Handbook of Obstetrics Guideline PDF

MOH/P/PAK/535.24(GU)-e ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE MINISTRY OF HEALTH MALAYSIA MEDICAL DEVELOPMENT DIVISION 1 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL...

MOH/P/PAK/535.24(GU)-e ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE MINISTRY OF HEALTH MALAYSIA MEDICAL DEVELOPMENT DIVISION 1 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION 2 ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE MINISTRY OF HEALTH MALAYSIA HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVELOPMENT DIVISION 3 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION MOH Handbook of Obstetrics Guideline was developed by the Obstetrical & Gynaecological and Paediatric Services Unit of the Medical Development Division, Ministry of Health Malaysia in collaboration with Jawatankuasa Pengurusan dan Perkembangan O&G KKM (JPPOBG) www.moh.gov.my Published in 2024 catalogue record of this document is available from the Institute of Medical Research, Ministry of Health; MOH/P/PAK/534.24(GU)-e It is also available from the National Library of Malaysia: e ISBN 978-967-25780-5-5 All rights reserved. No part of this publication may be reproduced or distributed in any form or any means, or stored in a database or retrieval system, without prior written permission of the Ministry of Health, Malaysia 4 ii  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE DISCLAIMER The Jawatankuasa Pengurusan dan Perkembangan O&G (JPPOBG) compiled the guidelines as an educational aid to good clinical practice. The information provides general advice for consideration by clinicians and other relevant health professionals, and should not be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of any patient. The ultimate judgment regarding a particular treatment or clinical procedure must be made by the clinician or other health professionals in light of clinical data presented by the patient and the diagnostic and treatment options available. The contents of the guidelines are not intended to be prescriptive directions defining a single course of management. This information has been prepared based on the information available at the time of its preparation, and each practitioner should be cognizant of the relevant information, research or material which may have been published or become available subsequently. Whilst the authors endeavour to ensure that information is accurate and current at the time of preparation, they take no responsibility for matters arising from changed circumstances or information or material that may have become subsequently available. The rapid advances in medical science mean that drug dosages, laboratory tests and diagnosis in particular, should be independently verified. iii 5  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Preface The practice of obstetrics involves decision-making during a major transitional period of a woman’s life, which frequently culminates in the most challenging, final 10 centimeter journey through the birth canal. Decision-making which is professionally responsible, empowers women, provides them a sense of autonomy and increases their satisfaction of clinical care received. In order to provide this, the attending clinician has to be able to provide evidenced-based and accepted professional standards of care. With this in mind, various guidelines have been drawn by different states and hospitals in Malaysia over the years to guide clinicians. The purpose of this handbook is to provide a compendium of these local guidelines with contemporary updates from reputable sources such as the Clinical Practice Guidelines (CPG) and training manuals from the Ministry of Health, publications from the World Health Organization (WHO), International Federation of Gynaecology and Obstetrics (FIGO) and guidelines from other international societies. The catalyst for this endeavor was mooted during the “Bengkel Halatuju Perkhidmatan O&G” in June 2022. The guideline editorial committee comprised of members of the Jawatankuasa Kecil Garis Panduan dan Amalan Klinikal, subcommittee of the Jawatankuasa Pengurusan dan Perkembangan O&G (JPPOBG) who drafted a scope based on existing local guidelines followed by nomination and amendment of the scope until a consensus was achieved. Various guidelines were compared and literature review was conducted by each member on their assigned topic to ensure that the contents were up to date. Individual topics were then discussed, amended and refined in various stages, first within the guideline editors and sent for internal review by all state consultants and other stakeholders. This handbook was designed for brevity and usability in mind, meant to aid the trainee or clinician during their daily encounter with obstetric patients within facilities (hospitals) of the Ministry of Health (MOH). iv 6  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE FOREWORD BY DIRECTOR-GENERAL OF HEALTH MALAYSIA Pregnancy, childbirth an the puerperium has been the number one cause of hospitalization in hospitals for the past decade. The Obstetrics and Gynaecology (O&G) service is unquestionably one of those with a lot of litigation and workload. We are combined in our commitment to make sure that O&G services at the Ministry of Health are provided with excellent quality and the highest calibre through the Jawatankuasa Pengurusan and Perkembangan O&G KKM (JPPOBG) under the auspices of the Medical Development Division, Ministry of Health Malaysia (MOH). The achieve Goal 3 in the 2030 Agenda of Sustainable Development Goals adopted by all the United Nations Members States in 2015, MOH is commited to ensuring that women in Malaysia are provided with consistent, high-quality, evidence-based maternity care. Malaysia has succeded in lowering the Maternal Mortality Rate since the 1960s as a result of ongoing efforts to improve the quality of services, including training for medical professionals an also practising evidence-based medicine. I would like to convey my gratitude to everyone who contributed, whether directly of indirectly to the creation of this handbook guidelines. All of these efforts should be fruitful for everyone concerned. DATUK DR. MUHAMMAD RADZI BIN ABU HASSAN Director-General of Health Malaysia 7 v  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION FOREWORD BY DIRECTOR OF MEDICAL DEVELOPMENT DIVISON, MEDICAL PROGRAMME, MINISTRY OF HEALTH MALAYSIA Evidence-based medicine has been given priority in numerous recent guidelines. It is our duty to determine which citeria, principally in terms of availability and case complexity, are appropriate for the current state of affairs in this nation. Regardless of their backround, giving patients the greatest care our priority. Thus, the creation of the Handbook of Obstetrics Guideline is regarded as a commendable attempt to enhance service quality through standardising and elevating the bar for health care provided by the O&G services. The Medical Development Division remains dedicated to organising plans, putting strategies in action, and carrying out MOH policies in close collaboration with the fraternity. Given that our contributors can contribute to the realisation of this handbook guidelines while still managing their existing wordload, recognition and gratitude are due for this kind of dedication. I would like to congratulate and acknowledge the effort of the drafting committee, especially the Jawatankuasa Kecil Garis Panduan dan Amalan Klinikal, Jawatankuasa Pengurusan dan Perkembangan O&G KKM (JPPOBG) and other contributors for this great initiative in preparing this edition. Thank you. DATO’ DR. MOHD AZMAN BIN YACOB Director of Medical Development Division vi 8  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE TABLE OF CONTENTS SECTION A Referrals -1 1. Antenatal specialist clinic 2 2. Combined (obstetric-medical) clinic 3 3. Early pregnancy assessment unit 5 4. Prenatal screening/diagnosis 6 5. Mid-trimester screening/anomaly scan 7 6. Inter hospital multidisciplinary referral 8 7. In-utero transfer 11 8. Obstetric retrieval team 13 SECTION B Early Pregnancy Problems - 15 1. Pregnancy dating 16 2. Bleeding in early pregnancy 18 3. Management of miscarriage 20 4. Pregnancy of unknown location 22 5. Molar pregnancy 24 6. Nausea & vomiting in pregnancy 26 vii 9 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION SECTION C Antenatal Problems - 29 1. Multiple pregnancy 30 2. Cervical insufficiency 37 3. Rhesus negative in pregnancy 40 4. Placenta praevia 45 5. Placenta accreta spectrum 48 6. Uterus larger than dates 51 7. Uterus smaller than dates 53 8. Abnormal lie and unstable lie at term 56 9. Breech presentation 58 10. Postdate pregnancy 62 11. Vaginal birth after Caesarean Section (VBAC) 64 12. Reduced fetal movement 67 13. Intrauterine fetal death (IUFD) 69 SECTION Selected Medical Disorders D in Pregnancy - 73 1. Anemia in pregnancy 74 2. Hypertensive disorders in pregnancy 77 3. Diabetes mellitus in pregnancy 82 4. Venous thromboembolism 88 5. Heart disease in pregnancy 92 6. Thyroid disease 99 7. Bronchial asthma 102 8. Hepatitis B 106 9. HIV in pregnancy 109 10. Syphilis in pregnancy 114 viii 10  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE SECTION Intrapartum Care (Normal E and Abnormal Labour) - 119 1. First stage of labour 120 2. Second stage of labour 122 3. Third stage of labour 124 4. Episiotomy 125 5. Obstetric anal sphincter injury (OASIS): Third and Fourth Degree Perineal Tears 127 6. Induction of labour/Augmentation 129 7. Operative vaginal delivery 134 8. Term prelabour rupture of membranes (Term PROM) 140 9. Preterm prelabour rupture of membranes (PPROM) 143 10. Preterm labour 147 SECTION F Obstetric Emergencies - 151 1. Maternal collapse 152 2. Amniotic fluid embolism 159 3. Obstetric haemorrhage 162 4. Preeclampsia with severe features and Eclampsia 182 5. Uterine inversion 192 6. Maternal Sepsis 198 7. Shoulder dystocia 203 8. Cord prolapse 212 9. Assisted vaginal breech delivery 215 10. Acute management of obstetric thromboembolism 221 11 ix HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION SECTION G Postpartum Care - 225 1. Routine postpartum care 226 2. Contraception 227 3. Postpartum placement of intrauterine contraceptive device 234 SECTION H Appendix - 243 1. Compilation of recommendations for antenatal corticosteroids to reduce neonatal morbidity and mortality 244 2. Oxytocin Induction/Augmentation Regime 249 3. Antibiotic prophylaxis in labour and delivery 251 4. Common drugs and dosages in pregnancy 254 5. Use of misoprostol in the medical management of miscarriage and termination of pregnancy 277 6. PPH box checklist 280 7. PPH management checklist 281 8. Resuscitative hysterotomy instrument checklist 284 12 x ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE SECTION A Referrals 1  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Referrals (from health clinics and non-specialist hospital) This chapter covers urgent and non-urgent referrals of obstetrics cases for specialist care. The use of SBAR (situation, background, assessment and recommendation) tool is recommended to facilitate effective communication between referring and referral centres. A1. Antenatal Specialist Clinic 1. Fetal indications: i. Suspected fetal growth restriction (FGR) ii. Fetal macrosomia or large for gestational age (LGA) iii. Polyhydramnios (AFI > 25 cm or DVP > 8cm) iv. Oligohydramnios (AFI < 5 cm or DVP < 2 cm)* v. Malpresentation after 36 weeks’ gestation vi. Antepartum haemorrhage (APH) follow-up vii. Suspected placenta praevia viii.Intrauterine fetal death (IUFD) ix. Multiple pregnancies x. Suspected fetal anomaly (if MFM unit not available) 2. Maternal indications: i. History of recurrent miscarriages (3 consecutive first trimester miscarriages) ii. Previous spontaneous preterm deliveries iii. History-indicated cervical cerclage and cases requiring cervical surveillance iv. Maternal obesity (BMI > 40 at booking) v. History of uterine or cervical surgeries vi. Hypertensive disease in pregnancy vii. Gestational diabetes and pre-existing diabetes in pregnancy viii. Stable maternal medical disorders such as epilepsy, bronchial asthma, hyperthyroidism, hypothyroidism** 2  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE ix. Maternal mental health problems in pregnancy or history of postpartum depression/psychosis x. Active substance abuse in pregnancy xi. Malignancy in pregnancy xii. Medico-legal cases in pregnancy e.g. OSCC This list is not exhaustive and further discussion with referral centres is recommended for cases requiring antenatal specialist clinic review. *Cases with borderline low AFI or DVP may be referred to antenatal specialist clinic assessment as well for confirmation of diagnosis. **Unstable or poorly controlled conditions may require urgent combined clinic appointment or admission. Adapted from: 1. Penang State Obstetrics Protocol, 2021. A2. Combined (Obstetric-Medical) Clinic 1. Maternal cardiac conditions: i. Any cardiac cases with modified WHO classification risk classes II, III and IV ii. Ischaemic heart disease iii. Chronic rheumatic heart disease iv. Heart rate abnormalities/arrhythmias v. Congenital heart disease 2. Maternal renal conditions: i. Chronic kidney disease ii. Acute renal disease iii. Lupus nephritis 3. Maternal respiratory conditions: i. Restrictive lung disease ii. Reversible lung disease 3 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION 4. Maternal neurological conditions: i. Myasthenia gravis ii. Myotonic dystrophy iii. Epilepsy. iv. Stroke (ischaemic/haemorrhagic). v. Guillain-Barre syndrome vi. Multiple sclerosis vii. Spinal cord injury viii. Migraine 5. Maternal rheumatological conditions: i. Systemic lupus erythematosus (SLE) ii. Antiphospholipid syndrome (APS) iii. Rheumatoid arthritis iv. Psoriatic arthritis v. Vasculitis 6. Maternal endocrinological conditions: i. Poorly controlled diabetes or diabetes with complications (retinopathy, nephropathy, end organ involvement) or Type I diabetes ii. Thyroid disease iii. Diabetes insipidus iv. Prolactinomas v. Adrenal disease vi. Calcium metabolism and parathyroid disease 7. Maternal gastroenterological conditions i. Intrahepatic cholestasis of pregnancy ii. Acute fatty liver of pregnancy iii. Hepatitis in pregnancy iv. Liver cirrhosis +/- portal hypertension v. Inflammatory bowel disease 4  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE 8. Maternal haematological conditions i. Immune thrombocytopenia ii. Bleeding disorders iii. Clotting disorders iv. Blood malignancies 9. Maternal infective conditions i. Viral hepatitis ii. Tuberculosis iii. Malaria iv. HIV This list is not exhaustive and further discussion with referral centres is recommended for cases requiring combined clinic review. Adapted from: 1. Penang State Obstetrics Protocol, 2021. A3. Early Pregnancy Assessment Unit (EPAU) (Only stable cases should be reviewed in EPAU. Unstable cases should be discussed directly with referral centres for immediate management) This list is not exhaustive, and further discussion with referral centres is recommended for cases requiring EPAU assessment. 1. Vaginal bleeding and/or pain in early pregnancy 2. Rupture of membranes in early pregnancy 3. Pregnancy of unknown location (PUL) 4. Nausea and vomiting in pregnancy (NVP) 5  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION A4. Prenatal Screening/Diagnosis DESCRIPTION Prenatal screening Prenatal diagnosis What it is To screen for chances of fetus To diagnose if fetus actually having aneuploidy or genetic has a certain disorder disorder Type Non-invasive Invasive Methods Combined test (nuchal Chorionic villous sampling translucency, maternal age, +/- (CVS) nasal bone, tricuspid valve flow, ductus venosus, PAPP-A and Amniocentesis free β-hCG) Maternal cell-free DNA (NIPT) Quadruple blood screening test (AFP, hCG, uE3, inhibin A) Timing Combined test (11 to 13+6 weeks, CVS (11 to 14+6 weeks) CRL 45-84mm) Amniocentesis (15 weeks NIPT (11 weeks onwards) onwards) Quadruple blood screening test (14 weeks onwards) Indication Advanced maternal age Abnormal morphological scan History of inherited genetic High-risk from screening test disorder High-risk heritable genetic Parental wishes disorder. Previous aneuploidies Adapted from: 1. Obstetrics and Gynaecology Protocol, State of Kedah, 2019. References: 1. Neocleous AC et. al. First Trimester Noninvasive Prenatal Diagnosis: A Computational Intelligence Approach. Journal of Biomedical and Health Informatics.2015.2462744, IEEE. 2. Navaratnam K et. al. Amniocentesis and Chorionic Villus Sampling. BJOG: An International Journal of Obstetrics & Gynaecology. 2021;129(1):e1- e15 6  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE A5. Mid-trimester Screening/Anomaly Scan Performed between 18-22 weeks, to refer earlier if indication arises. The following list is the indication for mid-trimester screening by MFM, however if the services are not available, scans can be performed by general O&G specialists. Indications: 1. Pre-existing diabetes mellitus in pregnancy or high HbA1c* 2. Parent with heritable structural anomalies (such as cleft lip, cardiac lesion) 3. Family history of heritable genetic anomalies 4. Exposure to teratogenic drugs just prior to or during early pregnancy 5. Placenta praevia anterior with previous lower segment caesarean section for placenta accreta spectrum assessment. 6. Detection of structural anomaly in current pregnancy 7. Previous pregnancy with structural anomalies* 8. Previous pregnancy with genetic disorders or aneuploidies 9. History of intrauterine death 10.History or risk of fetal anaemia 11.Monochorionic twin pregnancies or higher order multiple pregnancies 12.Positive results for infections (Toxoplasmosis, Chickenpox, Rubella, CMV, HSV, VDRL) 13.Maternal age* ≥40 14.Abnormal/high-risk first trimester screening *Discussion with referral MFM centres. This list is not exhaustive and further discussion with referral centres is recommended for cases requiring anomaly scans. Adapted from: 1. Penang State Obstetrics Protocol, 2021. 2. Obstetrics and Gynaecology Protocol, State of Kedah, 2019. 3. Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018. 7  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION A6. Inter Hospital Multidisciplinary Referrals 1. Multidiciplinary referral. Flowchart 1: Multidisciplinary referral for obstetric cases (medical/surgical conditions) Adapted from: 1. Obstetrics and Gynaecology Protocol, State of Kedah, 2019. 8  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE 2. Referral to paediatric team (this list is not exhaustive and to refer to local paediatric guidelines) Fetal reasons: i. Prematurity < 36 weeks ii. Birth Weight < 1.7 kg or > 4 kg iii. Any congenital anomalies iv. Presumed fetal compromise v. Grunting/flat baby vi. APGAR score < 7 at 5 minutes vii. Multiple pregnancies Maternal reasons: i. Active chickenpox/recent infection within 7 days of infection ii. Active herpes simplex 2 and vaginal delivery iii. Pulmonary tuberculosis (untreated or sputum still positive) iv. Hepatitis B or C positive v. Rhesus negative mother vi. Unbooked/unscreened mother vii. HIV positive mother viii. Congenital heart disease (if no anomaly scan done) ix. Maternal SLE x. Maternal diabetes on hypoglycaemic agents 9  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Intrapartum events: i. Foul-smelling liquor or chorioamnionitis ii. Prolonged leaking or any leaking with vaginal GBS infection iii. Instrumental delivery iv. Cord prolapse v. Meconium-stained liquor vi. Severe APH requiring delivery eg bleeding placenta praevia vii. Maternal pyrexia viii. Abruptio placenta ix Any emergency caesarean section with suspected fetal compromise x. Any caesarean section done under general anaesthesia Adapted from: 1. Sarawak General Hospital, Labour Ward Manual, 2020. 10  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE A7. In-utero Transfer Flowchart 2: In-utero transfer 1. Maternal medical or surgical condition requiring specialist support. INDICATIONS 2. Fetal medical or surgical condition requiring iatrogenic delivery at specialist centre with facilities and capacity for FOR IN-UTERO neonatal management 3. Antenatally diagnosed potentially lethal fetal conditions. TRANSFER 4. High risk of spontaneous or iatrogenic birth a unit without facility to manage the newborn (usually due ti prematurity). 1. Pregnancy less than 22 weeks gestation for fetal reasons. 2. Antenatally diagnosed potentially lethal fetal conditions. 3. Active labour. 4. Maternal condition which may require intervention RISK during (eg anterpartum haemorrhage or uncontrolled hypertension) PRESENT 5. Known maternal or fetal compromise requiring immediate delivery, including abnormal cardiotocograph. 11  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION 1. Discuss case with referral obstetrician and paediatrician. 2. Recommend antenatal corticosteroids from threshold of viability* to 34+6 days of gestation; for 35+0 to 36+6 weeks of gestation, short term respiratory benefits should be weighed against risk of neonatal hypoglycaemia and long-term Neurodevelopmental concerns. 3. Consider tocolysis to complete antenatal corticosteroids, not ARRANGE recommended in preterm prelabour rupture of membranes. 4. Recommend maternal antibiotics administration in suspected FOR or confirmed clinical chorioamnionitis, preterm prelabour rupture of membranes, and preterm labour with intact TRANSFER membranes with risk of vaginal GBS infection. 5. Discuss maternal magnesium sulphate administration to prevent cerebral palsy based on individual cases from 23+0 to 23+6 week gestation, offer from 24+0 to 29+6 week of gestation, and should be considered from 30+0 to 33+6 week of gestation. Adapted from: 1. Penang State Obstetrics Protocol, 2021. 2. Obstetrics and Gynaecology Protocol, State of Kedah, 2019. 3. Department of Obstetrics and Gynaecology, Hospital Tengku Ampuan Afzan, Kuantan. Department of Obstetrics and Gynaecology, Kulliyyah of Medicine, IIUM, Kuantan. A Quick Guide to Labour Ward Management. 2019. References: 1. Preterm Labour and Birth. NICE guideline {NG25}. Published 20 November 2015. 2. Stock SJ et al. Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality. BJOG: An International Journal of Obstetrics & Gynaecology. 2022;129(8):p.e35-e60. 3. Thomson AJ. Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation. BJOG: An International Journal of Obstetrics & Gynaecology. 2019;126(9):p.e152-e166. 4. Watson H et al. All The Right Moves: Why in utero Transfer is Both Important for the Baby and Difficult to Achieve and New Strategies for Change. F1000Research.2020.9(Fa cultyRev):979. 5. Soe A et al. Perinatal Management of Pregnant Women at the Threshold of Infant Viability (The Obstetric Perspective). RCOG: Scientific Impact Paper No. 41. 2014. 12  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE A8. Obstetric Retrieval Team Each hospital should have a clear individualized workflow for the obstetrics retrieval process, taking into consideration the local logistic limitations. The following is a synopsis of the Obstetric Retrieval Team’s operations: Purpose 1. Resuscitation of unstable obstetric patients by retrieval team from specialist centre. 2. Subsequent transfer to specialist centre for further care. Indications Unstable obstetrics patients in district hospital, health clinics and private healthcare facilities, e.g. (not exhaustive): 1. Massive antepartum or postpartum hemorrhage, with ongoing bleeding 2. Maternal collapse 3. Obstetric shock 4. Life-threatening complications during surgery which is not able to be managed by referring centre Information required from referring centre 1. Situation 2. Severity of patient condition 3. Ascertain whether blood is needed for resuscitation and maternal blood group if required 4. Determination of location Plan of Actions 1. Effective communication with referring center for updates 2. Inform consultant on call 3. Activate retrieval team including booking of ambulance/helicopter/boat as required 4. Gather retrieval equipment and tools 13  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Team members may include: 1. Obstetric specialist 2. Obstetric medical officer 3. Anaesthetist 4. Anaesthetic medical officer 5. Midwife/staff nurse 6. Ambulance driver +/- PPK or flying squad 7. Assistant Medical Officer if necessary 8. Paediatric medical officer/specialist if necessary Retrieval equipment and tools 1. Delivery set (O&G team) 2. Obstetric haemorrhage kit (O&G team) – refer to Appendix (PPH Box and Management Checklist) 3. Intubation set, inotropes, oxygen supply, defibrillator (by anaesthetic/ emergency department) 4. Medications, syringes, needles, infusion pumps, fluid expanders, Foley’s catheter, nasogastric tube as necessary 5. +/- blood products 6. +/-transport incubator with Neopuff (by paediatric department) 7. +/- portable ultrasound machine Subsequent Management 1. Depart to location – to inform referring centre about estimated time of arrival 2. Provide immediate resuscitation 3. Transfer patient to referral centre 4. Update team in referral center including team in Emergency Department about estimated time of arrival Adapted from: 1. Department of Obstetrics and Gynaecology, Hospital Tengku Ampuan Afzan, Kuantan. Department of Obstetrics and Gynaecology, Kulliyyah of Medicine, IIUM, Kuantan. A Quick Guide to Labour Ward Management. 2019. 2. Obstetrics & Gynaecology Department, Hospital Tuanku Fauziah, Kangar, Perlis. Obstetrics Protocol. 2020-2025. 3. Sabah Obstetric Shared Care Guidelines. 2020. 4. Sarawak General Hospital, Labour Ward Manual, 2020. 5. Penang State Obstetrics Protocol, 2021. 14 ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE SECTION B Early Pregnancy Problems 15  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Early Pregnancy Problems This chapter covers common early pregnancy problems encountered by managing doctors, including pregnancy dating issues, bleeding in early pregnancy, pregnancy of unknown location, miscarriages, molar pregnancy, and nausea and vomiting in pregnancy. B1. Pregnancy Dating Flowchart 3: Approach to determine gestational age 16  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE Determination of dates based on ultrasonography: Gestational age Parameters measured Management < 9 weeks CRL Use LMP if USG date within +/- 5 days of LMP, otherwise use ultrasound REDD. 9-13+6 weeks CRL Use LMP if USG date within +/- 7 days of LMP, otherwise use ultrasound REDD. 14+0 – 15+6 BPD, HC, AC, FL Use LMP if USG date within +/- 7 days of LMP, otherwise use ultrasound REDD. 16+0 – 21+6 BPD, HC, AC, FL Use LMP if USG date within +/- 10 days of LMP, otherwise use ultrasound REDD. 22+0 – 27+6 BPD, HC, AC, FL Use LMP if USG date within +/- 14 days of LMP, otherwise use ultrasound REDD.* ≥ 28 weeks BPD, HC, AC, FL Use LMP if USG date within +/- 21 days of LMP, otherwise use ultrasound REDD.* *requires serial growth scans to exclude small/large for gestational age babies Adapted from: 1. Obstetrics and Gynaecology Protocol, State of Kedah, 2019. 2. Sarawak General Hospital, Labour Ward Manual, 2020. 3. Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018. Reference: 1. ACOG. Methods for Estimating the Due Date. Committee Opinion, Number 700, May 2017. 17 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION B2. Bleeding in Early Pregnancy Flowchart 4: Management of bleeding in early pregnancy 18  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE Adapted from: 1. Obstetrics and Gynaecology Protocol, State of Kedah, 2019. 2. Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018. 3. Penang State Gynaecology Protocol, 2021. 4. Perak State Gynaecology Protocol, 2021. 5. Sabah Obstetric Shared Care Guidelines, 2020. Reference: 1. NICE guideline [NG126]. Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management. April 2019. 19  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION B3. Management of miscarriage Diagnosis Criteria Expectant Medical Surgical Management Management Management Confirmed IUP 1. If bleeding - - with embryo / worsens or persists fetal heartbeat and beyond 14 days, presents with vaginal return for assessment bleeding. 2. If bleeding stops, and advice to start or continue routine No history of antenatal care previous miscarriages IUP confirmed with 1. If bleeding 1. Offer Threatened scan, presents with worsens or persists vaginal miscarriage vaginal bleeding. beyond 14 days, micronized return for assessment progesterone and 400mg BD 2. If bleeding stops, Has history of advice to start or 2. If fetal miscarriage continue routine heartbeat antenatal care confirmed, continue progesterone until 16 completed weeks of pregnancy Risks rendering Not suitable 1. Offer 1. Offer women unsuitable for expectant medical surgical for expectant management management management management: where clinically 2. Offer appropriate: - Incomplete/ 1. Increased risk of vaginal Missed bleeding (e.g., late misoprostol Manual miscarriage first trimester) or, (oral is an vacuum acceptable aspiration 2. Previous adverse alternative) – under local and/or traumatic refer appendix anesthetic experience with for regime pregnancy or, or 20  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE Diagnosis Criteria Expectant Medical Surgical Management Management Management 3. Increased risk 3. Offer pain Surgical from effects of relief and anti- management haemorrhage (e.g., emetics. in theater coagulopathies or unable to have 4. Repeat UPT blood transfusion) ,or after 3 weeks and to return if 4. Evidence of UPT positive. infection Women with 1. Expectant Discuss option Discuss miscarriage who management for 7 to to allow women option to do not have 14 days to make allow women risks mentioned informed choice to make above (suitable 2. If resolution informed for expectant of bleeding and choice management) pain indicate that miscarriage has Incomplete/ completed, advise Missed women to take a UPT miscarriage after 3 weeks and to return if UPT positive 3. Offer a repeat scan after 7 to 14 days and the process of miscarriage has not begun or if there is persisting and/or increasing bleeding and pain (suggesting incomplete miscarriage). Discuss all options (continued expectant, medical and surgical management). Reference: 1. NICE guideline [NG126]. Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management. April 2019. 21 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION B4. Pregnancy of Unknown Location Flowchart 5: Management of pregnancy of unknown location 22  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE Adapted from: 1. Obstetrics and Gynaecology Protocol, State of Kedah, 2019. 2. Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018. 3. Penang State Gynaecology Protocol, 2021. 4. Perak State Gynaecology Protocol, 2021. Reference: 1. NICE guideline [NG126]. Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management. April 2019. 23 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION B5. Molar Pregnancy Flowchart 6 : Approach to Molar Pregnancy 24  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE *This guideline does not cover the management of complex molar pregnancies such as ectopic molar or twin pregnancy of a viable fetus with presumptive coexisting molar pregnancy. Adapted from: 1. Obstetrics and Gynaecology Protocol, State of Kedah, 2019. 2. Penang State Gynaecology Protocol, 2021. Reference: 1. Tidy J et al. GTG 38: Management of Gestational Trophoblastic Disease. BJOG: An International Journal of Obstetrics & Gynaecology. 2020;128(3): e1-e27. 25 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION B6. Nausea and Vomiting in Pregnancy Flowchart 7: Management of nausea and vomiting in pregnancy 26  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE *Complications: 1. Continued nausea and vomiting and inability to keep down oral antiemetics 2. Continued nausea and vomiting associated with ketonuria and/or weight loss (greater than 5% of body weight) despite oral antiemetics 3. Confirmed or suspected comorbidity 4. Abnormal urea and electrolytes 5. Haematemesis 6. Persistent ketonuria after day case hydration 7. Second attendance for day case hydration Motherisk PUQE-24 scoring system In the last 24 hours, for how long Not at all 1 hour or 2-3 hours 4-6 hours More than have you felt nauseated or sick to (1) less (2) (3) (4) 6 (5) your stomach? In the last 24 hours have you 7 or more 5-6 times 3-4 times 1-2 times I did not vomited or thrown up? times (5) (4) (3) (2) throw up (1) In the last 24 hours how many No time 1-2 times 3-4 times 5-6 times 7 or more times have you had retching (1) (2) (3) (4) times (5) or dry heaves without bringing anything up? Recommended antiemetics First line Cyclizine 50mg PO, IM or IV, 8 hourly Prochlorperazine 5-10 mg PO 6-8 hourly; 12.5mg IM/IV 8 hourly, 25mg PR daily Promethazine 12.5-25mg 4-8 hourly PO, IM, IV or PR Chlorpromazine 10-25mg 4-6 hourly PO, IV or IM; or 50-100mg 6-8 hourly PR Second line Metoclopramide 5-10mg 8 hourly PO, IV or IM (maximum 5 days’ duration) Domperidone 10mg 8 hourly PO; 30-60 mg 8 hourly PR Ondansetron 4-8 mg 6-8 hourly PO; 8mg over 15 minutes 12 hourly IV Third line Corticosteroids: hydrocortisone 100mg twice daily IV and once clinical improvement occurs, convert to prednisolone 40-50 mg daily PO, with the dose gradually tapered until the lowest maintenance dose that controls the symptoms is reached 27  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Adapted from: 1. Obstetrics and Gynaecology Protocol, State of Kedah, 2019. 2. Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018. 3. Penang State Gynaecology Protocol, 2021. 4. Perak State Gynaecology Protocol, 2021. References: 1. Shehmar M et al. GTG 69: The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum. RCOG 2016. 2. Consensus Statement on Management of Hyperemesis Gravidarum. KKM.600- 27/7/1jld.6(61), 25 February 2020. 28  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE SECTION C Antenatal Problems 29 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION C1. Multiple Pregnancy 1) Overview a. Background incidence: 1 in 80 pregnancies. b. Monozygous twinning rates are relatively constant. Incidence: 4 per 1000 births. c. Dizygous twinning rates vary enormously depending on age, parity, racial background and assisted conception techniques. d. Overall, perinatal and maternal morbidity is higher in multiple pregnancies than in singletons. e. Preterm delivery and complications of prematurity are the main contributors to adverse outcomes. 2) Antenatal Follow-up a. Ultrasound should be done at the time of diagnosis of twin pregnancy to determine chorionicity. b. Ultrasound for chorionicity should be done before 13+6 weeks of gestation. c. Referral to O&G team to confirm chorionicity, counseling and outline antenatal follow-up plan. d. Antenatal care should be shared between Specialist hospitals and the MCH clinic. e. All monochorionic (MC) twins or higher order pregnancy (≥3) required follow-up with an O & G specialist clinic. f. Consider inpatient surveillance for higher order pregnancy after 26-28 weeks till delivery. g. Uncomplicated Monochrionic (MCDA & MCMA): 2 weekly after 16 weeks until delivery. h. Uncomplicated Dichorionic Diamniotic (DCDA): 4 weekly until 28 weeks then 2 weekly until delivery. 30  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE * Good Practice Points During Ultrasound Scan 1. Look for separating membrane – lack of separating membrane suggests a monoamniotic twin (MCMA). 2. Determine Chorionicity: ØØ Number of placental mass: 2 separate masses suggest dichorionic ØØ Lambda or T-sign (1st trimester): Lambda = Dichorionic; T-sign = Monochorionic ØØ Thickness of the separating membrane: 8 cm 3) Risk of Twin Pregnancies Maternal Risk Fetal Risk Anaemia Fetal Growth Restriction Preterm Delivery Congenital Anomalies Hypertension Twin to Twin transfusion syndrome Antepartum Haemorrhage Polyhydramnios Polyhydramnios Cord accident Increased risk of operative delivery Increased risk of operative delivery Postpartum Haemorrhage 31 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION The challenges of managing monochorionic pregnancies arise from the vascular placental anastomoses that are almost universal and connect the umbilical circulation of both twins: a. Twin-to-twin transfusion syndrome (TTTS) – 10-15% of monochorionic pregnancies b. Twin reversed arterial perfusion (TRAP) sequence – 1% c. Twin anaemia polycythaemia sequence (TAP) – 1% d. Selective fetal growth restriction (sFGR), commonly due to unequal placental sharing and velamentous cord insertion – 25-35% e. Consequence of the co-twin fetal demise – 2.6% f. Management of discordant malformations g. Monochorionic, monoamniotic pregnancies with risk of cord entanglement – 1% 4) Twin-to-Twin Transfusion Syndrome a. Ultrasound examinations between 16-24 weeks focus primarily on detection of TTTS. b. After 24 weeks, the main purpose is to detect fetal growth restriction, which may be concordant or discordant. c. The Quintero classification system of TTTS has some prognostic value but the course of condition is unpredictable and may involve improvement or rapid deterioration. d. Laser ablation of vascular connection is the recommended treatment for the majority of pregnancies with TTTS that requires intervention (stage II-IV), and urgent referral to a laser surgery facility should be considered. e. Early referral is recommended to allow optimal treatment before the onset of severe disease and cervical shortening. f. Laser treatment is done between 16-26 weeks and can be considered between 26-28 weeks. 32  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE 5) The Quintero Classification System STAGE Classification There is discrepancy in amniotic fluid volume with oligohydramnios I of a maximum vertical pocket (MVP) < 2cm in one sac and polyhydramnios in other sac (MVP > 8cm). II The bladder of the donor twin is not visible. Doppler studies are critically abnormal in either twin and are characterised as abnormal or reversed end-diastolic velocities in III the umbilical artery, reverse flow in the Ductus venosus or pulsatile umbilical venous flow Ascites, pericardial or pleural effusion, scalp edema or overt IV hydrops present. V One or both babies are dead. 6) Selective Fetal Growth Restriction a. More common especially in monochorionic twins – 10% incidence. b. Estimate fetal weight discordance using 2 or more biometric parameters at each ultrasound scan from 20 weeks. c. Consider a 25% or greater in size between twins as a clinically important indicator of fetal growth restriction. d. Doppler velocimetry is used to evaluate the haemodynamic status of the 2 fetuses. e. Abnormal doppler (umbilical artery) may lead to 40% risk of IUD of affected twin. 33 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION 7) Death of one of a monochorionic twin pair a. Death of one twin in a monochorionic pair may result in death or neurological disability in the survivor. b. Chance that the surviving twin in a monochorionic twin will either die or suffer major morbidity is up to 17%. c. These events occur around the time of fetal death, postulated due to agonal hypotension as the blood volume of the survivor is ‘dumped’ precipitously into the corpse of the co-twin through shared vascular communications, or possibly due to the release of thromboplastins from the deceased twin into the shared circulation. d. One of the advantages of laser therapy (or cord ligation) in TTTS is that it provides some neuroprotection for the surviving twin in the event of co-twin demise. e. Delivery of survivors at preterm gestation will not prevent further damage unless there is evidence of cardiotocography (CTG) abnormalities or significant fetal anaemia. f. Ongoing ultrasound or MRI assessment of the brain in the survivor to diagnose neurological damage secondary to hypovolaemia may be appropriate. 8) Delivery a. Uncomplicated MCMA: by 32-34 weeks b. Uncomplicated MCDA: by 36-37 weeks c. Uncomplicated DCDA: by 37-38 weeks d. Uncomplicated triplet: offer delivery at 35 weeks e. Complicated twin pregnancies: decision is made on a case by case basis after detailed review by O&G specialist / consultant. f. Can be vaginal birth or caesarean section.** **Twin Birth Study No significant benefit of planned caesarean sections for twins vs planned vaginal birth. It is reasonable to aim for vaginal delivery if the first twin is cephalic and mother has no previous caesarean sections. 34  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE g. Caesarean section is recommended in: ØØ Non-cephalic first twin ØØ Women with previous LSCS/ uterine scar ØØ MCMA twins ØØ Any other complicated twin pregnancy. 9) Management of Twin in Labour Labour Stage Remarks Intravenous line +/- IV Hydration Blood test: FBC, GSH Ultrasound assessment to determine: -- presentation of each fetus -- liquor volume -- placental site -- viability of each twin, fetal heart location of each twin to ease the CTG fetal cardiac probe placement. Upon admission -- estimated fetal weight (if not recently performed) of labour ward Consult specialist before induction of labour or / 1st stage of augmentation labour Inform specialist when patient admit to labour room Inform paediatric team to standby for 2nd stage Continuous CTG monitoring of both fetuses, considering inserting an internal probe for the leading twin. Always compare both twin tracings to ensure that 2 different heart rates are being traced and the same twin is not being monitored twice. Ideally, both twins should be traced by one machine. 35 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Labour Stage Remarks Medical officer to standby during delivery Ultrasound machine to standby – to confirm the presentation of 2nd twin after delivery of 1st twin Delivery of 1st twin as per singleton and medical officer should help to stabilise the 2nd twin in a longitudinal lie. Clamp the cord using plastic cord clamps and cut in between the clamps, postpone taking any sample for cord blood until the 2nd twin is delivered. Perform abdominal palpation to confirm the lie and presentation of the 2nd twin. May use the Second stage of transabdominal ultrasound scan labour Continuous CTG monitoring Consider to commence oxytocin infusion if contraction is inadequate after delivery of 1st twin. Consider performing ECV or internal podalic version if in non-longitudinal lie. If it is a longitudinal lie, encourage pushing with each contraction. Once the 2nd twin delivered, clamped and cut the cord as usual. Proceed to withdraw any cord blood as necessary. Cord pH should be taken if the baby is not vigorous. Give uterotonic agent after delivery of 2nd twin as prophylaxis of postpartum haemorrhage. Deliver the placenta using controlled cord traction Third stage of Check placenta to confirm chorionicity and ensure labour placenta and membrane are complete Start oxytocin infusion as there is a risk of uterine atony and PPH following delivery of multiple pregnancies. 36  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE Adapted from: 1. Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018. 2. Sabah Obstetric Shared Care Guidelines 4th Edition, June 2020. 3. Obstetrics Protocol, O&G Department, Hospital Tuanku Fauziah, Kangar Perlis. 4. Penang State Obstetrics Protocol, 2021. 5. A Quick Guide to Labour Room Management, Hospital Tengku Ampuan Afzan Kuantan & IIUM, 3rd Edition. 6. Sarawak General Hospital Labour Ward Manual, 2020. 7. Obstetrics & Gynaecology Protocol, State of Kedah, 2019. References: 1. Royal College of Obstetricians and Gynaecologists. Management of Monochorionic Twin Pregnancy. Green-top Guideline No.51. London: ROCG; 2017. 2. NICE guideline (NG137). Twin and Triplet Pregnancy, 2019 C2. Cervical Insufficiency 1) Overview a. Cervical insufficiency is the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions, labour, or both. b. Presentation: ØØ Vaginal discharge, show or sensation of pressure at perineum ØØ History of painless dilatation of the cervix ØØ History of rupture of membranes before onset of contractions c. Investigation: ØØ Blood: FBC ØØ Imaging: Transvaginal ultrasound at 16-24 weeks of gestation for ØØ cervical length shortening, of 4mL is detected, follow-up samples are required at 48 hrs following an intravenous dose of anti-D or 72 hrs following an Intramuscular dose to check for clearance of fetal cells ØØ For any potentially sensitising events, minimum dose of 500 IU RhoGAM® should be administered within 72 hrs regardless of whether the woman has already received RAADP at 28 weeks ØØ In the event of continual uterine bleeding (clinically judged to represent the same sensitising event), minimum of 500 IU RhoGAM® should be given at 6 weekly interval. ØØ If further intermittent uterine bleeding, estimation of FMH should be done at 2 weekly interval. ØØ If the 2 weekly FMH test shows the presence of fetal cells, additional RhoGAM® should be administered ØØ The additional dose should be calculated: IM 125 IU or IV 100 IU for each mL of fetal red cells detected (minimum 500 IU) Following ØØ Give RhoGAM® 500 IU within 72 hrs following delivery delivery if: of Rhesus D oo Baby is confirmed to be Rh D positive positive oo Cord blood sample cannot be obtain child oo If there’s an intrauterine fetal death (IUFD) and hence no sample can be obtained from the baby 42  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE 5) Delivery a. Timing of delivery: follows obstetric indication. b. Check the antenatal history of RAADP. c. Ensure the availability of 1-2 units of packed cells before induction, vaginal delivery or caesarean section. d. Fetal monitoring / labour augmentation as in normal cases. e. If LSCS, intra-operatively: remove placenta by CCT, avoid MRP to minimize the risk of feto-maternal haemorrhage. f. At delivery, remember to send cord blood for ABO and Rhesus grouping. g. If suspected hemolytic disease of newborn or in the presence of maternal antibodies (sensitised mother), to send cord blood for haemoglobin level, Direct coomb’s test, serum bilirubin. 6) Kleihauer-Betke Testing a. To quantify the amount of FMH. b. Ideally should be done in all rhesus negative women post-delivery. c. Kleihauer-Betke test should be done if a higher degree of fetal-maternal haemorrhage is suspected (i.e LSCS, MRP etc). d. Maternal blood should be taken within 1-2 hours of delivery to allow sufficient time for dispersal of fetal cells in the maternal circulation. e. If the amount of FMH exceeds the dose of RAADP, give additional RhoGAM® based on the calculation of 125 IU/mL of FMH. f. Repeat Kleihauer testing after 72 hours to ensure that fetal cells have been cleared. g. Repeat RhoGAM® if fetal cells are still present in the repeat Kleihauer testing. h. When large doses of RhoGAM® (> 15,000 IU), be wary of hemolytic reaction due to intended destruction of foreign RhD +ve red cells. 43  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Flowchart 9: Management of Rhesus Negative in Pregnancy Adapted from: 1. Hospital Tuanku Ja’afar, Negeri Sembilan O&G Protocol, 2018. 2. Sabah Obstetric Shared Care Guidelines 4th Edition, June 2020 3. Obstetrics Protocol, O&G Department, Hospital Tuanku Fauziah, Kangar Perlis 4. Sarawak General Hospital Labour Ward Manual, 2020 References: 1. Royal College of Obstetricians and Gynaecologists. The Management of Women with Red Cell Antibodies during Pregnancy. Green-top Guideline No.65. London: ROCG; 2014 2. British Committee for Standards in Haematology (BCSH) Guideline for the Use of Anti-D Immunoglobulin for the Prevention of Hemolytic Disease of the Fetus and Newborn; 2014 44  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE C4. Placenta Praevia 1) Overview a. Majority of women who were told to have a low-lying placenta during the 2nd trimester will “resolve”, with only 1 in 200 having this condition at delivery. b. At 18-24 weeks, if the placenta extends beyond the internal cervical os by 15-25mm, the probability of placenta praevia at delivery is 20%. c. If it extends by >25mm, this likelihood is increased to 40-100%. d. Transvaginal ultrasound is safe in the presence of placenta praevia and is more accurate than transabdominal ultrasound in locating the placenta. e. In the absence of transvaginal ultrasound, ensure transabdominal ultrasound is done with a FULL BLADDER to increase accuracy. f. For pregnancies beyond 16 weeks of gestation, the placenta is: ØØ Normal: if placental edge is ≥ 20mm from the internal os ØØ Low-lying: if the placental edge is 50% predicted or best PEF: 94% Maintain SpO2 >94% β2-agonist pMDI Administrator: Administrator: preferable with spacer β2-agonist (salbutamol β2-agonist (salbutamol 5 mg) via (4 puffs up to a maximum 2.5-5 mg) via oxygen driven oxygen driven nebuliser, repeat of 10 puffs) or nebuliser nebuliser, repeat every 20 every 20 minutes for 1 hour (salbutamol 5mg); minutes for 1 hour Ipratorium bromide nebuliser repeat every 20 minutes for Ipratorium bromide 0.5 mg every 4 - 6 hours 1 hour nebuliser 0.5 mg every 5 - 6 IV hydrocortisone 200 mg or Prednisolone 1 mg/1kg hours prednisolone 1 mg/kg with with maximum of 50mg IV hydrocortisone 200 mg or maximum of 50 mg Continue of increase prednisolone 1 mg/kg with LIFE-THREATENING usual treatment maximum of 50 mg FEATURES Consider IV magnesium sulphate No 1.2 - 2 g infusion cover 20 improvement minutes Consider intubation Senior specialists may consider use of IV β2-agonist or IV Improvement No aminophyline improvement Improvement Continue oral prednisolone 5-7 days MONITOR PROGRESS Step up usual controller Follow up 1-2 weeks Written Asthma Action plan SpO2 SpO2 PR RR PR Measure ABG: (severe RR hypoxia, normal of PaCO2) Measure ABG: (severe CXR (if pneumothrax or consoliation suspected) hypoxia, normal of PaCO2) Monitor PEF CXR (if pneumothrax or Monitor concious level - to consoliation suspected) consider intubation if panties Monitor PEF become drowsy REFER FOR ADMISSION REFER FOR CRITICAL CARE Modified from MOH CPG Management of Asthma 2017 104  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE 4) Postpartum care a. Asthma medications are safe in breastfeeding. b. Non-steroidal anti-inflammatory agents (NSAIDs) should be avoided where possible. c. Beta-blockers should be avoided as other antihypertensives are available. 5) Prevention of asthma in the offspring a. Breastfeeding may reduce the risk of subsequent childhood asthma. b. Despite initial data showing that high dose Vitamin D (4400 IU/day) supplementation in pregnancy vs low dose (400 IU/day) can reduce the risk of asthma in offspring, this benefit was not sustained beyond the first 3 years of life (Litonjua AA et al. NEJM 2020). Weighing against the risk of toxicity, high dose Vitamin D is not routinely recommended. Reference: 1. MOH. Clinical practice guidelines: Management of asthma 2017. 2. Global Initiative for Asthma: Pocket guide for asthma management and prevention 2020. 105 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION D8. Hepatitis B 1) Overview a. Hepatitis B-associated deaths in adults are largely due to infections acquired at birth or the first 5 years of life. b. The national immunization programme for Hepatitis B began in 1989 and has been a notifiable disease since 2010. c. 12.6 in 100,000 cases of Hepatitis B were notified in 2015, with approximately half of the patients diagnosed between 20-40 years of age. d. The National Strategic Plan for Hepatitis B and C (2019-2023) recommends routine HbsAg screening during the initial visit. 2) Acute Hepatitis B infection a. Usually mild and not associated with increased maternal mortality or teratogenicity. Acute viral hepatitis is a common cause of jaundice in pregnancy. b. Antivirals are usually not indicated except in acute liver failure. c. 10% risk of perinatal transmission. Antivirals may be required if HBV DNA remains high at the time of delivery. 3) Chronic Hepatitis B infection (HBsAg +ve> 6 months) a. Liver function test should be checked every trimester. b. HBV DNA viral load should be checked if ALT is raised. c. HBV DNA viral load should be routinely checked at 26-28 weeks and tenofovir disoproxil fumarate (TDF) 300mg/day started if HBV DNA ≥ 5.3 log10 IU/mL (≥ 200,000 IU/mL). d. Studies have shown that mothers may transmit HBV to her infant even when the infant receives the timely birth dose vaccine, HBIG and completes the hepatitis B vaccine series beyond this threshold. e. Risk of transmission is as high as 85% in HBeAg +ve mothers, without intervention. f. Tenofovir (TDF) is the drug of choice and should be started from 28 weeks of pregnancy. It can either be stopped at delivery or at 4 weeks postpartum. 106  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE g. Lamivudine and telbivudine should not be used as they have a low barrier to drug resistance mutations, unless tenofovir is contraindicated (ex. Renal impairment) h. Invasive diagnostic procedures should not be withheld, but women should be counseled on increased risk of transmission if viral load is ≥ 7.0 log10 IU/ mL (SMFM) 4) Intrapartum considerations a. Hepatitis B infection is not an indication for caesarean section. b. It is reasonable to avoid fetal scalp sampling or fetal scalp electrodes, especially in women with high viral load. c. Whilst WHO recommends delayed cord clamping in women with HIV, there is no specific recommendation in Hepatitis B (WHO 2014). 5) Postpartum a. Stop Tenofovir at delivery or at 4 weeks postpartum. b. Postpartum flares (2 to 3 fold increase in ALT to >3 times the upper limit) may occur in up to 15-25% of women but are usually asymptomatic. c. Hepatitis B immune globulin (HBIG) and HBV vaccine should be administered to their newborn 350 cells/μL to-child transmission). -- Consider starting earlier if viral load > 100,000 copies/ml. 109 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Flowchart 19: Approach to HIV positive mother pregnancy *AZT=Zidovudine; NRTI=Nucleoside transcriptase inhibitor; EFV=Efavirenz; NVP=Nevirapine 2) Choice of ART for PMTCT (Prevention of mother-to-child transmission) a. 2 NRTI + [NNRTI OR Boosted Protease Inhibitor OR Integrase strand transfer inhibitor]. b. Preferred treatment: Tenofovir (TDF) + Emtricitabine (FTC) + Efavirenz (EFV) c. Other regimes are also acceptable, depending on the ID Physician. d. In women starting ART after 28 weeks, consider Raltegravir–based ART as Raltegravir crosses the placenta rapidly. 110  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE 3) Additional antenatal considerations a. Check CD4 count in early pregnancy and at delivery. b. Check viral load as baseline, 2 weeks after starting treatment (if newly started in pregnancy), 24 weeks, 32 to 36 weeks and at delivery. c. Delay invasive antenatal procedures such as amniocentesis until the viral load is < 50 copies/ml. Non-invasive prenatal testing should be offered. d. If an urgent invasive procedure is needed, ART should be initiated to include raltegravir and also a single dose of nevirapine 2 to 4 hours prior to the procedure. e. Serial growth scans should be performed from 26-28 weeks onwards. f. Watch out for complications of HIV/AIDS, e.g. Kaposi sarcoma, chest infection, herpes simplex. 4) Mode of delivery and intrapartum considerations a. External cephalic version is not contraindicated in women planning for vaginal delivery and viral load is 1000 copies/ml in women who present in labour, with rupture of membranes or planned for caesarean section. 111 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION h. Intrapartum IV AZT can be considered in women with a viral load between 50 and 1000 HIV RNA copies/mL, regardless of mode of delivery. i. Dose of IV AZT: 2 mg/kg/H for one hour, followed by 1 mg/kg/H until cord clamping. j. Allow at least 3 hours of infusion prior to elective caesarean section as the cord blood-to-maternal zidovudine levels are higher than those who received less than 3 hours of infusion (ACOG Opinion #751; 2018). k. Continue regular oral ART but omit oral AZT during AZT infusion. l. In the event of an emergency caesarean section, there is no need to complete 3 hours of AZT infusion prior to the operation. However, the paediatric team needs to be informed post-delivery to ensure adequate post-exposure prophylaxis. 5) Intrapartum considerations in women presenting with rupture of membranes Timing of rupture of Management membranes (ROM) -- Aim for early induction/augmentation and delivery within 24 hours Beyond 37wks -- Mode of delivery depends on viral load -- Low threshold to start antibiotics if suspected chorioamnionitis as the risk of MTCT is increased -- Management as per term PROM, with addition 34-37wks of antibiotics for GBS prophylaxis -- Antenatal corticosteroids -- Multidisciplinary discussion with paediatrician Before 34 wks and infectious disease physician -- May benefit from optimizing viral load in some cases, prior to delivery 6) Handling of the placenta by patients a. Use double gloves and an apron. b. For women who wish to bring home the placenta for cultural or religious purposes, the placenta should be immersed in Sodium Hypochlorite 1:10 for 10 minutes. c. Drain out and carefully seal in double plastic bags before handing over to patient/relatives. 112  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE d. Provide them with 2 pairs of disposable latex/rubber gloves. e. Educate them on the safe handling of the placenta at home. f. For women who do not wish to bring home the placenta, discard appropriately as biohazard clinical wastes. 7) Postpartum a. Refer to the ID physician regarding the continuation of ART. ART should be continued for life unless the woman is not motivated to be compliant, and her CD4 count is >350 cells/μl. b. Cessation of ART should be monitored by the ID team to minimize the risk of drug resistance. c. Baby should be referred to the paediatric team for further management and post-exposure prophylaxis. d. Generally, most forms of contraceptives can be used in women on ART, although higher dose estrogens may be required with some ARTs. There is concern about the efficacy of subdermal implants in patients on Efavirenz. Updated individual ART interactions can be found at University of Liverpool HIV Drug Interaction Checker (https://www.hiv-druginteractions.org/). e. Yearly cervical smears are advised. 8) Breastfeeding a. Breastfeeding is not recommended as it is associated with a 14% chance of vertical transmission. b. Suppressive maternal ART significantly reduces, but does not eliminate, the risk of vertical transmission of HIV through breastfeeding. The undetectable=untransmittable (U=U) statement applies only to sexual transmission, and there is currently lack of data to apply this to breastfeeding. c. Suppression of lactation can be considered. Reference: 1. Malaysian Consensus on Antiretroviral Therapy 2017. 2. BHIVA guidelines for the management of HIV in pregnancy and postpartum 2018 (2020 third interim update). 3. KKM. Garis Panduan Pengukuhan Program Pencegahan Jangkitan HIV dan Sifilis dari Ibu-ke-Anak 2021. 113  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION D10. Syphilis in Pregnancy 1) Overview a. Universal screening using RPR/VDRL is performed at booking. TPHA is required for confirmation as low levels of false-positive VDRL occur in other conditions such as SLE (12%) and pregnancy (0.7%). b. 3% of women may have false-negative results (-ve VDRL but +ve TPHA) due to prozone phenomenon. c. For high risk mothers, syphilis screening is repeated at 28-32 weeks. Acquired Late Syphilis (>2 years) Early Syphilis (2 years old) d. All newly diagnosed Syphilis should be notified. Screen for other sexually- transmitted diseases including Hepatitis B/C. e. Contact tracing of sexual partners within past 90 days (if primary Syphilis) and up to past 2 years (if secondary or early latent Syphilis). f. Risk of congenital Syphilis is higher with early Syphilis due to higher levels of spirochetemia. 2) Special considerations in pregnancy a. Doxycycline and tetracycline are teratogenic and should not be used in pregnancy b. Jarisch-Herxheimer reaction is more common in pregnancy, occuring in 50% of Syphilis of unknown duration, 60-90% of secondary Syphilis and more than 90% of primary Syphilis, reflecting the level of spirochetemia. 114  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE c. The onset of Jarisch-Herxheimer reaction is usually 2-12 hours after treatment and women should be cautioned about symptoms such as fever, malaise, joint pain, change in fetal movements (70%) and contraction pain (60%). d. Penicillin desensitisation as inpatient should be considered in women with a history of mild-moderate penicillin allergies as neither erythromycin nor azithromycin can prevent maternal-to-child transmission. e. ONLY penicillin can prevent maternal-to-child transmission. There is insufficient evidence to show the same effect in ceftriaxone at the time of writing. f. For women treated with alternative regimens, the newborn needs to be treated by the paediatric team. g. More than 30 days must have passed between the last dose of treatment to the time of birth to be considered protective against maternal-to-child transmission. *Alternative treatment Recommended Likely stage (ONLY if penicillin allergy and treatment failed desensitisation) Infection within Benzathine Penicillin Ceftriaxone 500 mg IM daily for past 2 years: G, 2.4 MU IM in a 10 days; - Primary single dose; - Secondary OR - Latent OR Erythromycin Ethylsuccinate 800 Procaine penicillin G, mg QID PO x 14 days; 600,000 units IM daily for 10 days OR Azithromycin 2 g PO x single dose NB. If drugs are missed ≥ 1 day during treatment, the whole course is repeated 115 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION *Alternative treatment Recommended Likely stage (ONLY if penicillin allergy and treatment failed desensitisation) Infection more Benzathine penicillin Erythromycin 500 mg QID PO for than 2 years: G, 2.4 MU IM weekly 28 days; - Late latent X 3 weeks (Day 1, 8 & - Gummatous 15); - Cardiovascular * OR OR Erythromycin ES 800mg QID PO Procaine penicillin G, for 28 days 600,000 units IM daily for 14 days NB. If drugs are missed ≥ 2 weeks between weekly doses, the whole course is repeated. *For cardiovascular syphilis, consider prednisolone 40-60 mg OD for 3 days, starting 24 hours before the antibiotics. Neurosyphilis Benzylpenicillin 4 Ceftriaxone 2 g IM (with MU IV 4 hourly for 14 Lidocaine as diluent); OR IV (with days; water for injection as diluent NOT Lidocaine) for 10-14 days (if OR no anaphylaxis to penicillin) Procaine Penicillin 2.4 MU IM daily; PLUS Probenecid 500 mg PO 6 hourly, both for 14 days. NB. For neurosyphilis, consider prednisolone 40-60 mg OD for 3 days starting 24 hours before the antibiotics. 3) Maternal surveillance a. Abstain from sexual intercourse for 2 weeks after the patient and partner have completed treatment. b. RPR/VDRL should be performed monthly till 4-fold reduction/non-reactive. Thereafter, RPR/VDRL is repeated two-monthly till delivery. 116  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE 4) Antenatal fetal surveillance a. Transplacental passage of spirochetes can occur at any stage in pregnancy. They have been found in pregnancy tissues as early as 9 weeks of gestation. b. Depending on the stage of the infection, there is a 40% chance of stillbirth and 30-40% chance of congenital Syphilis if left untreated. c. Fetuses with congenital Syphilis may exhibit fetal hepatomegaly (80%), fetal anemia (33%), placentomegaly (27%), polyhydramnios (12%) or hydrops (10%). d. These features are rarely seen prior to 16-18 weeks of gestation as the fetus is yet to be able to mount an inflammatory response. e. Severe features such as hydrops and fetal anemia are first to resolve if treatment is successful. f. Serial growth scans after 26-28 weeks is recommended due to risk of fetal growth restriction. 5) Intrapartum considerations a. Timing and mode of delivery is per routine obstetric indications in uncomplicated cases. b. In some cases it may be reasonable to delay planned induction to allow time for maternal antibiotics to confer fetal protection. c. There are no recommendations against amniotomy, fetal blood sampling or delaying cord clamping, especially in women who have completed treatment. d. VDRL/RPR should be repeated intrapartum or early postpartum to allow comparison with titres in the newborn. 6) Postpartum a. The paediatrician should be notified after birth and alerted if women have incomplete treatment, completed treatment less than 30 days ago or failed to demonstrate a 4-fold titre reduction after treatment ( see table below). b. Breastfeeding is not contraindicated if there are no active syphilitic ulcers on the breast. c. A follow-up plan should be coordinated with the family medicine specialist/ genitourinary medical team. 117  HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION Newborn should be considered for treatment with penicillin if any of these: ØØ Mother has incomplete treatment course ØØ Mother was treated with non-penicillin medication ØØ Mother completed treatment 5/mm3 or protein >50 mg/dl) ØØ Newborn RPR/VDRL at least 4-fold more than maternal titres Reference: 1. WHO Guideline on syphilis screening and treatment for pregnant women. 2017. 2. MOH. Garis panduan pengukuhan program pencegahan jangkitan HIV dan sifilis dari ibu-ke-anak. 2021. 118 ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE SECTION E Intrapartum Care (Normal & abnormal labour 119 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION E1. First Stage of Labour a. The first stage of labour is characterized by regular painful contractions which are increasing in intensity, frequency and duration. It is associated with progressive cervical effacement and dilatation up to full dilatation. b. It is divided to: úú Latent phase of labour: cervical os from closed to 3 cm. úú Active phase of labour: cervical os from 4 cm* to 10 cm. (*WHO Labour Care Guide 2020 uses 5 cm to define the onset of active phase of labour, and may be adopted by any labour unit) c. A complete assessment of a pregnant woman in labour should be done during admission. A high-risk case should be reviewed directly by a medical officer or specialist. d. During the latent phase of labour, fetal monitoring for pregnancy can be done by intermittent auscultation with handheld doppler ultrasound (daptone) or intermittent cardiotocogram (CTG) as required. e. A partogram is commenced once the labour progresses to active phase or earlier in certain circumstances, such as if amniotomy was performed. f. Monitoring of maternal and fetal conditions will be charted on partogram. g. Maternal monitoring: ØØ Blood pressure 4 hourly (more frequent in hypertensive disorders) ØØ Temperature 4 hourly ØØ Pulse rate 4 hourly ØØ Frequency of contractions half-hourly and pain score ØØ Urine output +/- urine ketone 4 hourly ØØ Vaginal examination 4 hourly ØØ Woman’s wishes, expectations and concerns h. Fetal monitoring: ØØ Once in the active phase of labour, monitor fetal heart rate every 15 – 30 minutes. (If daptone is used, perform auscultation during and immediately after contraction for at least 1 minute). ØØ High-risk women in active phase will require continuous CTG monitoring i. Mother-friendly care should be encouraged throughout the labour in order to promote Baby Friendly Hospital Initiatives. 120  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE j. A satisfactory labour progress is defined by: ØØ Contractions which are progressively increasing in frequency and duration. ØØ Rate of cervical dilatation of at least 0.5 cm per hour in primigravidas and 1 cm per hour in multigravidas during active phase. ØØ Presenting part remains well applied to the cervix with good descent. k. Hyperstimulation is defined as: ØØ More than 5 contractions in 10 minutes over a 30-minute period; or ØØ Each contraction lasts more than 2 minutes in duration. l. Meconium-stained liquor ØØ A specialist input should be obtained. ØØ Interpretation of CTG or fetal blood sampling should be done with caution when the liquor is meconium-stained. ØØ A trained healthcare professional in neonatal life support should be readily available during the delivery. Adapted from: 1. Sarawak General Hospital’s Labour Ward Manual 2020. 2. Obstetrics and Gynaecology Protocol State of Kedah 2019. 121 HANDBOOK OF OBSTETRICS GUIDELINE MEDICAL DEVEL OPMENT DIVISION E2. Second Stage of Labour a. The second stage of labour is defined as the period from the full dilatation of the cervix until the delivery of the baby. b. It is divided into passive and active second stage of labour: ØØ Passive: Full dilatation of cervix in the absence of involuntary expulsive contractions. ØØ Active: Full dilatation of cervix with expulsive contractions or with active maternal effort. c. Passive second stage of labour can be allowed up to one hour if there is no evidence of maternal or fetal compromise. d. In the event of prolonged second stage of labour, refer to a specialist if baby is not delivered after: ØØ Nulliparous: 2 hours of active second stage with regional anaesthesia, or 1 hour without regional anaesthesia. ØØ Multiparous: 1 hour of active second stage with or without regional anaesthesia. e. Shortening of the second stage of labour may be indicated in women with certain medical conditions (eg: cardiac diseases, hypertensive disorders in pregnancy etc). f. Appropriate universal precaution should be practiced including gowning, gloves with or without goggles. g. Episiotomy is performed only if indicated. Give local anaesthesia if an episiotomy is required. h. A paediatric doctor should be on standby for high-risk cases and instrumental deliveries. i. Ensure all medical equipment and gasses required for delivery and baby resuscitation are available and functioning. j. Fetal monitoring during second stage of labour: ØØ Monitor fetal heart rate can be achieved with CTG monitoring continuously or with daptone monitoring every 5 minutes after each contraction for one minute. ØØ CTG interpretation can be challenging especially when the mother is bearing down. 122  ME DI CA L DE V E LOPME N T DI VISION HANDBOOK OF OBSTETRICS GUIDELINE k. Intervention may be needed either via instrumental delivery or caesarean section in the following conditions: ØØ Prolonged second stage ØØ Pathological CTG ØØ Moderate and thick meconium stained liquor l. Give uterotonic when the anterior shoulder of the fetus is delivered. Options will be either Syntocinon 1 ml (10 IU) or intramuscular Syntometrine 1ml (oxytocin 5