttocks. - Continue treatment with MgSO4 for 24hrs after delivery or the last convulsion whichever occurs later. Monitor - The following every 4hrs. Knee jerk both legs Urine output (atleast 30ml/hr) Respiratory rate (atleast 16 - 18 /min) Serum Magnisum levels C) Withhold MgSO4 o If knee jerk absent o Urine output < 30ml/hr o RR < 16/min Inj. Calcium Gluconate 10% 10ml IV slowly to antagonize the effect of MgSO4. 2. Diazepam 3. Phenytoin 2 & 3 Should be used only in Situation II under the guidance of physician & respiratory care anaesthetist. D) Antihypertensives Management: 1. Oral Nifedepin 10mg. 2. IV Labetalol 10mg IV initial dose followed by 20mg IV after 10 minutes, If BP not controlled 40mg IV after 10 minutes. 3. IV Hydralazine 5 - 10mg every 15 - 20 minutes (maintain diastolic BP - 90mmHg)
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IV)DELIVERY:
Assess the Cervix & do Vaginal delivery by doing ARM & acceleration with oxytocin l drip. Prostaglandin gel if necessary can be used. l Deliver regardless of GA l Caesarian Section - If labour not progressing well l FH abnormalities l Cx unfavourable l
V) POSTPARTUM CARE
Continue l anticonvulsive therapy for 24 hours after delivery or last convulsion, whichever occurs last.
Continue antihypertensive therapy as long as the diastolic pressure is 110mmHg or l more Continue to monitor urine output. l Watch l carefully for the development of pulmonary oedema, which often occurs after delivery.
VI)COUNSELLING FOR FUTURE PREGNANCIES:

Onset of Preeclampsia ? 30wks - 40% recurrence in subsequent pregnancy.
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NAME OF THE CONDITION: PROLAPSE UTERUS

A) INTRODUCTION:
Genital prolapse is oldest and most common gynecological operative problem. The exact incidence in out country is not known, but from published data - 13% of total women have pelvic organ prolapse. Among these only 20% undergo surgery.
B) DEFINITION:
Pelvic organ prolapse is the downward displacement of the structures that are normally located adjacent to the vaginal vault.
I) WHEN TO SUSPECT/RECOGNISE:
The following history given by the patient should arouse a suspicion of prolapse of the uterus: 1. Mass coming down per vaginum, weakness in the perineal region, dragging sensation, bearing down sensation. 2. Urinary symptoms - incomplete voiding of urine, frequency of micturition, stress incontinence 3. Vaginal discharge - leucorrhoea, blood stained discharge 4. Incomplete evacuation of the faeces 5. Sexual dysfunction and dyspareunia - a huge prolapse may interfere with coites 6. Lower back pain - relieved by lying down 7. Systemic symptoms of precipitating diseases Chronic bronchitis and asthma l Mass per abdomen, ascites l Constipation l Retention of urine l
II) EXAMINATION OF THE PATIENT:

Local examination of external genitalia Perspeculum examination 710
Degree of prolapse - level of descent in relation to introitis Check for cervical changes
l elongation l decubitus
and hypertrophy of cervix, atrophy
ulcer or ulcer suspicious of malignancy. - white/blood stained
l keratinisation l discharge
Anterior /posterior vaginal wall defects Stress in continence Per vaginum examination: size, mobility of uterus, any other palpable mass Rectovaginal examination Abdominal examination - mass per abdomen/free fluid Spine - to rule out neurological and anatomical defect
III) DIFFERENTIAL DIAGNOSIS

l Congenital elongation of Cervix l Fibroid polyp l Gartner's cyst l Chronic inversion of uterus l Local mass in vagina
Situation 1
Diagnostic Criteria, Investigations, Treatment & Referral Criteria

a) Diagnosis
l Clinical diagnosis l Confirm the diagnosis by per speculum, per vaginal and rectovaginal examination. l Investigation
b) Investigation Routine Investigation 1. CBC, blood grouping and RH typing 2. FBS, PPBS
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3. Blood urea, serum creatinine 4. ECG, chest X-ray 5. Stool for ova, cyst and worms Special Investigations 1. USG of abdomen and pelvis to rule out associated pelvic pathology and renal problems due to pressure effect on ureter 2. Papsmear 3. D & C - if menstrual disturbances are present 4. Cervical biopsy - done when malignancy is suspected 5. IVP - where kinking of ureter is suspected in long standing cases and residual volume of urine is more than 100 ml c) Treatment Approach Types of management of prolapse 1. Expectant Management 2. Non- surgical pessaries 3. Surgical
Expectant Management
i. Physiotherapy
l Useful in minor degrees of uterovaginal prolapse l During 6 months following delivery.
PFMT (Pelvic Floor Muscle Training) - Kegel's exercise - Patient is taught to voluntarily contract the sphincters- initially 15 times each of 3 seconds, duration 6 times per day for 3 weeks and then less frequently for 6 months. ii. Pessary Treatment It is non-surgical and palliative. Ring and round pessaries are used.
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Indications:
l Pregnancy l Medical disorder which make operation unsafe
- Patient refuses operation - To help healing of decubitus ulcer Surgery Pre Operative Preparation 1. Daily vaginal douching to prevent the infection and sterilize the vagina. 2. Tampoon to reduce to the prolapse and replace the organ back. 3. It helps to prevent kinking of ureter and congestion of organs and also increase the blood flow. 4. If the vaginal walls are senile and atropic, oestrogen can be given in the form of cream twice daily. 5. Correction of anemia. 6. Treatment of UTI. 7. Treat diabetes and hypertension 8. Treat other systemic infection
Factors determining the choice of surgery Type of operation selected depends upon: 1. Age of the patient, her desire to preserve the menstral and reproductive functions and a functioning vagina. 2. Degree, type, components of prolapse Presence of adnexal or uterine pathology in the form of TO mass, myomas, ovarian tumors Innumerable surgeries have been designed; most suitable method for each patient is selected.
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Surgical Principles Management of advanced and symptomatic prolapse is primarily surgical. Anterior Compartment Defect: Anterior colporraphy Central Compartment Defect: Includes uterine prolapse, enterocele, eversion of vault The choice of operation to this defect ranges from
l Hysterectomy with colporraphy and colpopexy l Colpocleisis or colpectomy
Hysterectomy 1. Transabdominal surgery 2. Transvaginal surgery Transabdominal Surgery This route is useful when the abdomen is open for an unrelated reason such as removal of an ovarian tumor. In selected patients - Abdominal sacrocolpopexy in conjunction with TAH. Transvaginal Surgery Vaginal hysterectomy Enterocele Repair 1. Mild and moderate degrees of prolapse - posterior culdoplasty is done for closing cul-de-sac. 2. Advanced prolapse - posterior culdoplasty + suspension procedures + posterior colpoperiniorraphy Posterior Compartment Defect Posterior colpoperineorraphy- it is correction of rectocele with restoration of perineal body.
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Conservative Surgical Approaches

Sling Surgeries Indication: 1. Nuliparous prolapse 2. 2nd and 3rd degree prolapse with no or minimal cystocele and/or rectocele and no supravaginal elongation of the cervix 3. Women decides to continue child bearing function Conservative Surgeries Manchester's operation (fothergill's) l Shirodkar's modification of fothergills l Obliterative Procedures Lefort's operation - partial colpocleisis
d) Referral Criteria
Patients with following high risk factors should be refer to higher centers. 1. Previous history of pelvic surgery 2. Presence of urinary or fecal incontinence 3. Presence of urethral hypermobility 4. Presence of pelvic floor neuropathy 5. Co morbid medical conditions
Situation 2 Diagnostic Criteria, Investigations, Treatment A) Diagnosis

As in situation 1
B) Investigation
As in situation 1 in addition if urinary dysfunction is present, urodynamic studies like cystometry Urethrocystometry
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Uroflowmetry Mictruation cystourethrography Uroprofilometry Videocysourethrography MRI studies for defect in pelvic fioor muscle and supporting fascia Neuophysiological testing like concentric needle electromyography and single fibre electromyography.
c) Treatment.
1. As in situation 1 2. Anterior Compartment Defect Combined approach with urologist for treatment for Stress Incontinence when present
l Conservative therapy l Surgical repair
3. Central Compartment Defect Vault suspension procedures 4. All surgeries for patients with associated comorbid condition which can't be handled in situation 1
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OBSTETRICS & GYNAECOLOGY GUIDELINES

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OBSTETRICS & GYNAECOLOGY

OBSTETRICS AND GYNAECOLOGY

Dr.Anil Kamath-Surgical Oncologist Dr.Rajiv Aggarwal-Neonatology'st Dr.Sharath-Haemotologist Dr.Shakuntala Baliga

NAME OF THE CONDITION: ADENEXAL MASS

II. DIFFERENTIAL DIAGNOSIS:

or > 50 years old with one or more of the following

COMPLETE STAGING FOR OVARIAN CANCER

washings from pelvis, bilateral paracolic gutters, and infradiaphragmatic

l Biopsy of any additional suspicious findings

CRITERIA FOR LAPAROSCOPIC REMOVAL OF THE ADNEXAL MASS

NAME OF THE CONDITION: ANEMIA IN PREGNANCY

I. WHEN TO SUSPECT/ RECOGNIZE?

Moderate 5-7 gm/dl below 5 gm/dl

II. INCIDENCE OF THE CONDITION IN OUR COUNTRY

III. DIFFERENTIAL DIAGNOSIS

l Drug induced l Tuberculosis l Inherited disorders l Anemia caused by inflammation/ malignancy.

IV. OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT & REFERRAL CRITERIA

Treatment of Iron deficiency has included:

give it after meals Or

Or Parenteral Therapy: Indicated:

l Malaria prophylaxis in endemic area to be treated.

Treatment of Folic Acid/ Vitamin B12 deficiency

serum iron serum iron binding capacity

l Hb electrophoresis l Bone marrow aspiration/ Biopsy

C) Treatment: Same as situation 1

Treatment of IDA has included : l

Oral iron Intramuscular iron Iron dextran

Iron Sucrose Complex

Recombinant erythropoietin and

congestive cardiac failure/ PIH / Placenta Previa if associated/ where indicated.

2. At Super Specialty Facility in Metro location where higher-end technology is available

. FURTHER READING / REFERENCES

NAME OF THE CONDITION: ANTE PARTUM HAEMORRHAGE

Trauma to cervix or vagina

Carcinoma of cervix or polyps

Advancing maternal age

Multiparity Multifetal gestations

Prior cesarean delivery

Prior placenta previa

Differential Diagnosis : abruptio placentae, other minor causes.

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

results can occur secondary to focal uterine contractions or bladder distention.

the lower uterine segment.

determining the presence of placenta accreta.

Cause is unknown .But risk factors are

Complications: Complications include the following:

Fetal heart monitoring may l c) Treatment :-

a) Stable patient (Grade I) management :

a) Bleeding into myometrium results in hypotonic wall b) Risk of Postpartum Hemorrhage

Evaluation of foetal presentation, size, foetal well-being and placental

a transfusion if the patient is hemodynamically unstable after fluid resuscitation.

FURTHER READING / REFERENCES

NAME OF THE CONDITION: CAESAREAN SECTION

II. INCIDENCE OF THE CONDITION IN OUR COUNTRY

III. OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT AND REFERRAL CRITERIA:

IV. FURTHER READING/ REFERENCES:

Senior obstet Junior doctor Anaesthetist Nurses x3 Ot technician

NAME OF THE CONDITION: CARCINOMA CERVIX

II. INCIDENCE IN INDIA:

IV. DIFFERENTIAL DIAGNOSIS

a) Clinical Diagnosis: History:

l Per vaginal examination: Expanded firm/friable irregular cervix l Recto-vaginal

l Colposcope guided biopsy to be done in cases where there is abnormality detected