Booking: 1st visit at health centres <12 weeks (week 8 – 12) of pregnancy

History taking
Detailed menstrual history
1. Last normal menstrual period (LNMP)
2. Regularity of cycles  irregular do US
3. Contraceptive usage

Medical history
1. Allergies
2. History of blood transfusion  hepatitis
3. PMH / Drug history
4. Infections
5. Surgical/ hospital admission
6. FH: DM/ HPT, history of congenital anomalies/ abnormal pregnancy

Obstetric history
1. Complications: Previous recurrent miscarriage or termination of pregnancy
o IUGR and preterm labour/ IUD/ early or late neonatal death
o Previous LSCS, instrumentation, PPH, anaemia
2. History of baby with congenital abnormality
3. GDM/ PIH
4. Birth weight, method of delivery

Socioeconomic background

Physical examination
1. Height, weight, BP
2. General: Pallor, cyanosis, jaundice
3. Oral hygiene
4. Clubbing
5. Thyroid enlargement & signs of hypo/hyperthyroidism
6. Cardiovascular system
7. Respiratory system
8. Breast
9. Abdomen: Scars of previous operation/ pregnancy, PALPATION
10. Vaginal examination (when indicated)
11. Oedema, Varicose veins
12. Spine: kyphosis/scoliosis

Laboratory Investigations
1. Urinalysis: protein (albumin), sugar (glucostix), UFEME (indicated)
2. Blood:
 Haemoglobin, ABO and Rhesus group
 Syphilis (VDRL): (+)  TPHA treatment
 HIV (Rapid test): (+)  confirmatory test
 Hepatitis B (HBsAg) antigen (if indicated)
 Thalassaemia screening (if indicated)
 Tuberculosis (if indicated  TB screening questions)
 Malaria: if suspected  high grade fever +

Maternal vaccination
 Anti-tetanus vaccination (tetanus toxoid, TT)
Primigravida: at quickening  2nd dose after 4 weeks
Multigravida: single dose between quickening, < 37 weeks of gestation

OPTIONAL
Influenza: >20 weeks
Tdap: 28 – 36 weeks
Foetal growth assessment
1. SFH: Week 22 onwards  POA (weeks) = SFH (cm)
If SFH & POA ± >3cm  refer for US
2. Maternal weight gain

Colour coding of ANC

Red  Hypertensive crisis, Pre-eclampsia, eclampsia  BP (>160/100) ± URGENT referral to
proteinuria hospital.
 Symptomatic IHD Shared specialists care of
 RR: >22 breaths/min O&G + FM
 DKA
 Antepartum bleeding
 Abnormal FHR (22/52: <110bpm, 32/52: <160bpm)
 Anaemia: <7g/dL
  Premature contraction/ amniotic fluid without contraction
 Seizure
 Fever + sepsis
 Suspected dengue
 DVT/ PE
 Suicidal thought/ ideation
Yellow  Mother with HIV (+)/ Hep B (+)/ Tb/ Malaria/ Syphilis/ asymptomatic Referral for specialists O&G/
IHD/ GDM (+ under r(x)/ complications) FM in hospital
o Other PMH requires hospital treatment Shared care with MO/ nurse
o <20 years old/ > 40 years old
 BP: >140/90 - <160/100mmHg ± proteinuria
 Anaemia: 7 - <9g/dL (asymptomatic)
 Placenta previa (- bleeding),
 Maternal pyrexia ≥38 ̊C/ > 3 days
 Psychosocial issue
 Antenatal VTE >3
 BMI ≥ 40 kg/m2
 Less foetal movement (> 32 weeks)  URGENT referral
 Past EDD (>7 days)

Green Refer book Manage at KK: MO, shared

care with Community nurse
(under surveillance of MO)
White  Gravida 2 – 5 Manage at KK: Nurse.
 No complications of previous pregnancy Must fulfil ALL criteria
 No comorbidities/ any health issues WITHOUT any from R/Y/G
 Mother: 20-35 years + married + family support

TBL: Normal pregnancy and early pregnancy problems – hyperemesis, threatened abortions

CVS changes
a. decrease in peripheral resistance: fluctuation of hormones + > NO in endothelium + resistance to agII/ NE  decrease BP
b. Reduced CO/ BP when lying on their back

Impaired glucose tolerance in pregnancy  insulin secretion CANNOT meet demand

Human placental lactogen (= growth hormone) + ↑ progesterone, corticosteroid  hyperglycaemia

Thalassemia in pregnancy IDA in pregnancy

hypochromic microcytic anaemia In MOTHER:
Iron studies  determine IDA Lower immunity ++ susceptibility to infections
In MOTHER: Tiredness
Pregnancy-induced hypertension Lethargy + poor concentration
Gestational diabetes Postpartum depression
Anaemia
Polyhydramnios In CHILD:
Placental abruption Low birth weight
Urinary tract infection Preterm birth
Placental abruption
In CHILD: Postpartum haemorrhage
Miscarriage
Intrauterine fetal growth restriction REFER above Anaemia
Preterm labour
Stillbirth

Pulmonary changes
Dyspnoea  ↑ minute ventilation

Early pregnancy problems

Miscarriage: spontaneous loss of pregnancy before the age of foetal viability: early (<12 weeks), late (12-24 weeks)

Normal pregnancy TVUS

Vaginal bleed Cervix TVUS
Threatened ✓ Closed Intrauterine haemorrhages  subchorionic
haematoma
Determine presence of foetus  check cardiac
activity
Inevitable ✓ (+POC) Open Irregular tissue ± gestational sac
Complete ✓ Close Complete expulsion of POC
Missed - (No expulsion of POC) Close Embryo death  retained inside

Septic: Urgent hospitalisation + parenteral BS antibiotics

Recurrent: >2 miscarriage
genetic, endocrine, autoimmune, thrombotic, uterine structural abnormalities

Ectopic pregnancy
Abdominal pain: +distension + dizziness + pain at shoulder tip (referred pain)
vaginal bleeding in early pregnancy: Haemodynamically unstable + (+) UPT

Salpingectomy: removal of FT
Surgical: STOP active bleeding + remove pregnancy tissue
Medical management: Methotrexate
Expectant

GTD

Nausea & vomiting in Pregnancy

Morning sickness
Hyperemesis gravidarum
Excessive vomiting during pregnancy ≠ hyperemesis gravidarum

Doxylamine + Vitamin B6 (pyridoxine)

Meclizine/ Metoclopramide/ Ondansetron/ Dimenhydrinate/ Diphenhydramine
Sever/ refractory vomiting: Dropride/ Methylprednisolone/ Prochlorperazine

Maternal complications: Folate/ Fe deficiency, Hepatic dysfunction (hyperemesis), Thyroid dysfunction, Ulcerative oesophagitis,
Mallory- Weis tear
Foetal complications: IUGR, SGA, death  maternal Wernicke’s encephalopathy

Postpartum arthralgia

Normal pregnancy US

TBL: Medical problems in pregnancy & maternal safety - anaemia, hypertension, diabetes, urinary tract infection, depression

1. UTI
Week 6 — dilation of uterus/ hydronephrosis of pregnancy
Urinary stasis + uretero-vesical reflux >> decrease ureter and bladder tone, increase bladder volume + diluted urine
Glycosuria

1. Asymptomatic bacteriuria,
 2. Acute cystitis
 Dysuria, urgency, and frequency
 Usually, NO SYSTEMIC SYMPTOMS

3. Acute pyelonephritis
 High-grade fever, chills & rigors, headache, nausea, vomiting, lumbar pain
 Severe: Reduced urine output
 No immediate treatment given → preterm labour/ maternal septicaemia
 Referral to hospital indicated but not mandatory
o Mother: severe distress, dehydration, poor oral food tolerance
o Maternal and foetal complications, IV antibiotic is necessary

 7 to 10-day course of oral antibiotic treatment → asymptomatic bacteriuria and acute cystitis.
 Repeat urine culture 1-2 weeks after completing antibiotics
 Group B streptococcal (GBS) vaginal colonization: preterm premature rupture of membranes, neonatal sepsis & congenital
pneumonia

2. Asthma
 Severe asthma: >>risk of deterioration (late in pregnancy)
 Women whose symptoms improve during the last trimester → postnatal deterioration
 Controlled asthma:
o absence of daytime symptoms, night-time awakening due to asthma,
o need for rescue medication, exacerbations,
o limitation on activity including exercise,
o normal FEV1 or PEFR > 80%

3. GDM
Maternal risks Foetal risks
1. Polyhydramnios 1. Risk of NTD for mothers with pre-existing diabetes
2. Pre-eclampsia 2. CVS malformation: ASD, TgA
3. Micro and macrovascular complications: nephropathy, 3. Macrosomia  shoulder dystocia ++ possible brachial plexus
retinopathy, vasculopathy, neuropathy injury
4. High risk of operative delivery 4. Hypoglycaemia, hypocalcaemia
5. Recurrent UTI/ vulvo-vaginal infections 5. Jaundice, polycythaemia
6. Uncontrolled diabetes: IUD
Mothers with GDM
1. Medical nutrition therapy → healthy diet (CHO- controlled meal plan) + appropriate gestational weight gain

2. Uncomplicated pregnant mothers → 20-30 mins safe physical activities

Mothers with pre-existing T2DM

 Preconception care/ counselling: glycaemic control targets + achieve control before conception
 Before conception: HbA1c <6.5% → < risk of congenital malformations
 SMBG (+control diet & insulin) → ↓ preeclampsia, macrosomia, shoulder dystocia
o Fasting (8-hour overnight fast) and preprandial
o 1 or 2 hours after the start of each meal (postprandial)
o Bedtime and during the night when indicated
 SBGM targets:
 Fasting: ≤5.3 mmol/L
 1-HPP: ≤7.8 mmol/L
 2-HPP: ≤6.4-6.7 mmol/L

 Medication review: safety of medications

 Folic acid supplement → to prevent NTD
OAD in pregnancy
1. Metformin
2. Glibenclamide

Insulin
 Blood glucose targets not met after MNT and metformin therapy
 Metformin is contraindicated
 FPG ≥7.0 mmol/L at diagnosis (with or without metformin)
 FPG of 6.0-6.9 mmol/L with complications → macrosomia/ polyhydramnios (start insulin immediately, with or without
metformin).

1. Human insulin: SA, LA (NPH)

2. Insulin Analogues:
Rapid: Lispro, Aspatare (++ postprandial glucose control and preventing severe hypoglycaemia)
Basal: Detemir, Glargine

 Retinal Assessment during Pregnancy: booking, week-28

 Renal Assessment during Pregnancy: booking
o Referral to a nephrologist:
 serum creatinine is abnormal (> 120 µmol/L);
 urinary albumin: creatinine ratio (ACR) >30 mg/mmol
 total protein excretion exceeds 0.5 g/day

Postpartum management
 Women with insulin-treated pre-existing diabetes → reduce their insulin immediately after birth + monitor blood glucose
levels
 Women with GDM → discontinue their insulin immediately after delivery

4. PIH (REFER Hypertension)

Risks of hypertension in pregnancy

a. Superimposed pre-eclampsia: Essential hypertension
b. Intrauterine growth restriction (IUGR)
c. Pulmonary oedema

Therapeutics:
a. Methyldopa >> safest choice
b. Prolonged use of beta-blockers  small for gestational age (SGA)
c. Diuretics:
i. reduction in utero-placental blood flow >> IUGR
ii. increase in viscosity of maternal blood >> VTE
d. ACE inhibitors  neonatal renal agenesis + pulmonary hypoplasia
e. Angiotensin receptor blockers (ARBs) (CI pregnancy, breastfeeding)

1. Gestational hypertension is detected after 20 weeks → BP 140/90 on 2 occasions 4 to 6 hours apart

Assess severity:
 Blood pressure
 Urine albumin
 SFH
 Hb and platelet (baseline)
 Renal function (baseline)
 Liver function test (baseline)
 Uric acid (as a screening for referral)
Choice of anti-HPT:
 Methyldopa (alpha-2-agonist)
 Labetalol
 Nifedipine
Treatment target: (SBP: 140-149 mmHg/ DBP: 90-99 mmHg) → reduced antihpt if target achieved

2. Preeclampsia: gestational HPT + proteinuria

Mild: SBP 140 – 149 mmHg/ DBP 90 – 99 mmHg without proteinuria

Moderate: SBP 150 – 159 mmHg/ DBP 100 –109 mmHg
Severe: SBP ≥160mmHg/ DBP ≥110 mmHg
Booking → mothers with high risk for preeclampsia
1. Cardiprin 100mg ON/ Aspirin 150 mg ON once foetal heart activity is seen (not recommended > 20 weeks).
2. Recommended dose of Ca: 1.5 – 2g (> 20 weeks until delivery)
 Educate and advise mother to return immediately → impending eclampsia
 Mild gestational hypertension: weekly BP monitoring
o If BP well controlled → managed by MO/ FMS (20-24 weeks & 32-34 weeks)
 Moderate gestational hypertension: biweekly BP monitoring
o HPT + proteinuria or severe gestational hypertension→ referral

Severe preeclampsia
 SBP ≥160 mmHg / DBP ≥110 mmHg on two occasions at least 4 hours apart while the patient is resting
 Thrombocytopenia: platelet count <100,000/cm3
 Abnormal liver enzymes (elevated AST/ALT), severe persistent RUQ/ epigastric pain
 Pulmonary oedema
 New onset of cerebral or visual disturbances
 Parenteral magnesium sulphate → prevent fit (eclampsia)

 Headache, Blurring of vision

 Epigastric pain, nausea, and vomiting
 Hyperreflexia (ankle clonus)

Complications:
 Eclampsia
 Shortness of breath  acute pulmonary oedema
 Per vaginal bleeding and abdominal pain  placenta abruption

At KK level, refer to FMS or medical officer to attend urgently

1. To set IV access
2. Control BP in hypertensive crisis  oral Nifedipine 10mg stat
3. Consult O&G specialist on-call in nearest specialist hospital
4. Give bolus IM Magnesium sulphate injection + 2% lignocaine
5. Transfer patient to a specialist hospital once BP stable BUT DON’T delay
HELLP Syndrome
Pre-eclampsia +
 H = Hemolysis (↓ hemoglobin, ↓ haptoglobin, ↑ LDH, ↑ indirect bilirubin)
 EL = Elevated Liver enzymes (↑ AST, ↑ ALT)
 LP = Low Platelets (< 100,000 cells/mm3)

3. Chronic hypertension in pregnancy

 Start aspirin once foetal heart activity is seen and calcium after 20 weeks
 Recommended monitoring:
o Same like gestational HPT
o ++ ECG
 Choice of anti HPT:
o <20 weeks: Methyldopa
o >20 weeks: Methyldopa, Labetalol and Nifedipine
 Treatment target: (SBP: 140-149 mmHg/ DBP: 90-99 mmHg)

Chronic hypertension with superimposed preeclampsia

History of chronic hypertension + new onset of ≥ 1 of the following:

 Proteinuria
 Thrombocytopenia
 Impaired renal or liver function
 Symptoms of preeclampsia
 Or sudden worsening of existing proteinuria or hypertension

Eclampsia: New-onset seizures (generalized tonic-clonic, focal, or multifocal) in a patient with preeclampsia

1. Anaemia (REFER Anaemia)

2. Depression
Postnatal blue
Feel tearful, overwhelmed, irritable and emotionally fragile ++ sadness, loneliness, anxiety and insomnia
May occur immediately after childbirth first few days of delivery, peak around one week >> resolve end of 2nd week of
postpartum.
sudden hormonal changes, discomfort from breast engorgement and birth pain, stress of parenthood and childcare, isolation, sleep
deprivation and exhaustion.

Postnatal depression
MDD in postnatal period
Symptoms of depression for more than 2 weeks:
 depressed mood
 loss of interest and pleasure in activities they usually enjoy
 loss of appetite or eating much more than usual
 inability to sleep or sleeping too much
 fatigue
 diminished ability to concentrate or make decisions
 restlessness or becoming slow
 feeling worthless
 recurrent thoughts of death and suicide

Underrecognized & underdiagnosed  Screening for postnatal depression from 6 to 12 weeks postnatal > repeat once in postnatal
years

Useful tools include: Whooley Two-Question Screen, Patient Health Questionnaire-2 (PHQ-2) or Edinburgh Postnatal Depression
Scale (EPDS).

M(x):
1. Mild: psychosocial intervention (counselling, peer-support) OR psychological intervention (CBT, interpersonal
psychotherapy)
2. Moderate: risk-benefit of antidepressant + psychosocial and psychological intervention
3. Severe depression: Antidepressant
o SSRI: Sertraline 50-100 mg daily.
 o Consult/refer to FMS or psychiatrist: severe functional impairment, high risk of suicide or depression with
psychosis.
o Assess mother-baby interaction + advice parenting and childcare.

Puerperal psychosis  REFER to obstetric emergency

Close monitoring  first six weeks up to one year postnatal in women with severe mental illness
 Change in behaviour, agitation, suspiciousness, confusion, hallucinations
 Difficulties in mother-baby interaction + psychosocial problems– poor support, financial difficulties, etc
 Breastfeeding is encouraged
 Olanzapine
 Lithium and Clozapine not recommended to breastfeed
 Sleep preservation for prevention of relapse
TBL: Family planning, postpartum care & cervical cancer screening

Puerperium

Cervical screening
Avoid during menstruation, vaginal infection, 48 hours of vaginal creams/ douching

Family planning
Progestogen-only contraception – for breastfeeding/ contraindicated to take oestrogen (active breast cancer, SLE, unexplained vaginal
bleeding, IHD/stroke)
Etonogestrel implant inhibit ovulation + anti-cervical mucus effect
May cause irregular bleeding
IUD prevent intrauterine pregnancy
copper IUDs: usual menstrual periods ++ menorrhagia, dysmenorrhea
levonorgestrel IUDs: reduce blood loss  amenorrhea, light vaginal bleeding

Progestogen-only contraceptive pill  breastfeeding mom (oestrogen suppress milk ejection)

cervical mucus thickening (after >6weeks postpartum)

Combined oral contraception (COC)

Oestrogen: ethinyloestradiol (EE), oestradiol valerate (EV), oestradiol (E2)
Progestogen: levonorgestrel, norethisterone

Monophasic: EE + levonorgestrel/ norethisterone

Vaginal ring: inserted on days 1–5 of the menstrual cycle

Emergency contraception
1. Uliprisital acetate (SPRM): prevent/ delay ovulation
2. Levonorgestrel
Barrier methods: ♀/ ♂ condoms, diaphragms
Fertility awareness
 Basal body temperature method
 Calendar or rhythm
 Billings ovulation method
 Withdrawal method
 Lactational amenorrhoea
Menopause: permanent cessation of menstruation due to loss of ovarian follicular activity
1. Premenopausal: >5 years before last menses
2. Perimenopausal: presence of early menopausal symptoms
3. Menopause
4. Postmenopausal: >1year after last menses
Osteoporosis: drop of oestrogen levels >> accelerated loss of bone mass

Vasomotor: hot flushes, night sweat, palpitations, light-headedness, migraine

Psychological: depression, anxiety, sleep disturbance, mood swings, etc.
Urogenital: vaginal dryness, dyspareunia, stress incontinence

Premature ovarian insufficiency

Hormone replacement therapy: relief distressing symptoms

 Oestrogen
 progestogen
 selective oestrogen receptor modulator (SERM)
 tibolone

Side effects
Premenstrual syndrome
Nausea + breast symptoms
Heavy bleeding/ unschedulaed vaginal bleeding
TBL: Menstruation problems - Menorrhagia, amenorrhea, irregular cycles, AUB, premenstrual tension

Menstruation cycle
Chronic AUB: bleeding from uterine corpus  volume, regularity, duration present for last 6 months
Acute/ severe AUB: bleeding that require immediate intervention (previous chronic bleeding)

Intermenstrual bleeding

Structural causes
PALM: Polyp, Adenomyosis, Leiomyoma, Malignancy
Non-structural causes
COEIN: Coagulopathy, Ovulatory disorders, Endometrium, Iatrogenic and Not otherwise

FBC: anaemia (Hb), platelet

Iron studies: serum ferritin and serum transferrin
Pelvic exam + PAP smear
TVUS

AUB investigations
FBC: Hb, + Iron studies: transferrin, ferritin
PAP smear
PVUS/ TVUS
High vaginal swab/chlamydia and gonorrhoea PCR
Hysteroscopy
Diagnostic laparoscopy with or without excision

Amenorrhea

Primary: failure of natural menstruation to spontaneously begin at age of puberty (>15 y.o.)
 Menstrual delay: has other pubertal symptoms except menses
 Delayed puberty: NO development of expected puberty symptoms  investigate FSH level
 Physiological amenorrhea: postmenopausal, pregnancy, and breastfeeding (lactation)
 Pharmacological amenorrhea: Combined OCP, antidepressants, chemotherapeutic agents
Presence, timing, or absence of secondary sexual characteristics  Tanner pubertal development
Thyroid disease, renal disease, diabetes, malignancy
Life stressors, excessive exercise, weight change, potential for anorexia/ bulimia

Secondary: absence of menses (>6 months)  previously had menses

Oligomenorrhea: Cycles of >38 days

Hypothalamic (-) GnRH (supressed), FSH, LH  excessive exercise/ major weight reduction, eating disorders, ‘stress’
Pituitary: prolactinoma  hypothalamic (-) GnRH (supressed)
Ovarian: PCOS
Uterine

Dysmenorrhea
[1]: intense PAIN at onset of menses  radiate to back + nausea/ headache
[2]: prolonged, dragging PAIN + days before menses  HMB/ dyspareunia

Menorrhagia
 Uterine fibroids: + dysmenorrhoea, pelvic discomfort
 Postcoital bleeding: cervical cancer (until proven otherwise)  RULE out first
 Postmenopausal bleeding: endometrial cancer (until proven otherwise)
 Dysfunctional uterine bleeding  diagnosis of exclusion

Endometrial polyps: vaginal bleeding in premenopausal women

  TVUS: polyps  hyperechoic lesion with regular contours within the uterine lumen
 Saline infusion sonography
 Hysteroscopy with guided biopsy (gold standard)  use to diagnose + remove polyps

 Medication treatment: progesterone (medroxyprogesterone), levonorgestrel-releasing intrauterine system

 Surgery: Blind d&c
 Hysteroscopic polypectomy

Adenomyosis (ectopic endometrium within myometrium)

 hormone-dependent pelvic lesions: fibroids, endometrial hyperplasia, endometriosis
 Asymptomatic/ ++ menorrhagia, dysmenorrhea
 Infertility: hypermobility of the uterus
 Medical treatment: LNG-IUS, GnRH agonists

Uterine fibroids
 menorrhagia, dysmenorrhoea, and intermenstrual bleeding
 bloating, increased urinary frequency and bowel disturbance,
 transabdominal ultrasound (TAUS): visualize fibroids that extend into abdominal cavity
 TVUS: better visualisation of endometrium

Genital tract infections and pelvic pain

Chlamydia Gonorrhoea Herpes Syphilis Trichomoniasis HPV

Dysuria, Mucopurulent 1° HSV—itch + 1°: Painless papule Frothy, yellow Painless lump
vaginal discharge, vaginal discharge flu-like illness,  chancre vaginal discharge (genital/anal)
dyspareunia Low abdominal vulvitis 2°: polymorphic Vulvitis + vaginitis Perianal warts
pain rash (palm & sole)  itch
condyloma lata Dysuria
Anterior uveitis
3°: neurosyphilis,
CVS syphilis
Azithromycin. Ceftriaxone/ Symptomatic m(x) Doxycycline Metronidazole Cryotherapy
Doxycycline ciprofloxacin Azithromycin
Neonatal preterm ROM Meningitis Preterm delivery. Perinatal
conjunctivitis/ premature delivery Sacral Stillbirth. transmission
pneumonia radiculopathy Congenital syphilis
(urinary retention
+ constipation)

Pelvic inflammatory disease

 Pelvic pain: constant or intermittent
 Deep dyspareunia.
 Vaginal discharge + Irregular >> painful menses + IMB/PCB
 MUST have  Cervical motion pain + adnexal tenderness + Elevated temperature

Maternal complications

Secondary postpartum hemorrhage

Puerperal sepsis
DVT and pulmonary embolism

Breast feeding

Mastitis

Retracted nipples

Abscess

Engorgement

Lactation failure